Health inspection·January 28, 2025

F 0880 Level of Harm - Minimal harm or potential for actual harm of regular flea and tick treatment and a formal bathing and grooming schedule. The AD acknowledged the facility policy on animals was not being followed. The AD acknowledged residents were at risk of being exposed to infectious diseases and parasites carried by fleas and ticks if treatments were not completed and the cat did not have a bathing schedule. The AD acknowledged that the cat was seen in the facility unsupervised. Residents Affected - Few During an interview at the facility on 1/28/25 at 3:53 PM, Certified Nursing Assistant (CNA) 1 stated the cat lays down in the nurse ' s station. CNA 1 stated the cat is put outside, unsupervised, to sleep at night. During an interview at the facility on 1/28/25 at 4:21 PM, Licensed Nurse (LN) 1 stated the activity department was responsible the cat ' s care. LN 1 stated the cat was allowed to roam inside and outside the facility. LN 1 stated the cat had been seen inside resident rooms. LN 1 stated there were multiple cats who wandered outside the facility. During an observation and interview on 1/28/25 at 4:52 PM at the facility, Resident 1 stated she was allergic to cats and did not want them in her room. Resident 1 stated she had found the cat lying at the bottom of her bed in the middle of the night. Resident 1 stated the cat had entered her room multiple times despite staff applying a spray to keep it out. Resident 1 stated the spray the facility used was ineffective because it was mopped up daily with bleach by housekeeping. Resident 1 further stated that she witnessed the cat in the hallway with a mouse in its mouth. Resident 1 stated she felt the cat was an infection control problem. During the interview a second black and white cat was seen outside Resident 1 ' s window inside of the locked and gated back patio. The cat was seen walking towards the laundry room. During an interview on 1/28/25 at 4:58 PM at the facility, Resident 2 stated the cat had entered the room on multiple occasions and that she had informed the facility she was allergic to cats. Resident 2 stated the facility used a spray on the floor outside the room to keep the cat out but that it did not work. During an interview on 1/28/25 at 3:33 PM, the DON stated she was familiar with the facility animal policy. The DON stated the AD is responsible for supervising the facility cat and making sure the facility is compliant with the animal policy. The DON stated she was aware the cat had not been registered. The DON stated she was aware the cat ' s file did not contain documentation of flea and tick treatments or include a bathing and grooming schedule as required by facility policy. The DON stated if the facility was not following the animal policy, then the facility was not implementing infection control measures to keep residents safe. The DON stated the cat should always supervised and should be going home with the AD at night. The DON stated she was aware the cat had been left at the facility unsupervised. The DON acknowledged the facility was not respecting resident rights if the cat was allowed to enter rooms of residents who had a cat allergy or expressed a desire to not have the cat in their room. A review of the facility policy, revised 1/1/2012, titled, Infection Control- Policies & Procedures; Infection Control Manual, indicated, Purpose: to provide infection control policies and procedures required for a safe and sanitary environment. Policy: The Facility ' s Infection control policies and procedures are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections . A review of the facility policy, revised 11/1/2013, titled, Animals at the Facility, indicated, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056062 If continuation sheet Page 2 of 5 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 01/28/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Purpose: to provide residents with the opportunity to enjoy pets in a safe and sanitary manner, as preferred. Policy: The Facility will ensure that all animals brought to the Facility are healthy and supervised. Additionally, Facility pets will be cared for in a manner that ensures the health of the animals and residents. Procedure: I. Facility Pets: A. The activity department will be responsible for maintaining a file on each facility pet. The file will include . v. Documentation of registration, vi. Documentation of flea/tick control . vii. Bathing and grooming schedule . D. Pets shall be kept on a leash when walking outside of the Facility, E. Pets will be supervised at all times by activity staff or designee . F. Pets will have a designated area to sleep in at night, or be taken home by a Facility Staff member . H. The Director of Activities will assume the responsibility of care for pets . Based on observation, interview and record review the facility failed to follow its animal policy and infection control protocols by allowing a cat to roam in and out of the facility unsupervised without documented flea and tick treatment, proper registration, or adherence to resident preferences. As a result, the facility failed to maintain a sanitary environment placing residents at risk of infection, allergic reactions, and environmental contamination. Findings: Resident 1 was admitted to the facility on [DATE] with a diagnosis of asthma (a chronic respiratory condition that causes inflammation and breathing difficulty) per the facility admission record. Resident 2 was admitted to the facility on 12.31/24 per the facility admission record. During an observation of the facility building and grounds on 1/28/25 at 2:25 PM a long black pole with a blue feather toy and a silver bell was seen propped up against the wall in the hallway of the facility outside administrative offices. A cat scratching post and a pet food water dish were observed on the back patio nearby a small shelter resembling a cat house was also visible. During an observation on 1/28/25 at 2:30 PM in the activity room, the facility activities director (AD) was seen interacting with residents watching television