BALFOUR AT LITTLETON

A revisit survey was completed on 9/15/25 for all previous deficiencies cited on 4/15/25. The facility is in compliance with all deficiencies that were cited.

A revisit survey was completed on 9/15/25 for all previous deficiencies cited on 4/15/25. The facility is in compliance with all deficiencies that were cited.

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 complaint revisit was completed on 4/15/25 for all previous deficiencies cited on 3/1/23. A deficiency was cited. The regulations governing Assisted Living Residences were revised. The new Chapter VII regulations were implemented on 7/1/24.

Based on observation, interview and record review, the residence failed to ensure the care plan for each resident in a secure environment included a description of how the resident will have continuous independent access to his or her individual room along with the ALR's plan to protect the resident from unwanted visitors, affecting four of four sample residents (#8 and #15-#17) who resided in the secure environment. This deficiency was cited previously during a state licensure complaint on 3/1/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:Resident #8 was admitted to the residence on 5/26/22 with diagnoses including dementia. A care plan, dated 4/12/25, did not include a description of how the resident would have continuous independent access to her individual room. On 4/15/25 at approximately 2:30 p.m., the administrator said most residents in the secured environment do not have keys. She said she was unsure who had keys to their rooms. She said the residents who had keys had that documented in the care plan. She said care plans did not document how residents would have continuous access to their rooms while keeping unwanted guests out. She said she thought this was fixed by documenting the residents who had keys. She said she was unaware she needed to include a description of how the resident will have continuous independent access to their room, along with the residence's plan to protect the resident from unwanted visitors in the resident's care plan. Evidence obtained during the onsite visit revealed the residence additionally failed to comply with authorized practitioners' orders associated with medication administration for Residents #15-#17.

A relicensure survey with complaint #CO39807 was completed on 4/15/25. Deficiencies were cited. A change of ownership occurred on 10/1/24

Based on observation and interview, the residence failed to place in a visible location a list of all staff who have current certification in first aid or cardiopulmonary resuscitation (CPR) so that the information is readily available to staff at all times, affecting 70 current residents. Findings include:During the onsite visit on 4/14/25, the residence failed to have a list of staff members with current certification in first aid and CPR in a visible location and readily available to staff at all times throughout the residence. On 4/15/25 at 12:12 p.m., the administrator and health and wellness director (HWD) said they were not aware of the regulation requiring a list visibly posted. On 4/15/25 at 3:20 p.m., the administrator stated that there was no list of all staff who have current certification in first aid or CPR in a visible location at the residence.

Based on record review and interview, the residence failed to comply with authorized practitioner orders associated with medication administration, affecting three of five sample residents (#15, #17, and #20). Findings include:1. Resident #17 was admitted to the residence on 10/26/23. A written practitioner's orders, dated 3/13/25, directed the residence to administer four grams of cholestyramine daily for 30 days. According to the March 2025 and April 2025 medication administration record, staff documented the resident did not receive the medication 20 times from 3/14/25-4/15/25 due to the medication not being available. On 4/15/25 at approximately 7:30 a.m. Staff #12 said Resident #17 had never received her packets of cholestyramine. She said she notified the nurse. On 4/15/25 at approximately 2:30 p.m., the administrator said she expected the residence to have all medications in stock and administered as ordered. She said Resident #17 should have her medications available. Evidence obtained during the onsite visit revealed the residence additionally failed to comply with authorized practitioners' orders associated with medication administration for Residents #15 and #20.

Based on observation and interview, the residence failed to ensure the residence grounds were maintained to protect residents from slopes and hazards, affecting 70 current residents. Findings include:On 4/15/25 at approximately 8:00 a.m., 8:30 a.m., and 1:15 p.m., environmental tours revealed the residence had a sidewalk that spanned from the north-facing front of the residence to the west side of the building. The sidewalk had several areas that ranged from one foot to approximately a 24-foot section that led east to west, with ledges and drop-offs. An approximate four-inch drop off from the sidewalk to the ground that contained dirt, grass, or mulch. On 4/15/25 at approximately 8:30 a.m., Resident #23 was observed walking his dog on the path. He was observed stepping approximately 0.5 inches near a significant drop-off. On 4/15/25 at approximately 8:30 a.m., Resident #23 stated that he was "very aware" of the hazard. He stated that he needed to take his dog out several times a day and would be careful to avoid the drop-off on the sidewalk. On 4/15/25 at approximately 1:15 p.m., the health and wellness director (HWD) stated they were aware of the hazard and working to address the slope and sidewalk. She acknowledged it was a hazard for residents. Additionally, the HWD acknowledged that the courtyard in the secure environment contained safety hazards for residents. On 4/15/25 at 3:20 p.m., the administrator acknowledged the drop-off ledges were a hazard for residents.

