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Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Springs Health And Rehabilitation Center during CMS and state inspections, most recent first.
The facility did not provide required notice of transfer or discharge to the State LTC Ombudsman prior to the planned discharge of three residents with complex medical needs, despite facility policy and federal requirements. Staff interviews confirmed the omission, and there was no documentation in the records that the Ombudsman was notified before the discharges.
A resident admitted for hospice care with dementia and Parkinson's disease was prescribed lorazepam and quetiapine for anxiety and psychosis, but staff did not initiate monitoring for targeted behaviors or medication side effects until two days after starting the medications. Nursing staff and leadership confirmed that monitoring should have begun with the initiation of psychotropic medications, as required by facility policy.
A resident with a history of heart failure and kidney disease was transferred to a hospital due to low blood pressure and oxygen levels, but the facility failed to notify the responsible person and emergency contacts. The resident was admitted to the ICU and passed away shortly after. The facility's DON acknowledged the communication lapse, as the charge nurse assumed others had notified the family, contrary to the facility's policy.
A resident with acute congestive heart failure and other conditions was transferred to a GACH due to low blood pressure and oxygen levels. The facility failed to notify the resident's family of the transfer, resulting in the family discovering the resident's absence the following day. The resident was admitted to the ICU and passed away shortly after. The DON acknowledged the communication lapse, as the LVN responsible assumed others had notified the family.
A resident with atherosclerotic heart disease and polyneuropathy did not receive pain medications as ordered, leading to unmanaged pain. The MAR showed morphine sulfate was given for moderate pain and tramadol for mild and severe pain, contrary to physician orders. The DON confirmed the discrepancy, and the facility's policy emphasized proper medication administration and pain assessment.
A resident with a known allergy to aspirin was administered the medication for 19 days due to a failure to update the allergy list, resulting in a severe allergic reaction and hospitalization. Despite the resident's history, the facility did not prescribe medication to treat the allergic reaction symptoms, leading to a life-threatening condition.
The facility failed to ensure accurate MDS assessments for two residents, one with unplanned weight loss inaccurately coded as a physician-prescribed regimen, and another with severe cognitive impairment whose use of bed and wander alarms was not reflected in the MDS. Interviews confirmed the discrepancies between documented care and MDS coding.
A facility failed to ensure staff donned PPE before entering the room of a resident on contact precautions for MRSA. Despite a policy requiring gloves and gowns, a CNA entered the room without PPE. The resident was admitted with right foot osteomyelitis and was under contact isolation. Interviews confirmed staff awareness of the precautions, yet the protocol was not followed.
A resident with severe cognitive impairment and other mental health conditions was verbally abused by a CNA, who used explicit language towards the resident in the hallway. Multiple staff members confirmed the incident, and the CNA was terminated following an investigation.
The facility failed to report an incident of verbal abuse towards a resident to the CDPH within the required two-hour timeframe. Multiple staff members overheard the abuse, but the incident was not reported to the DSD until several hours later, resulting in a delay in notifying the CDPH. The resident involved has severe cognitive impairment and was exhibiting increased confusion and agitation at the time.
A facility failed to remove a CNA from patient care after the CNA was witnessed verbally abusing a resident with severe cognitive impairment. Despite immediate knowledge of the abuse, the CNA remained in the facility for approximately two hours, violating the facility's abuse prevention policy.
Failure to Notify Ombudsman Prior to Resident Discharge
Penalty
Summary
The facility failed to provide a copy of the notice of transfer or discharge to the State Long-Term Care Ombudsman prior to the planned discharge for three sampled residents. For each resident, documentation showed that the resident and their representative were notified of the discharge, and the discharge was carried out as planned. However, there was no evidence in the records that the Ombudsman was notified prior to the discharge, as required by facility policy and federal regulations. Interviews with facility staff, including the Social Worker, Case Manager, and Assistant Administrator, confirmed that the process for notifying the Ombudsman was not followed, with explanations including uncertainty about the Ombudsman's coverage and issues with email communication. The residents involved had significant medical conditions, including hemiplegia and hemiparesis following cerebral infarction, metabolic encephalopathy, dementia, acute osteomyelitis, and dissection of the descending thoracic aorta. Despite the facility's policy requiring notification of the Ombudsman and documentation of such notification in the medical record, this step was omitted for all three residents prior to their discharge. The facility's own policies also require that residents and their representatives be informed of their right to appeal the discharge, including contact information for the Ombudsman, but the lack of Ombudsman notification was a clear deficiency in the discharge process.
