Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Amaya Springs Health Care Center during CMS and state inspections, most recent first.
Improper medication storage and labeling were observed when an injectable heparin box was mixed with oral OTC meds in a cart drawer, discontinued medications for multiple residents were kept in storage instead of being disposed of or separated, and a resident with COPD and polyneuropathy had gabapentin, Senokot, an inhaler, and eye drops left at the bedside. The LN and DON stated injectable meds should not be co-mingled with oral meds, discontinued meds should be properly disposed of, and meds should never be left unattended at the bedside.
Missing CNA Performance Evaluations: The facility failed to document annual performance evaluations for two CNAs. During a review of personnel files with the DSD, no performance evaluation was found for one CNA hired in 2018 or another CNA hired in 2024. The DON stated staff should receive yearly evaluations, and the ADM acknowledged the evaluations were not completed.
Failure to manage a resident's behavioral symptoms: A resident with moderate cognitive impairment and psychiatric diagnoses was observed repeatedly yelling and screaming loudly in Spanish throughout the day, including in her room and the hallway. Staff reported they could not consistently redirect her, medications were ineffective, and her roommate said the constant yelling disrupted sleep and was bothersome. The DON acknowledged the resident's disruptive behavior had increased and that staff were no longer able to redirect her.
A nurse failed to follow EBP when administering medications to a resident with a g-tube and an EBP sign posted on the door. The nurse entered the room, checked g-tube placement, and gave meds via the g-tube without wearing a gown, then acknowledged the mistake. The DON stated staff were expected to follow EBP procedures for protection of staff and residents, and the facility policy included feeding tube care as a high-contact activity requiring EBP.
Failure to offer and administer flu and pneumococcal vaccines to two residents. One resident with Alzheimer’s disease had no documented offer or consent/decline for the seasonal influenza vaccine, and another resident with sepsis had consented to pneumococcal vaccination but there was no documentation that it was offered or given. The IPN confirmed neither vaccine had been offered, and the DON stated licensed nurses were expected to administer vaccinations when consented.
A resident receiving tube feeding did not have complete and clear medical records, as LNs failed to consistently sign the MAR for each administration and the physician's order lacked the required TF rate and total daily amount. This resulted in incomplete documentation of the resident's care, as confirmed by interviews with nursing staff and the DON.
The facility failed to follow its animal policy and infection control protocols by allowing a cat to roam unsupervised, lacking registration and flea/tick treatment documentation. Two residents with allergies reported the cat entering their rooms despite their preferences. The DON acknowledged the non-compliance, and the cat was seen unsupervised in various facility areas.
A resident with diabetes mellitus type two was not monitored for blood glucose levels according to standard care practices upon admission to the facility. The facility continued hospital orders for once-daily monitoring, which was not questioned by staff. The frequency was increased only after the resident's husband raised concerns, revealing an elevated blood glucose level of 477. The facility's policy required monitoring per physician's order, but the policy was not provided.
A resident with osteomyelitis was transferred to a hospital without receiving a required discharge notice. Staff interviews revealed confusion over who was responsible for providing the notice, leading to non-compliance with the facility's policy.
A resident transferred to a hospital was not given a written notice of the facility's bed hold policy, despite being awake at the time of transfer. The Bed Hold Agreement was incomplete, and staff interviews revealed a failure to follow the facility's policy requiring written notification upon hospital transfer.
The facility failed to notify a physician of a resident's low blood sugar readings and did not monitor fluid intake and output for two residents. One resident with diabetes had critically low blood sugar levels without physician notification or corrective action, while another resident with End Stage Renal Disease had unmonitored fluid intake despite restrictions. Interviews confirmed the lack of adherence to facility policies.
The facility failed to label and store food items properly in the kitchen, risking foodborne illness. Observations revealed opened jars of dressings without dates and improperly stored chicken in the freezer. The Dietary Manager acknowledged the need for proper labeling and storage, as per facility policy.
The facility failed to follow infection control practices by not cleaning nebulizer equipment after use for a resident with respiratory failure. Additionally, the water waste management program was not implemented as required, with no water testing conducted for two months due to a lack of testing kits, violating the facility's policy.
The facility did not ensure that the ICP completed the necessary specialized training. The IPN was left to manage the infection control program after the designated ICP quit and admitted to not having completed the required training. The DON confirmed that the ICP should have had the training, as per facility policy.