Based on record review and interview, the residence failed to provide pest control measures to ensure the residence doors, door screens, and window screens fit with sufficient tightness at their perimeters to exclude pests, affecting 46 current residents. Findings Include:On 4/15/25 at approximately 7:00 a.m., upon arrival, a window screen was observed leaned up against the building. On 4/15/ 2025, at approximately 8:00 a.m., a window on the rear east side of the residence was observed to have insufficient tightness. A window on the rear south side of the building had several window screens that were not sufficiently fitting, as well as warped windows that did not allow for sufficient tightness. On 4/15/25 at 1:18 p.m., the health and wellness director (HWD) stated that she was unaware that a screen had been leaned against the building or that other windows and window screens did not provide sufficient tightness. On 4/15/25, at 3:20 p.m., the administrator and HWD stated they were not aware of the regulation that required window screens to be sufficiently tight to exclude pests. They acknowledged that the residence failed to have a screen on one window and had insufficient fitting screens on several windows.

Based on observation and interviews, the residence failed to have a clean refuse storage area that had tight fitting lids and kept clean, affecting 70 current residents. Findings include: On 4/15/25, at 8:00 a.m., an observation of a refuse area surrounded by a wooden structure, with a door left open, revealed multiple recycling and refuse bins. One of the refuse bins contained five to six large bags of waste that could not fit in the bin with a tight-fitting lid. A used round food container, accompanied by several discarded napkins, were beneath the bin. A sticky, sweet-smelling substance was also present, covering a section of the area. On 4/15/25 at 1:18 p.m., an observation was made that the waste company had collected the garbage; however, the refuse under the bin had not been cleaned. On 4/15/25 at 1:18 p.m., the Health and Wellness Director stated she was aware that refuse bins did not have tight-fitting lids. She also acknowledged that the area was not cleaned and was a health hazard. On 4/15/25 at 3:20 p.m., the administrator acknowledged the failure of the residence to have tight-fitting refuse lids.

Based on observation, interview and record review, the residence failed to ensure the care plan for each resident in a secure environment included a description of how the resident will have continuous independent access to his or her individual room along with the ALR's plan to protect the resident from unwanted visitors, affecting four of four sample residents (#8 and #15-#17) who resided in the secure environment. Findings include:Resident #8 was admitted to the residence on 5/26/22 with diagnoses including dementia. A care plan, dated 4/12/25, did not include a description of how the resident would have continuous independent access to her individual room. On 4/15/25 at approximately 2:30 p.m., the administrator said most residents in the secured environment do not have keys. She said she was unsure who had keys to their rooms. She said the residents who had keys had that documented in the care plan. She said care plans did not document how residents would have continuous access to their rooms while keeping unwanted guests out. She said she thought this was fixed by documenting the residents who had keys. She said she was unaware she needed to include a description of how the resident will have continuous independent access to their room, along with the residence's plan to protect the resident from unwanted visitors in the resident's care plan. Evidence obtained during the onsite visit revealed the residence additionally failed to comply with authorized practitioners' orders associated with medication administration for Residents #15-#17.

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 7.14.7 The assisted living residence shall ensure that each resident receives proper administration and/or monitoring of medications. 14.27 No stock medications shall be stored or administered by qualified medication administration persons. A) All over-the-counter medications prescribed for administration shall be labeled or marked with the individual resident ' s full name. 14.31 (S1604) Medication audits are done on a quarterly basis, documented, and irregularities investigated.

A licensure complaint, prompted by #CO30879 and #CO31021 was completed on 3/1/23. Deficiencies were cited.

