Heather Knoll Retirement Village

In the surveyor’s words

From the most serious findings on record at Heather Knoll Retirement Village, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF600Nov 8, 2021

  Based on record review, interviews and review of the facility abuse policy, and review of facility self-reported incidents (SRIs) the facility failed to ensure Resident #30, Resident #34, #70 and Resident #103 were free from abuse. This affected three of five residents reviewed for staff treatment/abuse and one additional resident. The facility census was 102. Findings include: 1. Review of the medical record for Resident #103 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the current plan of care dated 08/16/21 revealed Resident #103 had an Activities of Daily Living (ADL)/self-care deficit related to her [CONDITION(S)] accident, cognitive impairment, and weakness. […]

• No harm, potential for more than minimal, isolatedF689Jan 29, 2026

  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. […]

• No harm, potential for more than minimal, isolatedF842Aug 15, 2025

  Based on record review and interview, the facility failed to ensure Resident #1's medical record was accurate and complete. This finding affected one (Resident #1) of three resident records reviewed for accurate documentation. The facility census was 110.Findings include:Review of Resident #1's medical record revealed the resident was admitted on [DATE] and discharged on 06/02/25 with diagnoses including chronic diastolic congestive heart failure, anxiety disorder and syncope and collapse.Review of Resident #1's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition, was always incontinent of bowel and bladder and was not on a toileting program.Review of Resident #1's Emergency Department Encounter note dated 06/02/25 revealed the… […]

• No harm, potential for more than minimal, isolatedF679Mar 6, 2025

  Based on observations, interviews, record review and policy review, the facility failed to provide meaningful activities of interest. This affected one resident #(#89) of one resident reviewed for activities. The facility census was 107. Findings include: Review of the medical record for Resident #89 revealed an admitted [DATE]. Diagnosis included heart failure, abnormal posture, and dependence on wheelchair. Review of the Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed Resident #89 had intact cognition. Under the area of activity preferences, when asked how important it was to him to keep up with the news, he responded it was somewhat important. […]

• No harm, potential for more than minimal, isolatedF690Oct 16, 2024

  Based on observation, interview, record review, review of facility policy and review of manufacturers instructions, the facility failed to ensure Resident #108 received proper treatment and care planned interventions to prevent the development of redness and moisture associated skin damage to his buttocks, scrotum, and penis. In addition the facility failed to ensure Resident #20 had appropriate incontinence care. This affected two residents (Resident's #20 and #108) out of four reviewed for incontinence care. […]