Health inspection·January 29, 2026

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, review of AccuWeather forecast and facility policy review, the facility failed to ensure Resident #61 did not exit the facility without staff knowledge, failed to complete a full investigation and health assessment after Resident #61 exited the facility without a coat in 18 degrees Fahrenheit (F) temperatures, and failed to notify Resident #61's responsible party of the incident. This affected one (Resident #61) of three residents reviewed for safety.Findings included:Review of the medical record noted Resident #61 was admitted on [DATE]. Diagnoses included unspecified dementia, anxiety disorder and repeated falls.Review of the plan of care dated 09/22/25 noted Resident #61 had general weakness and was at risk of decline in ambulation. The plan of care was updated on 01/28/26 stating Resident #61 had potential for falls/injury due to weakness, balance deficit, psychotropic medications, dementia, and orthostatic hypotension. No plan of care was created indicating Resident #61 was at risk for elopement.Review of the comprehensive Minimum Data Set (MDS) assessment, dated 11/25/25, revealed Resident #61 had intact cognition. The resident required partial assistance for bed mobility, transfers, and ambulation.Review of the nursing progress notes dated 01/18/26 at 12:59 P.M. noted Resident #61 was observed outside the facility by Certified Occupational Therapy Assistant (COTA) #205. No other documentation was provided, indicating the resident was found outside the facility without staff.Review of the AccuWeather forecast for [NAME], Ohio for 01/18/26 revealed a high temperature of 18 degrees F and a low temperature of 11 degrees F.Interview on 01/29/26 at 8:28 A.M., Certified Nurse Assistant (CNA) #203 stated she provided care for Resident #61, and he should not be outside by himself. CNA #203 stated she was not aware of Resident #61 leaving the facility without staff or family.Interview on 01/29/26 at 9:23 A.M., Unit Manager #204 stated she was not aware of Resident #61 leaving the facility and verified that Resident #61 should not be outside without staff or family.Interview on 01/29/26 at 9:55 A.M., Resident #61 stated he went out to the parking lot to see his car. Resident #61 stated it was dumb to go outside without a coat because it was cold outside. Resident #61 stated a therapy staff member observed him in the lot, put him in her car and drove him back to the entrance of the facility.Interview on 01/29/26 at 10:03 A.M., COTA #205 stated she observed Resident #61 outside in the parking lot which was approximately 20 feet from the building and 50 feet from the door. Resident #61 was assumed to exit the facility. Resident #61 was wearing street clothes, but no hat, coat or gloves. COTA #205 stated Resident #61 stated he was outside because he wanted to get some fresh air.Interview on 01/29/26 at 10:30 A.M., the Administrator, the Director of Nursing, (DON) and the Quality Assurance Nurse #206 stated no investigation was completed because Resident #61 had a BIMS (Brief Interview for Mental Status) of 15 which indicated the resident had intact cognition. The Administrator stated he spoke with Resident #61 who stated he was outside looking for something but was not specific.Interview on 01/29/26 at 11:26 A.M., Licensed Practical Nurse (LPN) #207 stated she administered Resident #61's medications before he left Page 1 of 2 365739 365739 01/29/2026 Heather Knoll Retirement Village 1134 North Ave Tallmadge, OH 44278

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to wait on his sister for lunch. LPN #207 stated she observed Resident #61 being wheeled back to the unit by COTA #205 stating he was found outside. LPN #207 could not verify the door Resident #61 used or how long he was outside. LPN #207 stated she spoke to Resident #61 briefly explaining that he needed to sign out next time and make sure he was wearing appropriate clothing for the weather. LPN #207 stated Resident #61 stated he did not realize it was that cold outside. LPN #207 stated no assessments were completed or documented, that she called the DON who said Resident #61 had a BIMS of 15 so nothing else needed to be done. LPN #207 stated the doors that she assumed Resident #61 exited through automatically lock so Resident #61 would not be able to return inside.Interview on 01/29/26 at 12:59 P.M., Nurse Practitioner #208 stated someone called her to tell her Resident #61 was observed outside the facility, but Resident #61 was dressed appropriately and no significant changes were noted. NP #208 stated she spoke with Resident #61 on 01/22/26 but did not ask about the incident on 01/18/26.Interview on 01/29/26 at 1:10 P.M., the family of Resident #61 stated she received a call a couple weeks ago from staff stating they caught Resident #61 trying to leave the facility. The family stated she received calls in the past stating Resident #61 was looking for the door but never left the facility. The family stated Resident #61 had short-term memory dementia with sundowning episodes. The family was not aware Resident #61 was observed outside without the facility without staff and not wearing a coat.This deficiency represents non-compliance investigated under Complaint Number 2723679. 365739 Page 2 of 2