GARDENS CARE HOMES - INDIAN TREE, THE

A licensure complaint, prompted by #CO41596, was completed on 2/25/26. Deficiencies were cited.

Based on observations, record review, and interviews, the residence failed to make available, either directly or indirectly through a resident agreement, a physically safe and sanitary environment, including, but not limited to, measures to reduce the risk of potential hazards in the physical environment related to the unique characteristics of the population, and personal services, affecting nine residents. (Cross-reference U2670)Findings include:1. ObservationsOn 2/25/26 at approximately 7:30 a.m., during an environmental tour of the residence, a strong sewage odor was detected. The fully accessible bathroom located in the northwest wing had a sign taped to the outside of the door stating "out of service." The door to the left, leading to the laundry room, was blocked by a box of copy paper covered with a lid; on top of the lid sat a spray bottle of surface cleaner and several crumpled paper towels. On 2/25/26 at approximately 12:13 p.m, during a tour of the laundry room, a sanitary sewer overflow was observed. A surcharge of backflowing wastewater came up from the floor waste gully directly in front of the front loading washing machine. Solid waste particles, sludge, and residual wastewater surrounded this central floor drain and radiated outwards to an approximate 3-4 foot diameter. Two laundry baskets containing cleaned linens were present in close proximity to the waste; splashes of the waste were observed on the linen. In the far northwest corner of the laundry room, a tall, deep freezer stood full of various frozen foods. To the right of this was a small, locked refrigerator containing several medication items, including eyedrops. Directly across from the clothes-drying machine, the water heater/boiler system had several areas of dried, solid waste splatter. Numerous cleaning items were stored in this room, including mop buckets. Staff #1 and #2 did not address this contamination or clean up, until approximately 1:30 p.m, when a plumbing technician arrived on site. The toilet in the middle of the house was still not flushing, and the floor drain in the laundry room was also not working, leaving only one functioning bathroom available to nine residents. 2. Record Review A maintenance request dated 11/3/25 read in pertinent part: Laundry room drain is spitting contaminated water, and the bathroom near the laundry room is leaking sewage from the toilet. A receipt from the plumbing company dated 1/7/26 read in pertinent part: "Plumbers came out and worked on the residence, including cleaning the main sewer line." The work order summary: Cable mainline into the building from outside risers on the south side wipes in line. A maintenance request dated 1/22/26 read in pertinent part: staff reported the bathroom/washer backing up sewage into the laundry room. A maintenance request dated 2/10/26 read, in pertinent part: "The bathroom was backed up, and sewage came out of the washroom drain." A maintenance request dated 2/12/26 read, in pertinent part, that the washroom plumbing was backed up, the shower was backing up, and residents could not shower or have laundry done. A maintenance form, dated 2/24/26, read in part that the laundry room is flooded with sewage again. 3. InterviewsOn 2/25/26 at approximately 11:45 a.m., the human resources director stated that the ongoing plumbing issues, which have caused two or three bathrooms within the residence not to function and have caused sewage to back up into the main drain and the laundry room, were unacceptable. She expected these issues to be resolved as quickly as possible. On 2/25/26 at 2:07 p.m., the administrator designee stated the sewage backing up into the laundry room had caused the bathroom and shower closest to the main drain to be out of service. Residents were unable to shower while this issue was present. She stated that residents' shower days were the same every week: Sundays and Wednesdays. The most recent plumbing issue started on 2/23/26. The administrator designee stated she informed the administrator of the issue; however, no resolution was reached until 2/25/26. Furthermore, she stated that the residents' laundry was not completed during the sewage backup. She instructed Staff #1 and #2 to clean the sewage as soon as they saw it in the main boiler room.

