Incident investigation·July 23, 2025

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a Case Management and was greeted by Administrator Wendy Cornejo. On 6/20/25 CCL received an Incident report for resident (R1). Incident report indicated that on 6/10/25 facility was made aware by R1's responsible party that R1's previously diagnosed cellulitis was a staphylococus aureus infection. Facility advised R1's responsible party that staphylococus aureus infections is a prohibited condition. R1 was then seen at their primary care physician the same day, 6/10/25. They then were evaluated at the Emergency Room (ER). The ER diagnosed R1 with septic bursitis of right elbow with a culture of MSSA. MRSA and MSSA are both types of staphylococus aureus, but MSSA is not antibiotic resistant. R1 was then admitted to the ER for antibiotic therapy. R1 was discharged with a diagnosis of traumatic olecranon bursitis with apparent cellulitis. LPA reviewed discharge papers for R1. Papers also note that cellulitis was resolved while in the hospital and infection resolved as well. Discharge papers dated 6/16/25 state that R1 did not need to be in isolation. R1 returned to the facility on 6/16/25. Care plan was updated, Home Health was ordered to monitor R1's elbow, and R1 continued oral antibiotics for approximately one week. Per Health and Wellness Director (HWD), Alyx Fischer, R1's elbow is now healed. No deficiencies cited. On 6/27/25 CCL received an Incident report for Memory Care resident (R2). On 6/27/25 R2 experienced two [2] falls in their room, one at 3:36am and one at 10:58pm. Falls captured on Safely you video and alerted staff. R2 was assessed by staff S1 and S2, no injuries observed by staff or reported by R2. After fall #1, R2 was assisted back into bed and S1 placed R2's wheelchair and their recliner next to R2's bed. After fall #2, R2 was helped back into bed by staff S3 and S1. Once again, S1 placed R2's wheelchair next to her bed. Continued on 809C... Continued from 809... Upon learning of the incident, HWD observed and interviewed R2, they did not recall having their furniture moved to prevent them from falling out of bed. Memory Care Director (MCD) notified R2's Power of Attorney (POA). All involved team members were placed on suspension pending an internal investigation. HWD reported to Sonoma Sheriff's office (event ID# SO251780006) and MCD, HWD, and Admin all interviewed S1, S2, and S3. S1 reported that they were trying to use the wheelchair and recliner as a fall prevention measure, they did not know it would be or could be considered a form of restraint. Investigation concluded approximately on 7/2/25 and S1 returned to work 7/1/25. S2 and S3 returned to work on 7/2/25. To address the issue of restraints and personal rights, facility conducted in-service training starting on 7/1/25 and concluding on 7/14/25, for all direct care staff. Training topics covered were restraints, personal rights, and mandated reporting. S1, S2, and S3 all participated in the in-service training. No deficiencies cited. On 7/22/25, Admin notified LPA of theft in facility. Minor instances of theft were previously reported to LPA earlier in the year, suspect unknown. On 7/21/25 at approximately 7:30pm, staff (S4) was caught on camera digging through a recently deceased resident's (R3) belongings. S4 was observed opening a drawer and pulling out an envelope of money. Money was stolen and put in S4's pocket. On 7/22/25 at approximately 10:00am, Admin and HWD contacted Sonoma Sheriff Department (event #SON-250000229 and SON-250000383). Deputy arrived at facility to take report and view video footage of theft. R3's responsible party was notified. At approximately 2:30pm on 7/22/25, S4 was arrested by deputy. Facility immediately terminated S4 as they were being arrested. Case is still being investigated. S4's private residence was searched and additional items of theft from residents of the facility were recovered. Police report pending. Admin will forward S4's information to CCL by 7/28/25. Video footage given to LPA. No deficiencies cited. Exit interview conducted with Admin and a copy of this report given.