Based on record review and interviews, the residence failed to establish a fall management program which included detailing in each resident's care plan the individualized approach necessary to address fall risks related to deficits in strength and balance, affecting one sample resident (#2) with a history of falls. Specifically, Resident #2 sustained a fall without injury on 12/11/22, 2/25/23. The residence's care plan for Resident #2 had not been updated to detail the individualized approach necessary to address Resident #2's fall risks related to documented deficits in strength and balance. Subsequently, Resident #2 sustained a series of additional falls on 2/18/22, 2/26/23 that resulted in skin tear on the right hand, 0.5 cm abrasion on the left lower abdomen; and 1.5 cm abrasions to the right elbow respectively. No additional individualized approached had been documented by the residence to address Resident #2's fall risk to prevent additional falls. Findings include:1. Residence Policy The residence's Fall Management and Risk Assessment policy, dated 12/2/22, read in part: "should a resident experience a fall, staff will provide immediate care and follow through the service planning. Care partners are instructed to summon immediate assistance from the health and wellness director or med tech on duty. The service planning is updated as needed with interventions. The service plan is updated as needed with interventions. The health and wellness director informs the physician of subsequent falls and instability and discusses any interventions for care such as pharmacy review of medications, physical therapy etc. Per the community's fall reduction program, each resident's service plan and fall risk assessment will be reviewed and updated whenever a resident has: a first fall (no prior documentation/reported fall), repeated falls, a fall with injury requiring medical intervention/treatment, a change in condition."2. Record review Resident #2 was admitted to the residence on 1/15/21 with diagnosis including unspecified abnormalities of gait and mobility, intervertebral disc displacement, spondylolisthesis.b. Progress notes for Resident #2, dated 12/11/22-2/26/23 were reviewed and revealed the following:On 12/11/22, Resident #2 was ambulating in his apartment and fell on the floor, vitals were obtained and no pain or injury was noted. On 2/18/23, Resident #2 was found on the floor in his room, an assessment was completed by a nurse and revealed injuries. Resident #2 was lifted off the floor. Resident #2 had a skin tear on the right hand below the thumb, an 0.5 cm abrasion to left lower abdomen. On 2/21/23, a follow up revealed Resident #2 had multiple skin tears because of fall on 2/18/23. On 2/24/23, Resident #2 was found on the floor in the dining room. On 2/25/23, Resident #2 had a fall at night. No bruising, bleeding or other injury was noted. On 2/26/23, Resident #2 had a fall and was found on the floor on his back in the corner of his room door and the wall. Staff heard resident scream and stated Resident #2 spun around a few times before falling. Resident #2 had a 1.5 cm abrasion to the right elbow.c. Fall risk assessments for Resident #2, dated 12/11/22, 1/15/23, 2/18/23, 2/24/23, 2/26/23, 2/27/23, were reviewed and revealed the following:On 12/11/22 and 1/11/23, Resident #2 had documentation of the history of falls. The assessment read Resident #2 had difficulty rising from the chair, uses chair arms to get up, bounces to rise. Resident #2 keeps head down when walking, watched the ground and grasps furniture, person or aid when ambulating. Resident #2 was documented as unable to walk unassisted. No additional interventions were noted to be implemented to prevent additional falls related to deficits related to balance and strength. On 2/18/23 and 2/24/23, Resident #2 had documentation of the history of falls. The assessment read Resident #2 used crutches, cane or walker. The assessment read Resident #2 stoopedbut able to lift head without losing the balance. Resident #2 was documented as his- steps were short and resident may shuffle. No interventions were noted to be implemented to prevent additional falls related to deficits related to balance and strength. On 2/26/23, Resident #2 had documentation of the history of falls. The assessment read Resident #2 had difficulty rising from the chair, uses chair arms to get up, bounces to rise. Resident #2 keeps head down when walking, watched the ground and grasps furniture, person or aid when ambulating. Resident #2 required staff assistance with all mobility. No interventions were noted to be implemented to prevent additional falls related to deficits related to balance and strength. On 2/27/23, Resident #2 had documentation of the history of falls. The assessment read Resident #2 used crutches, cane or walker. The assessment read Resident #2 stooped but able to lift head without losing the balance. Resident #2 was documented as his- steps were short and resident may shuffle. No interventions were noted to be implemented to prevent additional falls related to deficits related to balance and strength. d. The care plan for Resident #2, dated 1/17/22 was reviewed and revealed the following: On 1/17/22, Resident #2 was listed to be at risk for fall due to gait imbalance, poor safety awareness and weakness. Resident #2 had moderate dementia with short term memory and displayed deficits in judgment. Resident #2 was on safety checks every three hours at night. No interventions were noted to be implemented to prevent additional falls related to deficits related to balance and strength, nor did the care plan include a individualized approach necessary to address Resident #2's fall risk. 3. InterviewsOn 3/1/23 at 1:13 p.m., Staff #5 stated Resident #2 was considered a fall risk. Staff #5 stated Resident #2 was falling because he was unstable. She stated the interventions for Resident #2 to prevent him from falling was to keep Resident #2 out of his room in the common areas as much as they could. Staff #5 stated the staff were required to do 15 minutes, 30 minutes, one hour and two hour checks on Resident #2. On 3/1/23 at 1:20 p.m., the memory care director (MCD) stated Resident #2 had fallen approximately twice since he moved back to the secured environment on 2/24/23 The MCD stated she was responsible for updating the residence care plans and assessments. The MCD stated herself, the health and wellness director (HWD) and therapy director (TD) completed fall meetings every month where they discussed fall interventions for the residents. The MCD stated Resident #2 was transitioned to a wheelchair and the interventions that were in place for him were keeping him in the common area. The MCD stated herself and the HWD were responsible for updating the care plan. The MCD acknowledged she did not update the care plan for Resident #2 after he fell on 12/11/22, 2/18/23, 2/25/23, 2/26/23. On 3/1/23 at 1:35 p.m., Staff #1 stated she did not recall how often Resident #2 fell, however, she was aware he had fallen in the two days prior to his onsite visit. Staff #1 stated she was not sure what interventions were in place to prevent Resident #2 from falling. On 3/1/23 at 1:38 p.m., Staff #2 stated she considered Resident #2 a fall risk. Staff #2 stated Resident #2 fell because he was declining. Staff #2 stated she did not have access to the care plan and added the only intervention she could think for Resident #2 was to provide safety checks every one hour. Staff #2 stated she would try to get Resident #2 in the common area to prevent him from falling. On 3/1/23 at 1:49 p.m., Resident #2's family member stated Resident #2 had a series of falls. The family member stated Resident #2 was being transitioned to the wheelchair and added she was not sure if the residence had implemented additional measures to prevent additional falls for Resident #2. On 3/1/23 at 3:13 p.m., the administrator stated Resident #2 wasat risk of falling. She stated the resident had fallen many times because he was declining with additional falls after he moved to the secure environment. The administrator stated she was not aware of the interventions that were in place for Resident #2 and added she would have to speak to the wellness director and therapy team to ask about the resident's interventions. She stated the fall management care plan should be updated after each fall typically within one week. The administrator stated if a resident fell and there was no injury, staff would assist the resident off the floor and notify the resident's family, practitioner and the RCD. She stated an assessment and update to the care plan was required to be completed after every fall for a resident. The administrator stated Resident #2's care plan should have been updated to reflect individual approaches to minimize his risk of falls. The administrator stated she was not aware the care plan was not updated with individualized approaches for Resident #2.

