complaint·May 6, 2025

Hospital Physician corroborated this information by explaining that the pressure injuries could have developed over the course of a few days, but not in a single day. This suggests that the injuries likely developed during R1’s residency at Gardens at Laguna Springs. The Executive Director of the facility, Guadalupe Ramirez (S1), reported that R1 wore briefs that were changed after every meal or accident, and staff reportedly checked briefs every two hours. However, there was no documentation or staff reporting of any pressure injuries. Staff member (S3) stated that R1 wore pull-ups as a preventive measure, that R1 was sometimes incontinent, and that pull-ups were changed approximately three times per day. A review of R1’s medical records obtained from the hospital confirmed the presence of multiple pressure injuries which were described as "community acquired," with moisture components noted on the sacrum, bilateral buttocks, scrotum, penis, and coccyx. Based on the information gathered, the allegation that resident R1 sustained multiple pressure injuries while under the care of Gardens at Laguna Springs Memory Care is SUBSTANTIATED. A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are cited on the 9099D during this visit. Exit interview was conducted with Guadalupe Ramirez and a copy of this report and appeal rights were provided. {2 of 2} Interview with S1 stated that R1 had been eating less in the days leading up to the incident and this was discussed with W1, who agreed that R1 typically ate small portions. Staff were instructed to assist and hand-feed R1 when needed. Interview with S2 reported that R1 was offered meals three times daily along with snacks. S2 stated that R1 sometimes required encouragement or hand feeding, especially when tired. However, R1 never completely refused meals and always had access to food and snacks. On 07/15/2024, staff reported that R1 was lethargic and did not eat throughout the day because R1remained asleep. Upon finding R1 being nonresponsive, staff checked R1’s blood sugar and found it to be low. 911 was called immediately, and R1 was transported to the hospital. Review of medical documentation from Emergency Medical Services (EMS) confirmed that R1 was hypoglycemic prior to hospital transport. Medical records from hospital listed acute respiratory failure as the primary diagnosis upon admission. Physician stated that low blood sugar could have contributed to R1's altered mental status and may have predisposed R1 to respiratory complications such as pneumonia. Additionally, per record reviews and interviews, there was no physician order in place at the facility for routine blood sugar monitoring for R1, despite a history of diabetes. Based on the gathered information, there is insufficient evidence to support the allegation that staff neglect resulted in R1’s hospitalization. Staff documentation and interviews consistently indicate that R1 was being monitored regularly, provided food, and offered assistance with eating. While R1 did experience a medical emergency due to low blood sugar, there is no clear indication that facility staff failed to meet R1’s basic care. Therefore, the above allegation was UNSUBSTANTIATED. {2 of 6} Allegation - Staff did not meet the residents bathing needs The investigation into this allegation consisted of review of facility records, interviews with staff and review of documentation related to R1’s bathing schedule and care. Review of the Resident Assessment dated 07/16/2024 , R1 requires assistance with bathing twice a week. The assessment specifies that R1 needs hands-on help with bathing, utilizing a shower chair, and staff assistance for scrubbing hard-to-reach areas. Review of the shower body audits for 07/10/2024 , 07/14/2024 AM , and 07/14/2024 PM reveal that on the dates R1 was scheduled for a shower, R1 refused to take a shower but accepted sponge baths instead. The audits also indicate that staff observed R1’s body during the sponge baths and did not note any wounds, bruises, burns, excoriations, or rashes. Review of staff statement, S1 documented a statement about R1's bathing needs, mentioning that R1's responsible party (RP) had accused the facility of failing to provide a shower on a specific date. However, Guadalupe clarified that the facility had provided sponge baths during the AM and PM shifts on that day, as R1 had refused the shower. Review of another staff statement, S2 confirmed that R1's shower schedule was set for two days a week (Tuesday and Saturday). On days when R1 did not have the energy for a shower, R1's responsible party agreed that staff could provide a bed bath. S2 also stated that when residents refused showers, staff attempted different techniques to encourage bathing, but residents could not be forced to bathe. When a shower or bed bath was provided, staff performed a skin assessment and documented any findings. Staff interviews confirmed that R1 had refused showers on occasion, it was explained that R1's physician’s report did not provide specific instructions for bathing or shower needs. Additionally, staff interviews confirmed that R1 was offered showers twice a week and provided with sponge baths as an alternative. Based on the gathered information, there is insufficient evidence to support the allegation that staff did not meet R1’s bathing needs. Therefore, this allegation was UNSUBSTANTIATED. {3 of 6} Allegation - Staff did not ensure a resident was properly fed The investigation into this allegation consisted of review of facility records, interviews with staff and review of documentation related to R1’s bathing schedule and care. Review of the Resident Assessment dated 07/16/2024 indicates that R1’s care plan for meals was labeled as "minimal," with the requirement for assistance with cutting food, encouragement for hydration, and supervision due to R1’s special dietary needs. These included a mechanical soft meal, avoidance of sugary desserts, and the need for thin liquids due to R1’s diabetes and lactose intolerance. R1’s care plan specifically outlined these requirements, and it was the responsibility of the facility staff to ensure the care plan is followed. Interview with W1 claimed that on 07/14/2024, staff reported that R1 had not eaten breakfast or lunch, and that staff had forgotten R1 was diabetic, leaving R1 without food until the W1 intervened. However, interviews with facility staff, including staff members S2 and S3, provided additional information. Statement from S2 revealed that R1 was offered food three times a day, with snacks, and that when