Based on record review and interview, the residence failed to comply with authorized practitioner orders associated with medication administration, affecting four of four residents whose medication was reviewed (#1-#4). Findings include:1. Resident #1 was admitted to the residence on 3/16/25 with a diagnosis consisting of preglaucoma, dry eye syndrome, and hypertension with inflammation to the left lower extremity and dermatitis. a. LatanoprostA written practitioner's order, dated 1/15/26, directed the residence to administer Latanoprost 0.005%, one drop into both eyes once daily at bedtime. However, the February 2026 Medication Administration Record (MAR) indicated it was not administered on 2/15/26 due to the medication being unavailable.b. LidocaineA written practitioner's order, dated 12/13/25, directed the residence to administer "Lidocaine (Xylocaine) 5% Ointment" twice daily in the morning and before bed (BID). However, the January and February 2026 MARs indicated it was not administered because the medication was unavailable on 1/25, 1/26, and 2/18/26. c. Artificial TearsA written practitioner's order dated 12/2/25, directed the residence to administer Artificial Tear Eye Drops 1.4%, one drop into both eyes four times daily. However, the February 2026 MAR read that it was not administered due to the medication being "unavailable, seems to be lost" on 2/15/26.d. AquaphorA written practitioner's order, dated 12/2/25, directed the residence to administer "White Petrolatum (Aquaphor Original) Ointment 41% twice daily before and after removing compression socks. However, the January and February 2026 MARs read it was not administered on 1/22, 2/7, 2/9, and 2/10/26 because the medication was unavailable. 2. InterviewsOn 2/25/26 at 8:00 a.m., Resident #1 stated that her eye drops and ointments were often not administered because they were unavailable in the residence. She stated that when she did not receive her eye drops, her eyes were extremely irritated and dry. The same was true for her ointment. When it was not administered, her skin felt rough and easily developed a rash. On 2/25/26 at 2:07 p.m., the administrator designee stated that medications were often unavailable or had not arrived at the residence in time for administration. She agreed that missing medications was not complying with the practitioner's orders. 3. There was a similar deficient practice for Residents #2-#4.

Based on observation, record review, and interview, the residence failed to have one functioning bathroom for every six residents, affecting nine current residents. (Cross-reference U1110)Findings include:1. ObservationOn 2/25/26, from 7:30 a.m. to 3:30 p.m., during an environmental tour of the residence, one full bathroom had a sign reading "out of service, do not use." There were two more bathrooms down the main hallway of the residence; however, only one toilet was fully functional. The other toilet was not flushing properly. Resident #7 was seen using that bathroom and was unable to flush the toilet. Staff had to remove the toilet tank lid and pull the metal string to flush the toilet for the residents. 2. Record ReviewA maintenance form, dated 2/24/26, read the toilet in the middle of the house still does not flush, and the toilet seat is falling off; and the bathroom closest to the laundry room cannot be used, leaving only one functioning bathroom available to nine residents. On 2/25/26, the day of the onsite investigation, the resident roster was reviewed, and read that there were nine current residents. 3. Interview On 2/25/26 at approximately 2:07 p.m., the administrator designee stated that, while the main drain in the laundry room was flooding, the residence could not use the bathroom closest to the laundry room. She stated that one of the other two bathrooms was not flushing properly, and residents could not flush the toilet without staff. The administrator designee acknowledged that there was only one working bathroom for all nine residents.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY. No response is necessary. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.7.9 The assisted living residence shall ensure that each staff member and volunteer receives orientation and training, as follows: (C) The assisted living residence shall provide each staff member or volunteer with training relevant to their specific duties and responsibilities prior to that staff member or volunteer working independently. This training may be provided through formal instruction, self-study courses, or on-the-job training, and shall include, but is not limited to, the following topics: (1) Overview of state regulatory oversight applicable to the assisted living residence;(2) Person-centered care, or accept proof of portable training in accordance with Part 7.9(D);(3) The role of and communication with external service providers;(4) Recognizing behavioral expression and management techniques, as appropriate for the population being served;(5) How to effectively communicate with residents that have hearing loss, limited English proficiency, dementia, or other conditions that impair communication, as appropriate for the population being served;(6) Training related to fall prevention, or accept proof of portable training in accordance with Part 7.9(D);(7) Training related to ways to monitor residents for signs of heightened fall potential such as deteriorating eyesight, unsteady gait, and increasing limitations that restrict mobility;(8) How to safely provide lift assistance, or accept proof of portable training in accordance with Part 7.9(D);(9) How to safely provide accompaniment, and transport of residents;(10) Maintenance of a clean, safe and healthy environment including appropriate cleaning techniques;(11) Food safety, or accept proof of portable training in accordance with Part 7.9(D); and(12) Understanding the staff or volunteer ' s role in end of life care including hospice and palliative care.