Based on observation and interview, the residence failed to ensure weekly menus were readily available for residents and public viewing, affecting 17 sample residents who resided in the secure environment. Findings include:On 3/1/23 from approximately 7:15 a.m. to 12:00 p.m., there was no weekly menu readily available for residents and public viewing in the secure environment. There was no evidence of a menu booklet accessible to residents. On 3/1/23 at 7:15 a.m., Staff #3 stated she was not sure where to locate the weekly menu in the secure environment. On 3/1/23 at 11:40 a.m., Staff #2 stated the staff got the menu with four options printed out the night before and added staff would ask the residents what they wanted by showing them the menu. Staff #2 stated the memory care director (MCD) then emailed the menu to the kitchen staff. Staff #2 acknowledged that there was no readily available menu posted for resident and public viewing. On 3/1/23 at 12:07 p.m., Former Staff #7 stated the weekly menus were not readily available for residents or public viewing in the secure environment. She also stated her last day at the residence was approximately three weeks prior to the onsite visit. On 3/1/23 at 1:18 p.m., Staff #6 stated she was not aware of where to locate the weekly menus for secure environment residents. On 3/1/23 at 3:00 p.m., the administrator stated weekly menus should have been in a menu booklet located in the dining area of the secure environment. She stated she expected weekly menus to be available at all times in the secure environment.

