F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
Based on observation, interview and record review, the facility failed to provide resident safety for 1 resident
(Resident 1) when Resident 1 eloped (leaving the facility unsafely or unescorted) from the facility ' s exit
door which was equipped with an audible alarm.
As a result, Resident 1 had a successful elopement and there was the potential risk for the elopement of
other residents.
Findings:
On 11/22/23 the Department of Public Health received a facility report of an elopement for Resident 1 on
11/22/23 at 4:30 A.M.
During a review of Resident 1 ' s facility record on 11/22/23 at 7:05 A.M., the record indicated .around
4;30[sic] am resident up on wheelchair and verbally responsive, no c/o[sic] and any discomfort.at[sic]
5Am[sic] went to resident room and unable to find resident on her room checked the whole building. But
resident nowhere to found and call 911 and informed resident is missing and gave description of resident .
During a review of Resident 1 ' s facility record on 11/23/23 at 7:41 A.M., the record indicated, .Spoke to
Sheriff .Deputy will give the facility a call if they find the resident. If ever they don ' t call. That means she is
not found yet .
On 11/22/23 at 1: 38 P.M., an observation of the facility was conducted. The facility building had two
entrances/exits. The facility entrance/exit had one main entrance with steps from outside and one
entrance/exit with a ramp from outside. These two entrances/exits were connected to the two hallways in
the building where resident rooms were located.
On 11/22/23 at 2: 45 P.M., a phone interview was conducted with CNA 1 with the DON 1 present. CNA 1
stated Resident 1 was last seen on 9/2/23 around 4:30 A.M. near the hallway in a wheelchair. CNA 1 stated
around 5:20 A.M. to 5:30 A.M., LN 2 was looking for Resident 1. CNA 1 stated he was making rounds on
the other side of the building on the other hallway. CNA 1 stated he was inside another resident's room
attending to the morning care and could not hear when the entrance/exit audible alarm sounded.
On 11/22/23 at 3:30 P.M., an observation and interview was conducted with CNA 2. The entrance/exit with
ramp from outside made an audible alarm when opened. CNA 2 stated the purpose of the audible alarm
was to alert staff when residents were going out the building.
(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
12/18/2023
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)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
On 11/22/23 at 3: 39 P.M. an observation and interview was conducted with LN 1. LN 1 demonstrated how
the audible alarm could be heard as long as the entrance/exit door was held open. LN 1 stated the audible
alarm was to alert staff and prevent elopement of residents.
On 11/22/23 at 3: 40 P.M. a phone interview with LN 2 was conducted with the DON 1 present. LN 2 stated
Resident 1 was out of bed on 11/22/23 early around 4:30 AM. to 5:30 A.M. LN 2 stated Resident 1 was
looking for coffee but informed her the kitchen was still closed. LN 2 stated this was during LN 2 ' s med
pass (administration of medications to residents). LN 2 stated when it was time to give medication to
Resident 1, Resident 1 was nowhere to be found. LN 2 stated we looked for Resident 1 in every room and
around the building. LN 2 stated around 4:30 to 5 A.M. he was on the other side of the building. LN 2 stated
the entrance/exit doors were closed which meant no one from outside could open them. LN 2 stated people
from inside the building could push open the entrance/exit door per fire safety compliance. LN 2 stated the
entrance/exit door audible alarm was on at the time of Resident 1 ' s elopement. LN 2 stated Resident 1
must have eloped from the entrance/exit with ramp outside because he was passing medications on the
other side of the building and Resident 1 was in a wheelchair. LN 2 stated the CNAs working that time were
providing care in other resident rooms. LN 2 stated the purpose of the audible alarm was to alert staff that
someone was going out the entrance/exit door. LN 2 stated the employees were not able to hear the
audible alarm when inside other resident ' s rooms and Resident 1 eloped as a result of staff not hearing
the audible alarm.
Event ID:
Facility ID:
056062
If continuation sheet
Page 2 of 2