A licensure complaint, prompted by #CO41033, was completed on 10/28/25. No deficiencies were cited.

A licensure complaint, prompted by #CO39008, was completed on 2/25/25. No deficiencies were cited.

A relicensure revisit was completed on 1/7/25 for the previous deficiencies cited on 10/2/24. The residence is in compliance with all regulations surveyed.

Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally

A relicensure survey was completed on 10/2/24. Deficiencies were cited.

Based on record review, observation, and interview, the residence failed to detail in a resident's care plan with the individualized approach necessary to address fall risk related to deficits, affecting one of three sample residents (#2). Findings include:Specifically, Resident #2 with a diagnosis of osteoporosis, osteoarthritis, chronic obstructive pulmonary disease, and a seizure disorder had three falls within 22 days. On 8/22/24, Resident #2 had an unwitnessed fall that resulted in injuring her arm on the edge of a dresser. On 8/23/24, Resident #2 had an unwitnessed fall that resulted in a bruise on her knees. On 9/13/24, Resident #2 had an unwitnessed fall that resulted in hitting her head on the wall, a skin tear on her left knee, and a small puncture wound near her right rib. The fall on 9/13/24 resulted in emergency medical services being notified and Resident #2 was transferred to the emergency department. The residence failed to update the care plan with individualized approaches necessary to address fall risk related to deficits after each of these falls. 1. ReferencesChapter VII regulations governing assisted living residences, part 2.10, defines "Care plan" as a written description, in lay terminology, of the functional capabilities of an individual, the individual's need for personal assistance, service received from external providers, and the services to be provided by the facility in order to meet the individual's needs. In order to deliver person-centered care, the care plan shall take into account the resident's preferences and desired outcomes. "Care plan" may also mean a service plan for those facilities which are licensed to provide services specifically for the mentally ill. 2. Resident #2 was admitted to the residence on 10/17/2021, with a diagnosis of osteoporosis, osteoarthritis, chronic obstructive pulmonary disease, and a seizure disorder. On 10/1/24 at 4:20 p.m., Resident #2 showed the left side of her abdomen which had bruising and a scabbed puncture wound from her fall on 9/13/24. On 10/1/24 and 10/2/24 throughout the onsite visit from approximately 7:00 a.m. to 5:00 p.m., Resident #2 was observed using her walker and oxygen at all times when ambulating throughout the day inside and outside of the residence. An incident report dated 8/22/24, reported Resident #2 was dizzy in her room and fell. She reported getting up from the bed too fast, fell, and hit her arm on the edge of her dresser. The fall was unwitnessed. An incident report dated 8/23/24, reported Resident #2 had an unwitnessed fall when trying to pick up her oxygen tank and then fell to her knees. A progress note dated 8/23/24, reported Resident #2 had fallen and had a red bruise on her left knee. A progress note dated 8/25/24, stated Resident #2 reported knee pain when bending it along with pain in her ribs, and underarm pit on her left side. On 9/13/24, Resident #2 had an unwitnessed fall that resulted in hitting her head on the wall, a skin tear on her left knee, and a small puncture wound near her right rib. The fall on 9/13/24 resulted in emergency medical services being notified and Resident #2 was transported to the emergency department. A progress note dated 9/15/24, stated Resident #2 reported knee pain from her fall. The staff observed bruising and Resident #2 getting a rash from the medical bandage behind Resident #2's knee. A progress note dated 9/18/24 read in part that Resident #2 reported being scared when the fall happened. An undated care plan read in part the following fall management interventions for Resident #2:Assist with walker safety and monitor when standing up from a seated position. Remind her to have her walker positioned safely prior to ambulating. Remind her to use grab bars for safety in the bathroom. Monitor and assist as necessary daily as needed. Remind resident to reposition walker after standing up to walker without catching her foot or oxygen tubing. However, the residence failed to update the care plan to detail the individual approaches necessary to address fall risk for Resident #2 after sustaining three falls from 8/22/24- 9/13/24. On 10/2/24 at 3:45 p.m., the operations compliance officer confirmed that no fall interventions were added to the care plan post-falls on 8/22/24, 8/23/24, and 9/13/24. The operations compliance officer reported they expected fall interventions to be added to the care plan post-falls to prevent future falls. On 10/2/24 at 3:45 p.m., the administrator designee confirmed that no fall interventions were added to the care plan post-falls on 8/22/24, 8/23/24, and 9/13/24. The administrator designee reported they expected fall interventions to be added to the care plan post-falls to prevent future falls.