Based on observation, interview and record review, the residence failed to reassess residents in the secure environment whenever the resident's condition changed from baseline status, affecting two of two sample residents (#1, #2) who had a condition change from baseline status. 1. Residence PolicyThe residence Change in Resident Policy, dated 5/9/22, read in part, "Community staff have the responsibility to provide care to each resident and summon medical attention when the resident has a change in status. Examples of change would include, but not limited to: decreased mobility/range of motion, weakness, decreased coordination, hallucinations or unusual behavior, change in level of consciousness, decrease in cognitive decline, pain or discomfort. If there is an actual change in status or ability to function the resident's physician should be immediately notified."2. Resident #2 was admitted to the residence on 1/15/21 with diagnosis including unspecified abnormalities of gait and mobility, intervertebral disc displacement, spondylolisthesis. The assessment for Resident #2, dated 1/15/23, read in part, Resident #2 was not always oriented to place and time. Resident #2 required assistance with re-direction and orientation. A progress notes for Resident #2, dated 1/28/23, 2/6/23, 2/11/23, 2/24/23 were reviewed and revealed the following:On 1/28/23, Resident #2 walked naked through the hall and called for help. On 2/6/23, Staff noticed Resident #2 in the common area hallways without clothes on and staff heard Resident #2 yelled. On 2/11/23, Resident #2 was very confused today. Resident #2 placed his waste basket into the toilet. Resident #2 came out of his room with his outer pants below his knees. Resident #2 was unable to put into words what he wanted that morning. On 2/24/23, Resident #2 was moved to the secure environment from the non secure environment. Resident #2 had moderate dementia with significant short-term memory and possibly long term memory loss. Resident #2 displays a deficit in judgment and will be supported to make appropriate decisions about his care and environment. Resident #2 has increased gait instability. Resident #2 was not capable of independent decision making. Resident #2 urinates in inappropriate places and the resident does not undress or disrobe in public areas. However, there was no evidence the residence re-assessed Resident #2 after moving him to the secure environment on 2/24/23. On 3/1/23 at 3:24 p.m., the wellness director (WD) stated Resident #2 was moved to the secure environment on 2/24/23 because he had a physical, cognitive decline and increased care needs. She stated herself and the memory care director (MCD) were responsible for reassessments. The WD stated she did not have time to reassess Resident #2 after his move to the secure environment on 2/24/23.3. Resident #1 was admitted to the residence on 3/4/22 with diagnoses including dementia and physical debility. On 3/1/23 at 7:15 a.m., Staff #3 stated Resident #1 had a condition change from baseline in the past few months prior to the onsite visit due to a physical and cognitive decline. She stated the resident required two person transfer assistance, wound care, and external hospice services. On 3/1/23 at 11:32 a.m., the legal representative for Resident #1 stated the resident required external hospice services at the beginning of February 2023 due to wounds on the resident's coccyx area. She stated external hospice visited approximately four times a week to provide the resident with wound care. The legal representative confirmed the resident had a physical and cognitive decline since October 2022 when she was last assessed. She added, the resident currently required two person transfer assistance, external hospice services and wound care. On 3/1/23 at 3:00 p.m., the administrator stated the wellness director was responsible for ensuring residents were reassessed in the secure environment whenever the resident's condition changed from baseline status. She confirmed the resident had a condition change from baseline due to a cognitive and physical decline. She confirmed the resident should have been reassessed due to the condition change from baseline. On 3/1/23 at 3:24 p.m., the wellness director stated she was responsible for ensuring residents were reassessed in the secure environment whenever the resident's condition changed from baseline status. She confirmed Resident #1 should have been reassessed after the resident required external hospice services and wound care. An assessment, dated 10/13/22, read in part, the resident required staff to standby for transfer assistance. However, the resident's wound care and need for external hospice due to a physical and cognitive decline was not included in the comprehensive assessment.