Failure to Monitor Behaviors and Side Effects for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure appropriate monitoring of a resident who was admitted under general in-patient hospice care with diagnoses including dementia, Parkinson's disease, and uncontrolled behaviors posing a danger to self and others. Upon admission, the resident was prescribed psychotropic medications, specifically lorazepam for anxiety, restlessness, agitation, and shortness of breath, and quetiapine fumarate for psychosis and unprovoked physical behavior. However, there was no documented evidence that monitoring for targeted behaviors such as anxiety and psychosis, or for side effects related to the use of these psychotropic medications, was initiated until two days after admission. Interviews with nursing staff and facility leadership confirmed that monitoring for behaviors and side effects should have been conducted from the time the medications were started. The facility's own policy required staff to monitor for adverse side effects associated with psychotropic medication use. The lack of timely monitoring was acknowledged by the RN, ADON, LVN, and DON, all of whom stated that such monitoring was expected and should have been implemented as soon as the medications were ordered.
Failure to Notify Family of Resident's Hospital Transfer
Penalty
Summary
The facility failed to notify the responsible person (RP) and emergency contacts of a resident's change of condition and subsequent transfer to a general acute care hospital (GACH). On January 17, 2025, the resident experienced low blood pressure and low oxygen levels, prompting the facility to initiate intravenous fluid hydration and consider an X-ray. The RP was informed of the low blood pressure and potential X-ray but was not updated about the resident's transfer to the hospital. The following day, a family member discovered the resident was not in their room and was informed by staff that the resident had been transferred to the GACH due to low blood pressure and low oxygen levels. The resident, who had a medical history including acute congestive heart failure, atrial fibrillation, and chronic kidney disease, was admitted to the intensive care unit at the GACH and passed away on January 19, 2025. The facility's Director of Nursing (DON) acknowledged the communication lapse, stating that the charge nurse, LVN 1, assumed other nurses had notified the RP, which did not occur. The facility's policy requires notifying the resident's representative of significant changes in health status, which was not adhered to in this case.
Failure to Notify Family of Resident's Hospital Transfer
Penalty
Summary
The facility failed to accurately document the notification of the Responsible Person (RP) regarding the transfer of a resident to a general acute care hospital (GACH). On January 17, 2025, the resident was transferred due to low blood pressure and low oxygen levels. However, the RP and family members were not informed of this transfer, leading to a lack of awareness about the resident's critical condition and subsequent admission to the Intensive Care Unit. The RP only discovered the transfer when a family member visited the facility the following day and found the resident missing from their room. The resident, who had been admitted to the facility with acute congestive heart failure, atrial fibrillation, and chronic kidney disease, passed away on January 19, 2025. The facility's documentation indicated that the RP was notified at 6:30 p.m. on the day of the transfer, but interviews and record reviews revealed that this notification did not occur. The Director of Nursing acknowledged the communication lapse, and it was found that the Licensed Vocational Nurse (LVN) responsible for the resident's care assumed that other nurses had informed the RP, which was not the case.
