Health inspection·January 7, 2026

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Responsible Party (RP) 1 was notified when Resident 1 was started on Lantus ([insulin glargine] medication used to manage high blood sugar levels for people with diabetes mellitus [DM - a disorder characterized by difficulty in blood sugar control and poor wound healing]) for one of three sampled residents (Resident 1) on 12/8/2025.This deficient practice resulted in the violation of Resident 1's RP 1 rights to be informed and involved in treatment decisions which could lead to distrust toward the facility and its practices.Findings:During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including cerebral infarction ([stroke] loss of blood flow to a part of the brain), metabolic encephalopathy (temporary or permanent damage to the brain due to lack of glucose, oxygen, or other metabolic agent, or organ dysfunction) and type 2 DM.During a review of Resident 1's History and Physical (H&P), dated 8/29/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 8/14/2025, the MDS indicated Resident 1 had severe cognitive impairment (ability to think and reason) and was rarely or never able to understand and be understood by others.During a review of Resident 1's Order Summary Report (Physician's Orders), dated 1/7/2026, the Order Summary Report indicated an order was placed for Resident 1 to receive Lantus Subcutaneous (under the skin) Solution 100 units/milliliter ([mL] unit of measurement) 16 units subcutaneously at bedtime for type 2 DM and hold if blood sugar (BS) is less than 150, ordered on 12/8/2025.During a review of Resident 1's Medication Administration Record ([MAR] a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 12/2025, the MAR indicated Lantus Subcutaneous Solution 100 units/mL was administered to Resident 1 at 9 p.m. from 12/8/2025 through 12/31/2025.During a telephone interview on 1/7/2026 at 10:30 a.m., RP 1 stated she was notified by Resident 1's insurance company that Resident 1 was started on Lantus. RP 1 stated she was furious at the facility for not informing her of the new medication added to Resident 1's medication regimen. RP 1 stated the facility undermined her authority and right to contribute to Resident 1's plan of care. RP 1 stated she feels distrustful toward facility and fears they will continue to make changes in Resident 1's plan of care without her knowledge.During an interview on 1/7/2025 at 3:30 p.m., the Director of Nursing (DON) stated that based on his review of Resident 1's medical records, there was no documentation indicating RP 1 was notified when Lantus was added to Resident 1's medication regimen. The DON confirmed the records contained no documentation of any discussion with RP 1 regarding Lantus prior to its initiation.During a subsequent interview on 1/7/2025 at 3:40 p.m., the DON stated it is important to inform RP 1 about any changes to Resident 1's care because it is their right to be involved and it provides them with the opportunity to ask questions and support Resident 1's needs. The DON stated that Page 1 of 2 055297 055297 01/07/2026 The Springs Post-Acute 10625 Leffingwell Road Norwalk, CA 90650

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few timely communication also builds trust between RP 1 and the facility. The DON stated the failure to keep RP 1 notified of the addition of Lantus to Resident 1's medication violated RP 1's rights and caused her to distrust the facility and its practices.During a review of the facility's policy and procedure (P&P) titled, Change in Resident's Condition or Status, dated 5/2022, the P&P indicated the facility shall promptly notify the resident, her attending physician and representative of changes in the resident's medical/mental condition and or status. The P&P indicated, regardless of the resident's current medical or physical condition, a nurse or healthcare provider will inform the resident of any changes in her medical care or nursing treatments. 055297 Page 2 of 2