Based on observation and interview, the residence failed to keep the residence grounds free of garbage and rubbish, affecting 10 current residents. Findings include:On 10/1/24 throughout the onsite visit from approximately 7:00 a.m. to 5:00 p.m, the backyard of the residence had a broken plastic container, tipped-over flower pots, an upside table with no surface, other broken furniture, and plastic wrapping under the overgrown trees. The backyard of the residence also had a used medical gloves, metal sheet material, leaves, sticks, large branches and an abundant amount of apples on the ground that were attracting wasps. The backyard patio of the residence had a used disposable medical gloves on the ground, leaves and sticks scattered, an open package of snow melt ice in a planter bag, a full fire-resistant garbage can, and another regular garbage can with a plastic garbage bag that contained cigarette butts and rubbish. The backyard patio had a garden hose on a walkway laying on top of a mouse trap box, utility buckets with rubbish inside, and a tipped-over broom. The back patio grill also located on the backyard patio had stacked planter bags, soil bags, and plantar pots with cigarette butts in it. On 10/2/24 throughout the onsite visit from approximately 7:00 a.m. to 5:00 p.m, the side yard of the residence near the driveway had a broken black plastic bin. In front of the residence garage there was a dishwasher, end table, durable medical equipment, fan, broom attached to a dustpan, and an unknown long white panel propped up alongside the garage wall. On 10/2/24 at approximately 3:50 p.m., the operations compliance officer confirmed that the residence was not free of garbage and rubbish when it should be. On 10/2/24 at approximately 3:50 p.m., the administrator designee confirmed that the residence was not free of garbage and rubbish when it should be.