The facility failed to prepare three residents for discharge according to its policy. One resident was discharged without a Notice of Proposed Discharge, and their care plan lacked specific interventions for their needs. Another resident received their discharge notice on the same day as discharge, and their care plan lacked goal-specific interventions. A third resident did not receive a 30-day discharge notice, and discharge planning began a month after admission. The facility's DON and SW acknowledged these failures.
The facility failed to provide supervised and assisted ambulation to a high-risk resident, resulting in an unwitnessed fall and a broken bone in her left ankle. Despite requiring supervision for various activities, the resident was observed walking without assistance, and multiple previous falls were documented. Interviews and records indicated that the resident had moderate cognitive impairment and required significant assistance, which was not consistently provided.
Improper Medication Storage and Unattended Bedside Medications
Penalty
Summary
Medications and biologicals were not stored and labeled in accordance with accepted professional principles when an injectable heparin box was found comingled with oral over-the-counter medications in a medication cart drawer. During the observation, the LN stated the injectable medication should not have been included with oral medications for safety and infection control, and the DON later stated injectable medications should not be co-mingled with oral medications for the same reason. The facility policy stated that medications and biologicals are to be stored safely and properly, and orally administered medications are to be kept separate. In the medication storage room, discontinued and no-longer-needed medications for eight residents were found together, including patches, injectable pens, oral inhalation medications, and medicated shampoo. The LN stated that two of the residents had expired, three had medications discontinued by the attending physician, and three had been discharged from the facility; she also stated the discontinued medications should have been disposed of according to facility policy and marked as discontinued. In addition, Resident 38, who was admitted with COPD and polyneuropathy, was observed sitting in a wheelchair with gabapentin, Senokot, an inhaler, and an eye drop left at the bedside. The resident was alert and verbally responsive, and an LN stated she had left the medications there and forgot to return, while the DON stated medications should never be left unattended at the bedside.
Missing CNA Performance Evaluations
Penalty
Summary
The facility failed to provide documentation verifying that performance evaluations had been completed for two CNAs. During a concurrent review of personnel files with the DSD, CNA 1, hired on 10/29/18, had no performance evaluation in the file, and CNA 2, hired on 9/17/24, also had no performance evaluation in the file. The DON stated that staff should undergo annual performance evaluations to ensure they have the necessary skills to provide quality care and maintain compliance. The ADM acknowledged that performance evaluations were not completed for CNA 1 and CNA 2 and stated that performance evaluations should have been completed yearly. The facility's provided document titled Performance Evaluations, dated 1/24, indicated that performance evaluations may be conducted annually, on or around the employee's anniversary date.
Failure to Manage Resident Behavioral Symptoms
Penalty
Summary
The facility failed to ensure that staff members had sufficient competencies and skills to meet the behavioral health needs of a resident with moderate cognitive impairment and psychiatric diagnoses including depression, adjustment disorder, and anxiety disorder. Resident 39 was admitted with brain disorders and had a BIMS score of 9. During multiple observations, the resident was heard yelling and screaming loudly in Spanish, including repeated shouting of words such as "Ya" and "hey," as well as incomprehensible words, while in her room and in the hallway. Staff interviews confirmed that Resident 39 yelled throughout the day and that staff were often unable to redirect the behavior consistently. CNA staff described the resident as alert but confused, yelling intermittently or all day, and repeatedly asking to go home or calling out her brother's name. The roommate reported being bothered by the constant noise and stated she was unable to get enough sleep because of the yelling. Nursing staff and the DSS stated the resident was agitated, yelled while staff were present, and that medications were ineffective. The DON stated the resident had an increased disruptive behavioral symptom, staff were no longer able to redirect her, and a psychiatric referral had been made. The facility's behavior management policy stated residents with behaviors such as crying and yelling would receive appropriate treatment to address the problem or attain the highest practical mental and psychosocial well-being.