Failure to Administer Pain Medications as Ordered
Penalty
Summary
The facility failed to administer pain medications as ordered by the physician for a resident, leading to potential unmanaged pain. The resident, who was admitted with diagnoses including atherosclerotic heart disease and polyneuropathy, had specific orders for pain management. The care plan indicated that medications should be administered as ordered, with tramadol prescribed for moderate pain and morphine sulfate for severe pain. However, the Medication Administration Record (MAR) showed that morphine sulfate was given for moderate pain and tramadol was administered for mild and severe pain, contrary to the physician's orders. The Director of Nursing (DON) confirmed during an interview that the medications were not administered according to the physician's orders. The facility's policy on pain assessment and management emphasized the importance of administering medications as ordered and conducting comprehensive pain assessments. Despite this, the resident's pain was not managed appropriately, as evidenced by the hospice nurse's progress note indicating the resident's pain was not controlled with the current medication regimen. The resident also exhibited signs of distress, such as confusion, sadness, and refusal of wound care.
Failure to Prevent and Treat Allergic Reactions
Penalty
Summary
The facility failed to ensure that a resident received the necessary care and treatment to prevent and treat allergic reactions. The resident, who had a known allergy to aspirin, was administered the medication for a total of 19 days. This oversight occurred because the resident's allergy to aspirin was not listed in the facility's allergy list, despite being documented in previous medical records. The administration of aspirin led to the resident developing a severe allergic reaction, resulting in toxic epidermal necrolysis, a life-threatening condition. Interviews with facility staff revealed that the Licensed Vocational Nurse (LVN) and the Director of Nurses (DON) were aware of the resident's allergies, but the allergy list was not updated to include aspirin. The Medical Doctor (MD) acknowledged that the resident's allergy to aspirin was known, but the medication was continued due to its perceived benefits for the resident's stroke condition. The facility's failure to accurately document and communicate the resident's allergies led to the administration of a contraindicated medication, resulting in severe adverse effects. The resident's family expressed concerns about the administration of medications to which the resident was allergic. Despite the resident's history of allergic reactions, the facility did not prescribe or administer medication to treat the allergic reaction symptoms. The resident's condition worsened, leading to hospitalization for further evaluation and treatment. The facility's policies on monitoring and documenting adverse drug reactions were not adequately followed, contributing to the deficiency in care.
Inaccurate MDS Assessments for Nutrition and Dementia Care
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the status of two residents, leading to deficiencies in the areas of nutrition and dementia care. For one resident, the MDS inaccurately indicated that their weight loss was due to a physician-prescribed weight-loss regimen, despite the absence of any such order. Interviews with the MDS Coordinator, MDS Assistant, and the Director of Nursing confirmed that the resident's weight loss was unplanned and due to poor intake, and the MDS should have been coded accordingly. For another resident, the MDS did not accurately reflect the use of a bed alarm or a wander/elopement alarm, despite documentation in the resident's care plan and progress notes indicating their use. The resident had severe cognitive impairment and was at risk for falls and wandering, necessitating these interventions. The Director of Nursing acknowledged the need for accurate MDS assessments, highlighting the discrepancy between the documented interventions and the MDS coding.
Failure to Adhere to PPE Protocols for Contact Precautions
Penalty
Summary
The facility failed to ensure that staff properly donned personal protective equipment (PPE) before entering the room of a resident on contact precautions. The facility's policy, revised on September 1, 2023, required staff to wear gloves and gowns when entering the room of residents with infections transmitted by direct or indirect contact, such as MRSA. Despite this policy, a Certified Nursing Assistant (CNA) entered the room of a resident diagnosed with MRSA without wearing any PPE. The resident had been admitted from a hospital with a diagnosis of right foot osteomyelitis and was under contact isolation for a right foot wound. An observation on July 2, 2024, noted a sign on the resident's door indicating the need for contact precautions, including the use of gloves and gowns. During an interview, the CNA acknowledged awareness of the contact precautions but failed to comply. The Director of Nursing and the Administrator both stated that staff were expected to wear the appropriate PPE before entering rooms of residents on contact precautions. This incident highlights a lapse in adherence to established infection control protocols within the facility.
