Health inspection·December 18, 2023

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. Page 1 of 2 056062 056062 12/18/2023 Amaya Springs Health Care Center 8625 Lamar Street Spring Valley, CA 91977

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. 056062 Page 2 of 2