Failure to Follow Enhanced Barrier Precautions During G-Tube Medication Administration
Penalty
Summary
The facility failed to ensure infection control procedures were followed when a Licensed Nurse did not wear a gown while providing medication administration to Resident 6, who had enhanced barrier precautions in place. During observation, the nurse prepared medications, entered the resident’s room, checked the resident’s g-tube placement, and administered the medications through the g-tube without first putting on a gown. The nurse then stated, "I have to correct myself, I forgot to put a gown on." Resident 6’s record showed admission to the facility with diagnoses that included urinary tract infections and a gastrostomy tube. An EBP sign was posted on the resident’s door. During a later interview, the nurse stated she should have worn a gown while passing medications to Resident 6 via the g-tube for infection control. The DON stated the expectation was for staff to follow EBP procedures for protection of staff and residents to prevent spread of infection. The facility policy on Enhanced Barrier Precautions stated that EBP is used for high-contact resident care activities, including device care or use such as feeding tube care.
Failure to Offer and Administer Flu and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to provide influenza vaccination for Resident 6 and pneumococcal vaccination for Resident 39. Resident 6 was admitted with a diagnosis of Alzheimer's disease, and the history and physical dated 11/1/25 identified the resident's family member as the responsible party for signing consents. On 1/28/26, review of Resident 6's clinical record showed no documented evidence that the facility offered influenza vaccination or that the responsible party consented or declined influenza vaccination for the 2025-2026 influenza season. During a joint review with the Infection Preventionist Nurse, it was stated that no influenza vaccination had been offered to Resident 6. Resident 39 was admitted with a diagnosis of sepsis, and the family member was the responsible party. Review of the immunization consent form dated 11/12/25 showed that the responsible party consented to pneumococcal vaccination, but there was no documented evidence that the facility offered or administered the vaccine. During the joint review, the Infection Preventionist Nurse stated that no pneumococcal vaccination had been offered to Resident 39. The Director of Nursing stated the expectation was for licensed nurses to administer vaccinations to residents when consented as part of primary care prevention of illness.
Incomplete Documentation of Tube Feeding Administration and Orders
Penalty
Summary
The facility failed to ensure that a resident's medical record was clear and complete regarding the administration of tube feeding (TF) formula. Specifically, licensed nurses did not consistently sign the Medication Administration Record (MAR) each time the TF formula was administered, resulting in incomplete documentation of the number of pouches given per day. Additionally, the physician's order summary and the MAR lacked critical information, such as the prescribed TF rate and the total number of pouches to be administered, despite the hospital discharge instructions specifying these details. A resident with a gastrostomy status was admitted with orders for TF that included specific instructions for preparation, dilution, and administration rate. However, the facility's documentation did not reflect the required TF rate or the total daily amount, and only one nurse signed the MAR daily, even though the TF was to be administered every eight hours. Interviews with nursing staff and the Director of Nursing confirmed these omissions and acknowledged that the records should have included complete orders and signatures for each administration to accurately track the care provided.
Facility Fails to Follow Animal Policy and Infection Control Protocols
Penalty
Summary
The facility failed to adhere to its animal policy and infection control protocols by allowing a cat to roam unsupervised within and outside the facility. The cat was not registered, lacked documentation of flea and tick treatment, and did not have a formal bathing and grooming schedule, as required by the facility's policy. The Activities Director (AD) admitted responsibility for the cat's supervision but acknowledged that the facility's animal policy was not being followed, placing residents at risk of exposure to infectious diseases and parasites. Two residents, one with asthma and another with allergies to cats, reported that the cat had entered their rooms multiple times despite their preferences against it. The facility attempted to use a spray to deter the cat from entering certain rooms, but it was ineffective as it was regularly cleaned away by housekeeping. The Director of Nursing (DON) confirmed awareness of the non-compliance with the animal policy and acknowledged that the cat should be supervised and taken home by the AD at night, which was not happening. Observations and interviews revealed that the cat was seen in various areas of the facility, including the nurse's station and resident rooms, and was left unsupervised outside at night. The presence of multiple cats wandering outside the facility was also noted. The facility's failure to follow its animal policy and infection control measures compromised the sanitary environment and resident rights, as residents with allergies were exposed to the cat against their wishes.
