Inspection Reports for
The Gardens at Laguna Springs

The complaint investigation was substantiated for the allegation that a resident sustained multiple pressure injuries. Other allegations including staff neglect resulting in hospitalization, failure to meet bathing needs, improper feeding, leaving a resident unattended, failure to ensure adequate hydration, and medication mishandling were unsubstantiated or unfounded.

The investigation substantiated that a resident sustained multiple pressure injuries while under care. All other allegations including staff neglect leading to hospitalization, unmet bathing needs, improper feeding, leaving a resident unattended, inadequate hydration, and medication mishandling were unsubstantiated or unfounded based on interviews, record reviews, and observations.

Six new complaints have been filed against the facility since the last meeting on 9/30/2022.

Since the last meeting, six new complaints have been filed and four Type A deficiencies cited related to Personal Rights of Residents, Administrator Qualifications and Duties, Basic services care and supervision, and Plan of Operation. The facility agreed to update policies and provide staff training to bring the facility into compliance.

The visit followed up on deficiencies identified during a complaint investigation dated 2022-09-19, control number 27-AS-20220919221525.

The facility was found to have multiple deficiencies including blocking a resident's doorway with a couch, inadequate administrator qualifications, failure to provide adequate supervision resulting in resident injuries, and failure to follow the plan of operation regarding combative and aggressive resident behavior.

The complaint investigation was substantiated for inaccurate medication logging but unsubstantiated for failure to follow modified diets and glucose testing orders. The substantiated allegation was related to medication logs not being accurately maintained, posing a potential health and safety risk.

The investigation substantiated that staff did not accurately log medication administration records (MARs) for resident R1, with multiple missing staff signatures on MARs for September 2022. The allegation that staff were not dispensing medication as prescribed was previously substantiated and resolved. Other allegations regarding modified diet and glucose testing were found unsubstantiated.

The facility failed to properly secure the delayed egress door, allowing R1 to exit unsupervised for approximately 9-10 minutes. The door has since been fixed and staff received in-service training on resident checks and door security. Deficiencies were cited related to basic service requirements and resident safety.

The visit was triggered by a complaint investigation concerning the lack of a diabetic diet menu and diabetic care plan at the facility. The deficiency related to the diabetic menu was dismissed as of 06/28/2022 after a Plan of Correction was submitted.

During the visit, the Licensing Program Analyst observed the Diet and Nutrition Care Manual and reviewed care plans for five diabetic residents. It was found that the facility does not have a specific diabetic diet menu, but diabetic diets are followed according to guidelines from the Diet and Nutrition Care Manual and diabetic protocols. No violations or deficiencies were issued during this visit.

The complaint investigation was substantiated for allegations that resident missed medications and staff did not follow physician's orders. The allegation that staff falsified medication records was unsubstantiated.

The investigation substantiated that resident R1 missed his morning insulin dose and was given insulin two hours late on separate occasions, posing an immediate health and safety risk. Another allegation of staff falsifying medication records was found unsubstantiated due to insufficient evidence.

The complaint was substantiated based on evidence including review of resident care records, medication administration records, observations of insufficient staffing during activities and meals, and interviews. The preponderance of evidence supported the allegations.

The investigation found that care was not completed on some days for resident 0, medications were not administered as required, and the facility lacked adequate staff to meet residents' needs during activities and meal times. Residents were observed unsupervised or not properly assisted, posing potential health and safety risks. The allegations were substantiated.

The visit was complaint-related, triggered by concerns about Resident 1's care, including failure to reassess after significant health changes, inadequate monitoring of suicidal ideations, and failure to address elopement and fall risks. The complaint was substantiated by observed deficiencies and incidents.

The facility failed to conduct reassessments after significant health changes for Resident 1, did not adequately monitor suicidal ideations, and did not address elopement and fall risks, resulting in multiple falls including one with serious injury. Additionally, cleaning cart compartments were left unlocked, making toxic cleaning supplies accessible to residents.

The complaint investigation was triggered by allegations including a water leak in a resident's room, failure to safeguard residents' personal belongings, inadequate laundry service, failure to prevent inappropriate behaviors, a resident sustaining a rash, failure to notify authorized representatives of injury, and improper cleaning of resident rooms. The investigation substantiated the first three allegations but found insufficient evidence to substantiate the others.

The investigation substantiated that the facility failed to maintain a resident's AC unit in good repair, resulting in water leakage and unsanitary conditions, and failed to safeguard residents' clothing and provide adequate laundry services. Other allegations related to preventing inappropriate behaviors, notification of injuries, and room cleanliness were found unsubstantiated.

The facility was found to have staff members not fingerprint cleared as required and lacked a certified administrator, posing immediate health and safety risks to residents. Deficiencies were cited under California Code of Regulations, Title 22, with civil penalties assessed.

The complaint was substantiated based on evidence that the eviction was unlawful and that staff did not meet dementia training requirements.

The investigation substantiated that a resident was unlawfully evicted without proper documentation and that several employees did not have timely dementia training documentation, resulting in non-compliance with training requirements.