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