Failure to Obtain Appropriate Blood Glucose Monitoring Orders
Penalty
Summary
The facility failed to obtain a physician order for appropriate blood glucose monitoring for a resident with diabetes mellitus type two. Upon admission, the resident's orders included monitoring blood glucose once per day at 5 P.M., despite the facility's usual practice of checking before each meal and sometimes at bedtime for residents on insulin. This discrepancy was not questioned by the facility staff, and the monitoring frequency was only increased after the resident's husband expressed concerns about her condition, which led to the discovery of an elevated blood glucose level of 477. The deficiency was identified during an unannounced visit following a complaint that the resident's blood glucose was checked only once per day. Interviews with facility staff, including a Licensed Nurse and the Director of Nursing, revealed that the facility continued the orders from the hospital without questioning the frequency. The facility's policy required monitoring per the attending physician's order, but the policy was not provided upon request. The resident did not receive additional insulin for the elevated blood glucose level, and the standard of care for blood glucose monitoring, as per the National Institute of Health, recommends testing before meals and bedtime for clients who can eat.
Failure to Provide Discharge Notice
Penalty
Summary
The facility failed to provide a written notice of discharge to a resident who was transferred to an acute care hospital. Resident 8, who was admitted with osteomyelitis, was transferred on 9/4/24 due to a change in condition. However, there was no documentation indicating that Resident 8 received a Notice of Proposed Transfer and Discharge form prior to the transfer. This oversight left the resident uninformed about the discharge process. Interviews with facility staff revealed a lack of clarity regarding the responsibility for providing the discharge notice. Licensed Nurse 6, who was involved in the transfer, admitted to not providing any paperwork to the resident and was unfamiliar with the required form. The Director of Nursing indicated that the Social Worker was responsible for issuing the notice, while the Social Worker stated that it was the responsibility of the licensed nurses. This confusion contributed to the failure to comply with the facility's policy, which mandates that residents receive a discharge notice 30 days prior or as soon as practicable.
Failure to Provide Written Bed Hold Notice
Penalty
Summary
The facility failed to provide a written notice of its bed hold policy to a resident at the time of discharge to an acute care hospital. Resident 8, who was admitted with osteomyelitis, was transferred to the hospital due to a change in condition. Despite being awake at the time of transfer, there was no documentation that Resident 8 received a written notice of the bed hold policy on the day of transfer or the following day. The Bed Hold Agreement signed by Resident 8 at admission was incomplete, lacking details about the transfer and notification of the bed hold option. Interviews with facility staff revealed a lack of adherence to the facility's policy, which requires written notification of the bed hold option upon transfer to a hospital. Licensed Nurse 6, who transferred Resident 8, confirmed that no written notice was provided. The Admissions Coordinator stated that the responsibility for offering the bed hold lay with the licensed nurses, and she did not provide written notice when notifying the resident's representative by phone. The Director of Nursing acknowledged that the facility did not provide written notice of the bed hold policy when residents were transferred to acute care hospitals.
Failure to Notify Physician and Monitor Fluid Intake
Penalty
Summary
The facility failed to notify the physician of a resident's low blood sugar readings and did not monitor fluid intake and output for two of the sampled residents. Resident 1, who was admitted with a diagnosis of diabetes, had blood sugar readings of 13 mg/dl and 59 mg/dl on two separate occasions. Despite the facility's policy requiring notification of the healthcare provider for blood sugar levels lower than 70 mg/dl, there was no documentation that the physician was notified, nor were there any records of attempts to raise the blood sugar or rechecks conducted. Interviews with the nursing staff and the Director of Nursing confirmed that the necessary actions were not taken. Additionally, Resident 30, who was admitted with End Stage Renal Disease, had orders for fluid intake and output monitoring, with a restriction to one liter daily. However, there was no evidence that these orders were consistently followed or that assessments were conducted. The Director of Nursing acknowledged that fluid intake and output should have been monitored and evaluated after seven days, as per the facility's policy. The lack of documentation and adherence to the physician's orders contributed to the deficiencies identified in the care of these residents.