Verbal Abuse Incident by CNA
Penalty
Summary
The facility failed to ensure that a resident was free from verbal abuse when a CNA was witnessed using explicit language towards the resident in the hallway. The incident occurred on March 28, 2024, at around 4:30 a.m., when multiple staff members overheard CNA 2 telling the resident, 'Shut the fuck up, you are a grown woman, why are you acting like that?' The facility's Assistant Administrator confirmed that the verbal abuse was substantiated through their investigation, and CNA 2 was terminated as a result. The resident involved had severe cognitive impairment, dementia, anxiety disorder, psychotic disorder, and mood disorder, and was observed to be calm but easily awakened with no physical injuries noted. Interviews with various staff members, including CNA 1, CNA 3, and CNA 4, corroborated the incident. CNA 1 reported hearing the explicit language while attending to another resident, and CNA 3 and CNA 4 also confirmed hearing the verbal abuse from CNA 2. The facility's policy on abuse prevention emphasizes the importance of providing an environment that prohibits and prevents abuse, including the use of derogatory language. Despite these policies, the incident of verbal abuse occurred, highlighting a failure in supervision and staff behavior management.
Failure to Timely Report Verbal Abuse Incident
Penalty
Summary
The facility failed to report an incident of verbal abuse towards Resident A to the California Department of Public Health (CDPH) within the required two-hour timeframe. On March 28, 2024, at around 4:30 a.m., CNA 2 verbally abused Resident A by saying, 'Fuck you, you are a grown woman, why are you acting like this?' This incident was overheard by multiple staff members, including CNA 1, CNA 3, and CNA 4. However, the incident was not reported to the Director of Staff Development (DSD) until around 11:30 a.m. by CNA 1, and subsequently, the CDPH was not notified within the mandated two-hour period. The delay in reporting was confirmed during an unannounced visit on April 10, 2024, and through interviews with the Assistant Administrator (AADM) and other staff members involved. Resident A, who has severe cognitive impairment with a BIMS score of 3, was admitted to the facility with diagnoses including dementia, anxiety disorder, psychotic disorder, and mood disorder. The resident's progress notes indicated increased confusion, agitation, and aggressive behavior on the day of the incident. Despite the facility's policy requiring immediate reporting of any alleged abuse, the staff failed to comply, resulting in a delay in the investigation and reporting of the verbal abuse incident. This failure potentially placed Resident A and other residents at risk for further abuse.
Failure to Remove CNA After Verbal Abuse Incident
Penalty
Summary
The facility failed to ensure that a resident was free from further abuse when a CNA was not removed from all patient care after being witnessed verbally abusing a resident in the hallway. The incident occurred on March 28, 2024, when CNA 2 was overheard by multiple staff members telling Resident A, 'Fuck you, you are a grown woman, why are you acting like this?' Despite the immediate knowledge of the abuse, CNA 2 was not removed from the facility until approximately two hours later. This delay in action was confirmed by the Assistant Administrator and multiple staff members, including CNA 1, CNA 3, and CNA 4, who all provided consistent accounts of the incident and the failure to follow protocol by LVN 1, who did not remove CNA 2 immediately after the abuse was known. Resident A, who has severe cognitive impairment with a BIMS score of 3, along with diagnoses of dementia, anxiety disorder, psychotic disorder, and mood disorder, was the victim of the verbal abuse. The resident's progress notes indicated increased confusion, agitation, and aggressive behavior on the day of the incident. The facility's policy on Abuse Prohibition and Prevention, which mandates the immediate suspension of personnel involved in abuse allegations, was not followed, leading to a potential risk for further abuse to Resident A and other residents.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Murrieta
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Murrieta Health And Rehabilitation Center | 2.6 mi | — | 21 | 0 |
| Temecula Healthcare Center | 6.4 mi | — | 7 | 0 |
| Menifee Lakes Post Acute | 12 mi | — | 8 | 0 |
| Fallbrook Skilled Nursing | 12.1 mi | — | 2 | 0 |
| Hemet Hills Post Acute | 16.6 mi | — | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.