Springs Road Healthcare

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety for a census of 58 when:1. Dietary Supervisor (DS) and Dietary Aide (DA) 1 were not wearing a beard net while inside the kitchen.2. [NAME] residue was present on the floor surface of the food warmer.3. The top surface of the knife holder had accumulated dust and residue.4. Black residue was present on the floor beneath the dishwasher area.5. Three quarter size hotel pans were stacked wet while stored away.6. Flies were present in the kitchen area and dry storage area.7. Four lunch trays containing uncovered desserts were transported through the hallway. These failures had potential to cause food-borne illnesses in a highly susceptible population who received food from the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to secure resident medical records containing Protected Health Information (PHI, any individually identifiable health information held, transmitted, or maintained by the health facility), for four Residents (Resident 11, Resident 39, Resident 59, and Resident 69) out of census of 58 residents, when the Treatment Nurse (TN) left printed wound treatment records on top of an unattended cart. This failure had the potential for unauthorized access by visitors, families, and other residents to Resident 11's, Resident 39's, Resident 59's, and Resident 69's medical records containing PHI.

Inspectors wroteBased on interview and record review the facility failed to ensure services meet professional standards of quality for four residents (Resident 16, Resident 39, Resident 74, and Resident 6) for a census of 18, when:Medications were given without meals, as prescribed for Resident 16, Resident 39, and Resident 74;Medication with a box warning ((also known as black box warning- the strictest, most serious safety alert mandated by the U.S. Food and Drug Administration (FDA [a federal agency of the United States government responsible for protecting public health]) was being administered for Resident 6 without monitoring for side effects to highlight severe, life-threatening, or permanently disabling risks)). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were properly labeled and stored in accordance with the accepted professional principles and current standard of practice for Resident 33 and Resident 22 and for census of 58 when:1. Resident 33 was found to have medications at the bedside.2. An opened, unlabeled box of Lidocaine Patches 5% was found in the medication cart, containing one unopened packet and 2 opened packets; and3. Resident 22's white envelope containing twenty-five dollars in cash were found inside the narcotic box in medication cart. These failures had the potential for diversion of unlabeled medications and risk resident's safety. Stored personal valuables in the narcotic cabinet compromise the security of the controlled medications.1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper infection control practices were implemented when: 1. Licensed Nurse (LN) 1 did not wear gown and gloves as indicated in Enhanced Barrier Precaution (EBP, an infection control intervention to reduce transmission of multi-drug-resistant organisms) guidance before entering the room and helped reposition Resident 9; 2. LN 3 took Resident 75's blood sugar and used disinfectant to clean the glucometers (hand-held devices that measure a person's blood glucose/sugar levels) that were not recommended by the manufacturer; Infection Preventionist (IP) B sanitized the glucometer using alcohol wipes before and after resident use; LN 3 stated she/he sanitized glucometer before and after resident use, using the alcohol wipes or the purple-top wipes (germicidal wipes); and, 3. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to develop a communication/language barrier (an obstacle that prevents two or more people from understanding each other, that can lead to miscommunication) comprehensive care plan (CP- a personalized, written document that outlines how staff will manage a resident's medical, physical, and personal care needs daily) for one resident (Resident 6) out of 18 sampled residents, when there was no documented evidence of Resident 6's care plan addressing his preference to communicate in Spanish. This failure had the potential for miscommunication and misunderstanding when discussing medications, treatments, and care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure its medication error rate remained below five percent (5%) for two residents (Resident 25 and Resident 3) out of 18 sampled residents, when:Licensed Nurse (LN) 3 did not wear gloves when administering prescribed hazardous medication; and,LN 1 did not follow the physician's order when administering Resident 33's prescribed medications. These failures resulted in the facility's medication error rate of 6.45%, which had the potential for harm, worsening of existing conditions, or the development of new illnesses for Resident 25 and Resident 33.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents' (Resident 1) Physician Orders for Life-Sustaining Treatment (POLST- a medical order that tells healthcare providers what treatments a patient wants or does not want, especially in serious illness or end-of-life care) was not implemented following the resident's return from the emergency room. This failure has resulted in Resident 1's POLST not implemented and reduced the facility's potential to provide necessary care and services to attain or maintain the resident's highest practicable wellbeing.

Inspectors wroteBased on interview and record review, the facility failed to provide professional standards of care for one of three sampled residents (Resident 1) when the x-ray (used to detect broken bones) order for Resident 1 was not carried out correctly. This failure resulted to an x-ray performed on Resident 1's right knee instead of the left knee. Resident 1's x-ray on the left knee indicated a fracture of the distal femur (a break in the thigh bone just above the knee joint) which required further evaluation and treatment in the acute care hospital. A review of the admission Record indicated Resident 1 was admitted April of 2023 with diagnoses including type 2 diabetes mellitus with diabetic polyneuropathy (long -term high blood sugar damages multiple nerves which leads to pain, tingling, burning, or numbness in the feet or hands) and weakness. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of abuse was reported timely within the required timeframe for two of four sampled residents (Resident 1 and Resident 2) when an allegation of abuse was not reported to the California Department of Public Health (CDPH). This failure of timely reporting had the potential to cause a delayed response by enforcement agencies to ensure resident safety. During a review of Resident 1's admission record (AR), the AR indicated Resident 1 was admitted to the facility in June 2025 with multiple diagnoses including gastroenteritis (an inflammation of the stomach and intestines, causing symptoms like nausea, vomiting, diarrhea, abdominal cramps). [...]