R1 was tired or uninterested in eating, staff would either try to hand-feed R1 or leave food nearby for R1 to eat independently. S2 confirmed that R1 always had access to food, and there was never a failure to offer meals. S3’s statement further supported this, detailing how R1 had been sleeping throughout the day on 07/15/2024, and that R1’s family had requested staff not to disturb R1 during these periods of deep sleep. S3 confirmed that snacks and ice water were provided, in case R1 woke up hungry. Review of the facility’s documentation and progress notes indicated that R1 had been monitored for vital signs, though there was a noted discrepancy regarding blood sugar monitoring. However, no direct evidence was found in the records to suggest that R1 was not offered food or hydration. Based on these findings, there is no sufficient evidence that staff did not provide adequate meals or assistance with feeding to R1. While there may have been lapses in documentation and monitoring, these do not directly support the allegation of neglecting R1’s basic nutritional needs. Therefore, the allegation is UNSUBSTANTIATED. {4 of 6} Allegation - Staff left a resident unattended The investigation into this allegation consisted of interviews with facility staff and other relevant parties. Interview with W1 revealed that R1 reported being left alone for five hours without staff checking in and that R1 felt thirsty but was unable to get up. Interviews with multiple facility staff consistently indicated that staff were attentive and followed regular check-in procedures. Staff reported that they generally checked on residents every hour, and more frequently if necessary, depending on the resident’s individual needs and mobility. Interview with staff member S1 confirmed that most residents, including R1, spent much of the day in the common area under staff supervision. Residents who chose to stay in their rooms were checked on after every meal and monitored by motion detectors that alerted staff if residents moved. S1 further stated that staff would often check on residents anytime they passed by their rooms, in addition to the standard hourly checks. Interview with S2 similarly indicated that staff were in frequent contact with residents, aiming to check on them hourly and monitoring for signs of medical concerns, such as pressure injuries. S2 also explained that residents like R1 wore briefs, which staff checked and changed every two hours or sooner if needed. S3 added that residents were generally checked on every 30 to 45 minutes when in their rooms, with the assistance of motion detectors to alert staff of movement. Additional interviews with staff members (S4, S5, S6) consistently confirmed that hourly rounds were conducted, residents were checked on regularly, and those with mobility issues, like R1, received assistance as needed. S6 further explained that R1 was a fall risk, used a walker, and was regularly monitored through both direct staff supervision and motion detectors. Given the consistent staff reports regarding the frequency of resident checks, the use of motion detectors, and the regular visual supervision of residents in common areas, there is insufficient evidence to support the allegation that R1 was left unattended for an extended period. Therefore, the allegation is UNSUBSTANTIATED. {5 of 6} Allegation - Staff did not ensure a resident consumed an appropriate amount of liquid The investigation into this allegation consisted of interviews and record reviews. According to review of R1’s Resident Assessment dated 07/16/2024, R1’s care plan indicated a "minimal" need for meal support, including assistance with cutting food and encouragement to stay hydrated. R1 was also prescribed a special diabetic diet with mechanical soft foods, thin liquids, and no sugary desserts, which the staff was aware of and worked to accommodate. Interview with staff S3 revealed that staff routinely left snacks and ice water within R1’s reach and continued to provide meals even when R1 appeared to have decreased appetite. S3 reported that although R1 sometimes ate only a few bites, staff never observed R1 outright refusing food, and meals were still provided regardless of R1’s intake. S3 also stated that on 07/15/2024, R1 was sleeping throughout the day per family instructions not to disturb, but meals, snacks, and water were still left nearby to ensure that R1 could access food and hydration if he woke up. Interview with W1 indicated expressed concerns that R1 had not eaten breakfast or lunch on 07/14/2024 and required assistance to eat, interviews with staff indicated that R1 was consistently provided food and water and that staff followed facility procedures to encourage consumption. Staff S1 confirmed that the facility did not formally document the amount of food and liquid consumed; however, all staff was to ensure residents had access to food and water throughout the day. Although the facility lacked documentation tracking R1’s food and fluid intake, there is no sufficient evidence demonstrating that staff did to offer or encourage proper hydration. Therefore, the allegation that staff did not ensure R1 consumed an appropriate amount of liquid is UNSUBSTANTIATED. Note that an unsubstantiated finding means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of this report and appeal rights were provided. {6 of 6} Further review of the MAR showed that the facility accurately documented the administration of medications and that the MAR orders matched the Medication Orders signed by R1’s Primary Care Provider on 07/03/2024. While LPA Valerio was unable to review physical medication bottles or packets due to the resident no longer being at the facility the documentation on file supports that staff followed the physician’s written instructions. Additionally, a review of R1’s progress notes revealed that while blood sugar monitoring was not documented—due to not having a physician order for glucose testing—other vitals such as temperature, pulse, blood pressure, respiratory rate, and oxygen saturation were recorded. Based on the information gathered throughout this investigation, here is no evidence to support that staff mishandled R1’s medication administration. Staff administered medications according to the documented physician orders, and no direct errors in medication handling by the facility were identified. Therefore, the allegation is UNFOUNDED. A finding of unfounded means the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview was conducted with Guadalupe Ramirez and a copy of this report was provided. {2 of 2}