Based on observation, interview and record review, the residence failed to ensure the care plan for each resident in a secure environment included a description of how the resident will have continuous independent access to his or her individual room, affecting 11 of 17 sample residents (#1-#5, #9-#14) who resided in the secure environment. Findings include:1. Resident #1 was admitted to the residence on 3/4/22 with diagnoses including dementia. On 3/1/23 at approximately 11:10 a.m., the resident was in the common area and her bedroom door was locked. A care plan, dated 10/13/22, did not include a description of how the resident would have continuous independent access to her individual room. On 3/1/23 at 11:32 a.m., the legal representative for Resident #1 confirmed the resident was unable to independently access her room due to it being locked from the outside. She stated staff had to assist the resident in accessing her room. 2. Resident #2 was admitted to the residence on 1/15/21 with diagnoses including Alzheimer's disease. On 3/1/23 at 11:10 a.m., the resident was in the common area and his bedroom door was locked. A care plan, dated 1/17/22, did not include a description of how the resident would have continuous independent access to her individual room. 3. Resident #3 was admitted to the residence on 11/20/18 with diagnoses including dementia. On 3/1/23 at 11:10 a.m., the resident was in the common area and her bedroom door was locked. A care plan, dated 1/24/23, did not include a description of how the resident would have continuous independent access to her individual room. On 3/1/23 at 11:39 a.m., the legal representative for Resident #3 confirmed the resident was unable to independently access her room due to it being locked from the outside. She stated staff had to assist the resident in accessing her room. 4. Resident #4 was admitted to the residence on 6/23/22 with diagnoses including cognitive impairment. On 3/1/23 at 11:10 a.m., the resident was in the common area and her bedroom door was locked. A care plan, dated 9/20/22, did not include a description of how the resident would have continuous independent access to her individual room. On 3/1/23 at 11:48 a.m., the legal representative for Resident #4 confirmed the resident was unable to independently access her room due to it being locked from the outside. He stated staff had to assist the resident in accessing her room. 5. Resident #5 was admitted to the residence on 5/8/22 with diagnoses including dementia. On 3/1/23 at 11:10 a.m., the resident was in the common area and her bedroom door was locked. A care plan, dated 9/15/22, did not include a description of how the resident would have continuous independent access to her individual room. 6. Resident #9 was admitted to the residence on 4/28/22 with diagnoses including dementia. On 3/1/23 at 11:10 a.m., the resident was in the common area and her bedroom door was locked. A care plan, dated 4/28/22, did not include a description of how the resident would have continuous independent access to his individual room. 7. Resident #10 was admitted to the residence on 4/12/19 with diagnoses including Alzheimer's disease. On 3/1/23 at 11:10 a.m., the resident was in the common area and her bedroom door was locked. A care plan, dated 10/27/22, did not include a description of how the resident would have continuous independent access to her individual room. 8. Resident #11 was admitted to the residence on 12/19/19. On 3/1/23 at 11:10 a.m., the resident was in the common area and her bedroom door was locked. A care plan, dated 12/19/19, did not include a description of how the resident would have continuous independent access to her individual room. 9. Resident #12 was admitted to the residence on 8/8/20 with diagnoses including Alzheimer's disease. On 3/1/23 at 11:10 a.m., the resident was in the common area and her bedroom door was locked. A care plan, dated 9/28/20, did not include a description of how the resident would have continuous independent access to her individual room. 10. Resident #13 was admitted to the residence on 6/27/21 with diagnoses including Alzheimer's disease. On 3/1/23 at 11:10 a.m., the resident was in the common area and her bedroom door was locked. A care plan, undated, did not include a description of how the resident would have continuous independent access to her individual room. 11. Resident #14 was admitted to the residence on 11/8/20 with diagnoses including vascular dementia with behavioral disturbance and hallucinations. On 3/1/23 at 11:10 a.m., the resident was in the common area and her bedroom door was locked. A care plan, undated, did not include a description of how the resident would have continuous independent access to her individual room. On 3/1/23 at 11:30 a.m., the activities director (AD) stated Residents' #1-#5 and #9-#14 doors were locked automatically. The AD stated she was not aware if the residents could access their rooms independently. On 3/1/23 at 11:40 a.m., the maintenance director (MD) stated all the doors of the residents residing in the secure environment remain locked. The MD stated some of the doors remained unlocked if the family of the resident had requested them to be unlocked, however, he was not sure which doors remained unlocked. He also stated he was not sure why the doors remained locked, however, they remained locked since he began employment in Novemeber 2022. The MD stated the residence followed what was carried out by the former administrator. The MD stated if residents were unable to access the room independently staff would assist the residents. On 3/1/23 at 3:00 p.m., the administrator stated the wellness director was responsible for ensuring care plans included all the required information. However, she stated she was not aware that a description of how secure environment residents would have continuous independent access to their individual rooms was required to be included in the care plans. She confirmed the resident doors were locked and that they all required staff assistance to access their rooms. On 3/1/23 at 3:24 p.m., the wellness director confirmed she was responsible for ensuring care plans were completed as required. However, she stated she was not aware that a description of how secure environment residents would have continuous independent access to their individual rooms was required to be included in the care plans.