Inspectors wroteBased on observation, interview and record record review, the facility failed to ensure four of 21 sampled residents (Residents 108, 53, 1, and 10) in a census of 61 privacy when curtains did not reach around personal space and vertical blind slats were missing. These failures resulted Resident 10 felt ashamed and increased the potential for increased feelings of reduced self esteem and embarrassment.

Inspectors wroteBased on observation, interview and record review, the facility failed to accurately label medications for a census of 61 when: 1. Resident 54's insulin order was not reflected correctly on the medication label, and 2. The medications lacked resident labels and open dates, and the label was unclear and difficult to read. These failures had the potential for residents to receive the wrong medications, incorrect dosages of medications, and expired medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure an accurate inventory of narcotics (a medication that is used to relieve pain) for one of three sampled residents (Resident 35) when two tablets of narcotics were not entered into the residents Medication Administration Record (MAR, document that serves as a legal record of the drugs administered to a resident). This failure had the increased potential for drug diversion (when healthcare staff obtain and use prescription medicines illegally), and inaccurate monitoring of the amount and frequency of medications given to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 24 sampled residents (Resident 34) received a thorough monthly pharmacy medication regimen review (MRR). This failure placed Resident 34 at risk for receiving unnecessary, ineffective, and/or excessive dose of Lorazepam (a psychotropic medication to treat anxiety).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure infection prevention and control program were maintained and to provide a sanitary environment when two lounge chairs in the dining/activity room were worn out, threadbare and available for resident use. This failure increased the risk for the transmission of communicable diseases.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the physician ' s order were followed to properly manage one out of two sampled resident's (Resident 1) pain. This failure resulted in inadequate pain management for Resident 1.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure there was an updated discharge plan for one out of two sampled residents (Resident 1) when: 1. There were no regular re-evaluation of Resident 1 to identify changes that require the modification his discharge plan. The discharge plan was not updated, as needed, to reflect these changes. 2. Resident 1 was not involved in the development of the discharge plan and was not informed of the final discharge plan. 3. There was no documentation that Resident 1 has been asked about his plans in returning to the community after he completed skilled services on 12/15/24. These failures to fully prepare Resident 1 be discharged for discharge from the facility could result to safety issues, prevent Resident 1 to be an active partner to effectively transition him to post-discharge care to prevent potential readmissions.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure one out of two sampled residents (Resident 1) was safe during transfer when four certified nursing students were allowed to assist a staff member to transfer Resident 1 from his bed to the shower chair. This failure resulted to Resident 1 to fall on 11/15/24.

Inspectors wroteb. Review of the admission Record indicated, Resident 34 was admitted to the facility on [DATE], with diagnoses which included chronic pain syndrome. During a concurrent observation and interview with Resident 34 on 6/5/23 8:40 AM, a white oblong pill sitting on a plastic spoon was on a table next to Resident 34's bed. When asked about the pill, Resident 34 stated, That's my Percocet! (opiate/narcotic pain medication) and immediately picked up the pill, put it in his mouth, and swallowed it. Resident 34 stated the night shift nurse, Licensed Vocational Nurse 5 (LVN 5) brought him the Percocet a few hours prior. Resident 34 reported, Sometimes they watch me swallow the pills but sometimes they don't, and I can keep it for later. During a concurrent interview and record review with (LVN 2) on 6/5/23 at 9:44 AM, Resident 34's Medication Administration Record was reviewed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure professional standards of practice were followed for the care and maintenance of a PICC (Peripherally Inserted Central Catheter) (a long catheter that is inserted through the skin into a large vein just above the heart used for administering antibiotics or fluid) for one of 17 sampled residents (Resident 28). As a result of this failure, Resident 28 was at risk for infection and complications from his PICC.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were in stock and available to administer, for one unsampled resident (Resident 250). As a result of this failure, Resident 250 was at risk for potential complications of not receiving medications timely.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide food at an appetizing temperature for 3 of 17 sampled residents (Resident 9, Resident 28, Resident 100) and one unsampled resident (Resident 10). This failure resulted in residents' dissatisfaction with their meals and the potential to decrease the amount of food consumed by residents, therefore reducing nutritional support aiding in recovery from illness or injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to keep the kitchen and equipment clean, free from residual food build up and grime. This failure resulted in unsanitary work areas where pathogens could potentially affect the residents with food-borne illness.

Inspectors wroteBased on interview and record review, the facility failed to provide evidence of annual tuberculin skin test (a test to determine the presence of infection with tuberculosis and bacterial infection of the lungs) results for Infection Preventionist 1(IP 1). This failure had the potential to spread undetected Tuberculosis (TB) infection (spread through the air from one person to another when a person with TB coughs and speaks) to a universe of 55 Residents in the facility.