Based on observation and interview, the residence failed to keep the residence porches in good repair, affecting 10 current residents. 1. ObservationOn 10/1/24 throughout the onsite visit from approximately 7:00 a.m. to 5:00 p.m, the backyard patio was observed to have chipped and broken tile flooring at the edge of the patio on the left hand side. On 10/2/24 throughout the onsite visit from approximately 7:00 a.m. to 5:00 p.m, the front porch was observed to have unsecured tile as the floor that shifted when being walked on. 2. InterviewOn 10/2/24 at approximately 4:00 p.m., the operations compliance officer confirmed that the residence's front porch and backyard patio was not in good repair and could be a tripping hazard for residents. The operations compliance officer stated she submitted a work order to the residence maintenance team on 9/18/24, however, the damages have not been repaired. She agreed that the patio tiles should be fixed. On 10/2/24 at approximately 4:00 p.m., the administrator designee confirmed that the residence front porch and backyard patio was not in good repair and could be a tripping hazard for residents. The administrator designee agreed that the patio tiles should be fixed.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY. No response is necessary. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter VII6.8 The administrator, or individual appointed as an interim administrator, shall be responsible for the overall day-to-day operation of the assisted living residence, including, but not limited to: (A) Managing the day-to-day delivery of services to ensure residents receive the care that is described in the resident agreement, the comprehensive resident assessment, and the resident care plan; (B) Organizing and directing the assisted living residence ' s ongoing functions including physical maintenance; (C) Ensuring that resident care services conform to the requirements set forth in Part 12 of this chapter; (D) Employing, training, and supervising qualified personnel; (E) Providing continuing education for all personnel; (F) Establishing and maintaining a written organizational chart to ensure there are welldefined lines of responsibility and adequate supervision of all personnel; (G) Reviewing the marketing materials and information published by an assisted living residence to ensure consistency with the services actually provided by the ALR; (H) Managing the business and financial aspects of the assisted living residence which includes working with the licensee to ensure there is an adequate budget to provide necessary resident services; (I) Completing, maintaining, and submitting all reports and records required by the Department; (J) Complying with all applicable federal, state, and local laws concerning licensure and certification; (K) Ensuring the assisted living residence ' s compliance with the involuntary discharge requirements in Section 25-27-104.3 C.R.S., and these rules; and (L) Appointing and supervising a qualified designee who is capable of satisfactorily fulfilling the administrator ' s duties when the administrator is unavailable. (1) The name and contact information for the administrator or qualified designee on duty shall always be readily available to the residents and public. (2) The administrator or qualified designee shall always, whether on or off site, be readily accessible to staff.(3) When a qualified designee is acting as administrator in an assisted living residence that is licensed for more than 12 beds, there shall be at least one other staff member on duty whose primary responsibility is the daily care of residents. 9.3 The assisted living residence shall have an involuntary discharge grievance policy that complies with Section 25-27-104.3, C.R.S., and includes, at a minimum: (A) The individual designated by the assisted living residence to receive involuntary discharge grievances.(B) The ability for any of the persons the assisted living residence is required to notify in accordance with Part 11.16 to file a grievance challenging the involuntary discharge and/or reasons for the discharge with the individual designated in subpart (A), above, within 14 calendar days after written notice of the involuntary discharge is provided by the assisted living residence. (C) The ability for the resident, or other person allowed to file a grievance to receive assistance in preparing and filing a grievance without interference from the assisted living residence. (D) A requirement that grievances related to involuntary discharge be submitted to the individual designated by the facility in accordance with subpart (A) as follows:(1) In writing, or (2) Orally submitted to the individual designated in accordance with subpart (A), above. In the case of an oral submission, the assisted living residence shall ensure the individual submitting the grievance retains proof of the oral submission through a witness or other evidence. (a) If the grievance is orally submitted and witnessed, the assisted living residence shall ensure that the resident or other personfiling the grievance has the witness ' s name and contact information, and shall keep that information as part of the grievance documentation. (E) A requirement that no later than 5 business days after the submission of a grievance in accordance with subpart (D), above, the individual designated by the assisted living residence to receive involuntary discharge grievances shall provide a response to the grievance as follows: (1) A written response shall be provided to the individuals required to receive notice in Part 11.16, the state long-term care ombudsman, and the designated local ombudsman. (2) An oral explanation of the written response shall be provided to the resident and/or person filing the grievance, as appropriate.(3) The written response shall include the following statement regarding the filing of an appeal: "If the resident, or other person that submitted this grievance is dissatisfied with this response, they may file an appeal to the executive director of the Colorado Department of Public Health and Environment within 5 business days after receiving this written response. The appeal must include the original grievance, the original notice of involuntary discharge and supporting documentation given to the resident as part of that notification, and any additional information or documentation." (F) Acknowledgement that if the resident, the individual filing the grievance, or the assisted living residence is dissatisfied with the findings and recommendations of the Department related to an appeal, they may request a hearing conducted by the Department pursuant to Section 24-4-105, C.R.S. (G) A requirement that the assisted living residence not take any punitive or retaliatory action against a resident due to the resident filing a grievance or appeal pursuant to this Part. (H) A requirement that the assisted living residence continue to assist with planning a discharge or transfer of the resident while the grievance or appeal to the Department is pending. (I) A requirement that the resident be allowed to return to the assisted living residence if all of the following apply:(1) The stated reason for the involuntary discharge in the notice of involuntary discharge provided in accordance with Part 11.17 is nonpayment of monthly services or room and board, (2) The assisted living residence discharged the resident on or after the 31st day after the written notice of involuntary discharge was provided to the resident, and (3) The resident substantially complied with payments due to the residence, as determined through the grievance and appeal process. 10.1 The assisted living residence shall have readily available a roster of current residents, their room assignments and emergency contact information, along with a facility diagram showing room locations. 10.6 Each assisted living residence ' s emergency policies shall address, at a minimum, all of the following items: (A) Written instructions for each identified risk that includes persons to be notified and steps to be taken. The instructions shall be readily available 24 hours a day in more than one location with all staff aware of the locations; (B) A schematic plan of the building or portions thereof placed visibly in a central location and throughout the building, as needed, showing evacuation routes, smoke stop and fire doors, exit doors, and the location of fire extinguishers and fire alarm boxes; (C) When to evacuate the premises and the procedure for doing so;(D) A pre-determined means of communicating with residents, families, staff and other providers; (E) A plan that ensures the availability of, or access to, emergency power for essential functions and all resident-required medical devices or auxiliary aids; (F) Storage and preservation of medications; (G) Assignment of specific tasks and responsibilities to the staff members on each shift including use of a triage system to assess the needs of the most vulnerable residents first; (H) Protection and transfer of health information as needed to meet the care needs of residents; and (I) In the event relocation of residents becomes necessary, written agreements with other health facilities and/or community agencies. 22.32 The assisted living residence shall ensure that oxygen tanks are secured upright at all times in a manner that prevents tanks from falling over, being dropped, or striking each other.