and painting one resident's fingernails. During an observation and interview on 1/28/25 at 2:45 PM the facility case manager/infection preventionist (CM IP) was seen carrying a gray colored cat down the hallway inside the facility. The cat appeared agitated with claws extended and was yowling. The CM/IP initially stated the cat belonged to a neighbor and had entered the facility but then admitted the cat belonged to the facility. The CM/IP acknowledged the cat was in and out of the facility and was a potential infection control risk if left unsupervised. During an interview and review of the cat's file and facility animal policy, on 1/28/25 at 3:28 PM, the AD stated she was responsible for the supervision of the cat. The AD stated that the facility used a cat spray on the floor in front of the doors of residents who did not want the cat in their room. The AD stated the cat was not registered. The AD stated the cat's file did not include documentation of flea and tick treatment or a formal bathing and grooming schedule for the cat. The AD acknowledged the facility policy on animals required the cat to be registered and have documentation of regular flea and tick treatment and a formal bathing and grooming schedule. The AD acknowledged the facility policy on animals was not being followed. The AD acknowledged residents were at risk of being (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056062 If continuation sheet Page 3 of 5 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 01/28/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few exposed to infectious diseases and parasites carried by fleas and ticks if treatments were not completed and the cat did not have a bathing schedule. The AD acknowledged that the cat was seen in the facility unsupervised. During an interview at the facility on 1/28/25 at 3:53 PM, Certified Nursing Assistant (CNA) 1 stated the cat lays down in the nurse's station. CNA 1 stated the cat is put outside, unsupervised, to sleep at night. During an interview at the facility on 1/28/25 at 4:21 PM, Licensed Nurse (LN) 1 stated the activity department was responsible the cat's care. LN 1 stated the cat was allowed to roam inside and outside the facility. LN 1 stated the cat had been seen inside resident rooms. LN 1 stated there were multiple cats who wandered outside the facility. During an observation and interview on 1/28/25 at 4:52 PM at the facility, Resident 1 stated she was allergic to cats and did not want them in her room. Resident 1 stated she had found the cat lying at the bottom of her bed in the middle of the night. Resident 1 stated the cat had entered her room multiple times despite staff applying a spray to keep it out. Resident 1 stated the spray the facility used was ineffective because it was mopped up daily with bleach by housekeeping. Resident 1 further stated that she witnessed the cat in the hallway with a mouse in its mouth. Resident 1 stated she felt the cat was an infection control problem. During the interview a second black and white cat was seen outside Resident 1's window inside of the locked and gated back patio. The cat was seen walking towards the laundry room. During an interview on 1/28/25 at 4:58 PM at the facility, Resident 2 stated the cat had entered the room on multiple occasions and that she had informed the facility she was allergic to cats. Resident 2 stated the facility used a spray on the floor outside the room to keep the cat out but that it did not work. During an interview on 1/28/25 at 3:33 PM, the DON stated she was familiar with the facility animal policy. The DON stated the AD is responsible for supervising the facility cat and making sure the facility is compliant with the animal policy. The DON stated she was aware the cat had not been registered. The DON stated she was aware the cat's file did not contain documentation of flea and tick treatments or include a bathing and grooming schedule as required by facility policy. The DON stated if the facility was not following the animal policy, then the facility was not implementing infection control measures to keep residents safe. The DON stated the cat should always supervised and should be going home with the AD at night. The DON stated she was aware the cat had been left at the facility unsupervised. The DON acknowledged the facility was not respecting resident rights if the cat was allowed to enter rooms of residents who had a cat allergy or expressed a desire to not have the cat in their room. A review of the facility policy, revised 1/1/2012, titled, Infection Control- Policies & Procedures; Infection Control Manual, indicated, Purpose: to provide infection control policies and procedures required for a safe and sanitary environment. Policy: The Facility's Infection control policies and procedures are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections . A review of the facility policy, revised 11/1/2013, titled, Animals at the Facility, indicated, Purpose: to provide residents with the opportunity to enjoy pets in a safe and sanitary manner, as preferred. Policy: The Facility will ensure that all animals brought to the Facility are healthy and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056062 If continuation sheet Page 4 of 5 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 01/28/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete supervised. Additionally, Facility pets will be cared for in a manner that ensures the health of the animals and residents. Procedure: I. Facility Pets: A. The activity department will be responsible for maintaining a file on each facility pet. The file will include . v. Documentation of registration, vi. Documentation of flea/tick control . vii. Bathing and grooming schedule . D. Pets shall be kept on a leash when walking outside of the Facility, E. Pets will be supervised at all times by activity staff or designee . F. Pets will have a designated area to sleep in at night, or be taken home by a Facility Staff member . H. The Director of Activities will assume the responsibility of care for pets . Event ID: Facility ID: 056062 If continuation sheet Page 5 of 5