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Inspection visit

Health inspection

THE SPRINGS POST-ACUTECMS #0552971 citation on this visit
1 citation recorded

Inspector’s narrative

What the inspector wrote

This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

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 (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055297 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055297 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/07/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Springs Post-Acute 10625 Leffingwell Road Norwalk, CA 90650 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 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. Event ID: Facility ID: 055297 If continuation sheet Page 2 of 2

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Citations

1 citation recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0580GeneralS&S Dpotential for harm

    F580 - Notification of Changes

    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

FAQ · About this visit

Common questions about this visit

What happened during the January 7, 2026 survey of THE SPRINGS POST-ACUTE?

This was a inspection survey of THE SPRINGS POST-ACUTE on January 7, 2026. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at THE SPRINGS POST-ACUTE on January 7, 2026?

Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) tha..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

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Next steps

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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.