A revisit survey was completed on 3/22/24 for all previous deficiencies cited on 8/11/23. The facility is in compliance with all deficiencies that were cited.

A licensure complaint, prompted by #CO30797, was completed on 8/11/23. A deficiency was cited.

Based on interview and record review, the residence failed to implement the required process pending discharge of reassessing the resident to be discharged; revision of their care plan to identify current resident needs and what services to provide to meet those needs; and, ensure staff were aware of new directives and properly trained, affecting one sample resident (#1). Findings include:1. Residence Policya. Chapter VII regulations governing assisted living residences, part 2.7, defines an "at-risk person" as any person who is 70 years of age or older.b. The residence's undated discharge policy read in part that a resident may be discharged from the residence when the residence could not protect the resident from harming themselves or others.c. The residence's undated resident agreement read in part that the resident may be discharged when the resident posed a danger to self or others. 2. Resident #1 was admitted to the residence on 5/9/15, with diagnoses including dementia. A face sheet for Resident #1 read that her date of birth was 4/14/47, which meant she was 76 years old on 8/3/23. A local law enforcement report, dated 2/3/23, read in part that on 2/3/23 at 11:11 p.m., local law enforcement responded to a welfare check after concerned employees at a local supermarket reported an elderly customer who could not secure a ride home. At 11:20 p.m. local law enforcement provided Resident #1 a courtesy ride to the residence. An assessment, dated 2/7/23, read in part Resident #1 was a wandering risk, elopement risk, had poor safety awareness, and had behaviors. Resident #1 required supervision on outings, would need redirection to prevent elopement, and was cognitively unable to safely manage affairs independently. A progress note, dated 2/12/23, written by the former administrator designee (AD), read in part Resident #1 left the residence on 2/4/23 at 8:00 p.m. by taxi. She was returned to the residence by local law enforcement. A care plan, dated 2/16/22, read in part that Resident #1 displayed independence with shopping needs. However, she was known to be out of the residence for hours at a time. She had used taxi services and on occasion had not paid the fare. Further, she required an assistive device when walking and "was extremely hard of hearing."An incident report, dated 2/4/23 at 12:00 a.m., read in part: "Incident Classification: Behavior, Danger to self." Resident #1 left the residence in a taxi at 8:00 p.m. to go shopping. The AD offered to call for a taxi for her at 10:00 p.m.; however, the resident refused the offer. At 10:00 p.m., during staff shift change, the AD advised Former Staff #5 to notify her if the resident had not returned to the residence by 11:00 p.m. At 11:50 p.m., the AD received a telephone call from local law enforcement informing her the resident was in the store and was unable to secure a ride home. The police officer had attempted for 45 minutes to reach the residence by phone, without success. The officer escorted Resident #1 to the residence where doors were locked and lights were turned off. After 20 minutes, Resident #3 answered the back door and allowed the officer into the residence. Resident #4 and the police officer then returned to the front door and allowed Resident #1 entry. The police officer searched the residence for 20 minutes and found former Staff #6 asleep. An incident report, dated 8/4/23 at 8:05 a.m., read in part that on 8/3/23, Resident #1 had left the residence at approximately 4:00 p.m., and was dropped off by an unknown person at 10:45 p.m. There was no evidence the residence reassessed the resident after the incident on 8/3/23. A care plan, dated 8/11/23, read in part the exact same as the 2/16/23 care plan: Resident #1 required supervision, was considered a wandering risk, and required redirection to prevent elopement. Resident #1 was showing cognitive change with the inability to safely manage independent outings, falls, and had lost her identification card while out. There was no evidence that the residence revised her care plan to identify the resident's current needs and what services the residence provided to meet those needs. 