Incident investigation·July 23, 2025

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a Case Management and was greeted by concierge. LPA met with Rose Lazzarotto, Business Office Manger (BOM). Administrator Omar Mendoza was available by phone. On 6/16/25, facility submitted incident report indicating on 6/7/25 resident (R1) exited the community unassisted. Facility is located close to boutique hotel Pueblo Inn. A staff member of Pueblo Inn called the facility to alert them that R1 was at their property. Administrator sent staff S1 over to accompany R1 back to the facility. At approximately 11:00am S1 found R1 and accompanied them back to the facility. Health and Wellness Director (HWD), Norma Alvarez immediately notified R1’s family member and Primary Care Physician of elopement. Admin then discussed with family the need for a companion due to new exiting behavior exhibited. Companion was provided to R1 by family. However, Admin felt that transfer to a facility with Memory Care could be a positive intervention to her benefit, as risk of exiting behavior may continue in Assisted Living. So, R1 was moved to a sister community's Memory Care unit. R1 left facility on 6/30/25. Incident report indicates R1 has diagnosis of dementia. LPA reviewed R1's physician report and Care plan. Physician's report indicates that R1 did not have a history of disorientation, unsafe wandering, elopement, or sundowning behavior. However, physician's report indicates that R1 is not allowed to leave the facility unsupervised. LPA reviewed Care plan, Care plan indicates that R1 had mild neurocognitive impairment, but had no impairment with vision, hearing, communication, ambulating, or history wandering/elopement. When R1 was found by S1, R1 seemed anxious and stating they “wanted to go somewhere,” but care plan indicated that resident did not have current or history of anxiety. Admin advised LPA that in 6/3/25 R1 was moved from Independent Living to Assisted Living, as physician's report and care plan both indicated resident did not have history Continued on 809C... Continued from 809... of wandering behavior, sundowning behavior, or elopement, so resident not identified with risk of elopement. Admin advised LPA that he believes incident of elopement was not the result of a lack of staff supervision, but rather perhaps a progression of their dementia. Additionally, Admin disagrees with physician report assessment of R1 not being able to leave the facility unassisted as R1's physician report also indicates that R1 does not experience disorientation, lack of hazard awareness, lack of impulse control, unsafe wandering, elopement, sundowning behavior, expressions of frustration, hallucinations, or any other history of behavioral expressions that would make R1 at risk for elopement. LPA and Admin discussed thoroughly reviewing all residents' physician reports and if any discrepancies are found, Admin to immediately address discrepancies and get revised physician's report, if needed. Admin understands and agrees. No deficiency cited. Exit interview conducted with Administrator via telephone and a copy of this report was given to BOM.