Health inspection·June 18, 2024

F 0660 Plan the resident's discharge to meet the resident's goals and needs. 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 fully prepare three of four sampled residents, (1, 2, 4) for discharge in accordance with the facility discharge policy. Residents Affected - Few Findings: A review of the facility policy entitled Discharge and Transfer of Residents revised February 2018 indicated, .When a resident is admitted to the Facility, Facility Staff will initiate a discharge plan. The resident/ resident representative will be provided with a Notice of Proposed Transfer and Discharge 30 days prior to discharge or as soon as practicable. When the resident is near a planned discharge, the Interdisciplinary Team (IDT) will complete a Discharge Summary/ Post Discharge Plan of Care. Nursing Staff will complete a Discharge Summary/ Post Discharge Plan of Care for each resident, which will include a recapitulation of the resident ' s stay and final summary of the resident ' s status . 1. Resident 1 was admitted to the facility on [DATE] with diagnoses that included bilateral lower extremity lymphedema (a condition in which fluid that comes from the liquid part of the blood builds up in tissues causing swelling) with cellulitis (an infection of the skin) and maggot infestation and homelessness. Resident 1 was discharged from the facility on 4/6/24. Resident 1 was not provided with a Notice of Proposed Discharge. 2. Resident 2 was admitted to the facility on [DATE] with diagnoses that included rhabdomyolysis (breakdown of muscle tissue that releases chemicals into the blood that can cause kidney damage), difficulty in walking, and need for assistance with personal care. Resident 2 was discharged from the facility on 4/1/24. Resident 2 received a Notice of Proposed discharge on [DATE], the same date as her discharge. 3. Resident 4 was admitted to the facility on [DATE] with diagnoses that included cognitive communication deficit (difficulty communicating because of injury to the brain), toxic encephalopathy (brain dysfunction caused by exposure to a toxin), acute systolic heart failure (failure of the bottom left chamber of the heart), obstructive sleep apnea (a disorder in which a person frequently stops breathing during sleep), acquired absence of right leg below knee (removal of the leg below the knee), unsteadiness on feet, and need for assistance with personal care. Resident 4 was discharged from the facility on 4/23/24. Resident 4 received a Notice of Proposed discharge on e day prior to discharge. Direct care staff for Residents 1, 2 and 4 were not available for interview during the on-site investigation. (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 06/18/2024 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)