3. InterviewsOn 8/11/23 at 7:30 a.m., Staff #2 stated that Resident #1 was an elopement risk at night, so she checked on her every two to three hours. Staff #1 stated that the resident had not left the residence during her shift in the time she had worked at the residence (since 7/12/23). She added she received no new directives or training on what to do when the resident left and did not return to the residence. On 8/11/23 at 10:33 a.m., Staff #3 stated that on 8/4/23, Staff #4 informed her that Resident #1 had left the residence at approximately 4:30 p.m. and was brought back to the residence late at night by an unknown person. She stated, "I do not think that's safe at all. You never know what's going to happen." Staff #3 stated the residence provided no new directives or training after this event on how to ensure Resident #1's safety when she left the residence, adding that the care plan for Resident #1 indicated that she was an elopement risk. On 8/11/23 at approximately 11:00 a.m., Staff #4 stated that on 8/3/23 at 10:00 p.m., she was made aware that Resident #1 had left the residence at 4:50 p.m. and that she had not yet returned. Staff #4 stated that at 11:00 p.m., "Some guy knocked on the door. I said 'Who are you?' He said he found her at (a local shopping center) because she was waiting too long for a cab." She stated she had no idea who the man was, adding that it was "definitely not safe" for the resident to have gotten into his car. Staff #4 stated she was told to notify the AD if the resident had not returned by 12:00 a.m. on 8/4/23. She stated that the residence provided no new directives after this event on how to ensure Resident #1's safety when she left and did not return to the residence timely. On 8/11/23 at 11:33 a.m., a staff who wished to remain anonymous stated that on 8/3/23, Resident #1 left the residence at approximately 4:50 p.m. by taxi. S/he stated the resident was usually gone for two to three hours when she left. The anonymous staff stated s/he got concerned at 6:30 p.m. when s/he did not see that the resident had returned and searched the residence and the designated smoking area to see if the resident returned without telling her. S/he added that at 7:00 p.m., Resident #1 still had not returned, but s/he knew from past experience that s/he could only call in a missing persons report only after a person was missing for eight or more hours if they were considered "at risk." S/he stated s/he sent an electronic message to the AD at 9:05 p.m. that the resident still had not returned. The AD advised the anonymous staff to call the stores that she frequented to see if they had seen her, but no one had. The anonymous staff stated that at change of shift (approximately 10:00 p.m.) the resident still had not returned, so she advised Staff #4 (the oncoming staff for the overnight shift) to call the AD if the resident was not home by midnight because that would have been eight hours after she left the residence. The anonymous staff stated she later found out that the resident was brought back to the residence by an unknown person at 11:00 p.m. on the evening of 8/4/23. The anonymous staff stated she was not trained before or after this event on what to do when a resident left and did not return. S/he added that it was dangerous for the resident to have gotten in a vehicle with an unknown person, adding that the unknown person could have taken her elsewhere. On 8/11/23 at 11:55 a.m., the residence's compliance officer stated the residence should have reassessed Resident #1 and revised the care plan after the incident on 8/3/23, but they did not do so. She stated the residence should have provided staff with new directives and training on interventions for Resident #1's safety. However, she stated they did not do so after this incident. On 8/11/23 at 12:00 p.m., the AD stated it was "absolutely unsafe" that Resident #1 was returned to the residence in a vehicle by an unknown person. The AD stated the nurse was responsible for updating care plans. She stated the care plan had not been updated with interventions to ensure Resident #1's safety because the nurse traveled among the residence and its sister residences, and the nurse had not yet visited the residence while the AD was present. The AD stated she had not communicated any new directives or training to staff after the incident on 8/3/23.