Health inspection·April 5, 2024

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide supervised and assisted ambulation to one of one sampled Residents, (1), at high risk for falls. This failure resulted in Resident 1 experiencing an unwitnessed fall that resulted in a broken bone in her left ankle. Findings: Resident 1 ' s admission Record indicated admission to the facility on 5/5/22, and included diagnoses of paranoid schizophrenia (a pattern of thoughts, feelings and behaviors that include suspicion of others), generalized muscle weakness, essential hypertension (high blood pressure often requiring medication that can have side effects increasing risk for falls) and cognitive communication deficit (difficulty with thinking and communication). A review of the Minimum Data Set (MDS) section GG dated 11/11/23 indicated Resident 1 required supervision or touching assistance (assistance from one person) for toileting hygiene, lower body dressing, chair and bed to chair transfer, walking 10 feet or more. The MDS indicated Resident 1 required set up or clean up assistance with toilet transfer. A review of facility Change of Condition (COC) note dated 1/26/23 indicated Resident 1 had an unwitnessed fall on her right knee on the physical therapy patio. A review of the facility COC note dated 2/28/23 indicated Resident 1 had a witnessed fall on the floor with her walker directly in front of her. A review of the facility COC note dated 3/14/23 indicated Resident 1 had an unwitnessed fall and was found on the left side of her bed with her head between her bed and the side dresser, Patient said she hit her head and has level seven out of ten pain in her right leg. A review of the facility COC noted dated 5/3/25 indicated Resident 1 had an unwitnessed fall and was found kneeling by her bedside. A review of the facility COC note dated 2/2/24 indicated Resident 1 had an unwitnessed fall and was found on the floor in front of toilet with her underwear on but pants around calves and stated I fell. ' An observation of Resident 1 ambulating in the hallway with a walker was conducted on 2/15/24 at 1:10 P.M. During the observation, Resident 1 did not have assistance or supervision from a staff member. Resident 1 was noted to walk with a limp on her left side. In an interview with the Director of Nursing (DON) conducted on 2/15/24 at 1:30 P.M., the DON stated at the time of the most recent fall (Resident 1) had a Brief Interview for Mental Status (BIMS) of (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 04/05/2024 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)