Improper Food Labeling and Storage in Kitchen
Penalty
Summary
The facility failed to ensure proper labeling and storage of food items in the kitchen, which could potentially lead to foodborne illness. During an initial tour of the kitchen, it was observed that two large jars of dressings in the reach-in refrigerator were opened without any labeling or dating. Additionally, in the reach-in freezer, a large sealable bag containing chicken thighs was improperly stored with air inside, leading to icicle formation on the meat. There was also an opened clear bag of diced chicken that was manually tied instead of being properly sealed. The Dietary Manager confirmed that opened items should be labeled and dated, and that items in the freezer should be stored appropriately. The facility's policy, dated 6/4/24, specifies that refreezing defrosted food is not recommended and that foods to be frozen should be stored in airtight containers or wrapped in heavy-duty materials, with all food items labeled and dated.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to adhere to its infection control practices concerning the cleaning and storage of nebulizer equipment. A resident, who was readmitted with respiratory failure, had their nebulizer machine observed with tubing and a nebulizer cup and mask improperly stored. The licensed nurse admitted to administering nebulizer treatments without cleaning the mask and cup afterward, contrary to the facility's policy, which requires rinsing and drying the equipment before storage. Additionally, the facility did not implement its water waste management program effectively. The Maintenance Director revealed that water testing had not been conducted for two months due to a lack of testing kits, and there was no documented evidence of monitoring and tracking the water system. This was in violation of the facility's policy, which mandates quarterly water quality measurements and monthly chlorine level monitoring to prevent conditions conducive to Legionella growth.
Infection Control Preventionist Lacks Required Training
Penalty
Summary
The facility failed to ensure that the Infection Control Preventionist (ICP) completed the specialized infection prevention and control training. During an interview and record review, it was revealed that the Infection Preventionist Nurse (IPN) was left to manage the infection control prevention program after the designated ICP quit. The IPN admitted to not having completed the required specialized training. The Director of Nursing (DON) confirmed that the designated ICP should have undergone the necessary training, as per the facility's policy and procedure dated 2/19/21, which mandates that the Infection Preventionist have education, training, expertise, or certification in specialized infection control and prevention practices.
Failure to Prepare Residents for Discharge
Penalty
Summary
The facility failed to adequately prepare three residents for discharge in accordance with its discharge policy. Resident 1, who was admitted with conditions including bilateral lower extremity lymphedema and homelessness, was discharged without receiving a Notice of Proposed Discharge. The discharge care plan for Resident 1 was not resident-centered and lacked specific interventions for adjusting to living in a shelter or car with new medical needs. The discharge planning review for Resident 1 was conducted only one day prior to discharge. Resident 2, admitted with diagnoses such as rhabdomyolysis and difficulty in walking, was discharged on the same day she received her Notice of Proposed Discharge, contrary to the policy requiring a 30-day notice. The discharge care plan for Resident 2 lacked specific interventions regarding her goals. Similarly, Resident 4, who had multiple diagnoses including cognitive communication deficit and acute systolic heart failure, did not receive a 30-day notice of discharge. The discharge planning for Resident 4 began only one month after admission, and there was no discharge care plan or nursing discharge note available. The facility's Director of Nursing and Social Worker acknowledged the failure to implement all steps of the discharge process as per the facility's policy.
Failure to Provide Adequate Supervision and Assistance for High-Risk Resident
Penalty
Summary
The facility failed to provide supervised and assisted ambulation to a resident at high risk for falls, resulting in an unwitnessed fall that caused a broken bone in her left ankle. The resident had a history of paranoid schizophrenia, generalized muscle weakness, essential hypertension, and cognitive communication deficit. The Minimum Data Set (MDS) indicated that the resident required supervision or touching assistance for various activities, including walking and toileting. Despite these needs, the resident was observed ambulating in the hallway without assistance, and multiple Change of Condition (COC) notes documented previous falls, both witnessed and unwitnessed, indicating a pattern of inadequate supervision and assistance. Interviews with the Director of Nursing (DON) and Licensed Nurses (LNs) revealed that the resident had moderate cognitive impairment and required set-up and clean-up assistance for toilet transfers. The resident was not on a bowel and bladder program, which could have helped anticipate her needs. The Physical Therapy evaluation indicated that the resident required maximum assistance for walking, transferring, and toileting. The facility's policies on Fall Management and Ambulation of a Resident were not adequately followed, contributing to the resident's falls and subsequent injury.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Spring Valley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lemon Grove Care And Rehabilitation Center | 0.8 mi | ★★★★★ | 27 | 0 |
| Brighton Place Spring Valley | 1.1 mi | ★★★★★ | 2 | 0 |
| Bella Vista Health Center | 1.2 mi | ★★★★★ | 11 | 0 |
| La Mesa Healthcare Center | 1.8 mi | ★★★★★ | 3 | 0 |
| Community Care Center | 2.1 mi | ★★★★★ | 12 | 0 |
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