Health inspection·August 22, 2023

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their abuse policy when Resident 1 claimed an allegation of sexual abuse. Residents Affected - Few This failure had the potential for Resident 1 to not receive the appropriate follow up care. Findings: Resident 1 was admitted to the facility on [DATE], per the undated admission Record. A record review was conducted on 7/27/23. Per a Minimum Data Set (an assessment tool) Basic interview for Mental Status (BIMS) score, dated 7/1/23, Resident 1 had mildly impaired cognition. Per an Alert Note, dated 7/26/23 at 11:42 A.M., Licensed Nurse (LN) 1 documented Resident 1 had reported being sexually assaulted the previous night. LN 1 documented she conducted an assessment and found no evidence of bruising, abrasions, or discoloration on Resident 1's skin. Per a Progress Note, dated 7/26/23 at 11:50 A.M., the Administrator (Admin) documented she had received a report that Resident 1 had been sexually assaulted by another resident. The Admin and LN 1 documented an interview with Resident 1. Per a Progress Note, dated 7/26/23 at 2:46 P.M., the Admin documented she had reported the allegation to the police, and alerted other agencies of the incident. Per a facility policy, revised March 2018 and titled, Abuse-Reporting & Investigations, Purpose To protect the health, safety, and welfare of facility residents by ensuring that all reports of resident abuse .and suspicion of crimes are promptly reported and thoroughly investigated .II. Immediate Action .iv. Upon receiving allegations of sexual abuse, the Administrator or designated representative will notify the Attending Physician to promptly examine the resident or obtain an order to transfer Resident to the acute hospital for examination . On 7/27/23 at 12 P.M., an interview was conducted with the Director of Nursing. The DON stated two nurses had examined Resident 1 following her allegation, but they had not requested the physician to either examine the resident or send her out to the hospital as directed by their policy. On 7/27/23 at 12:20 P.M., an interview was conducted with LN 1. LN 1 stated she had examined (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: 056062 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 056062 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Amaya Springs Health Care Center 8625 Lamar Street Spring Valley, CA 91977 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)