Other·March 1, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an abbreviated standard survey to investigate one entity reported incident. Entity Reported Incident Number: CA00466981 Representing the California Department of Public Health: Surveyor: 23046, HFEN The inspection was limited to the specific entity reported incident investigated and does not represent the findings of a full inspection of the facility. Two deficiencies were written as a result of entity reported incident CA00466981.

F157 SS=D NOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC) CFR(s): 483.10(b)(11)

F157 09/02/2016 A facility must immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention; a significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications); a need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or a decision to transfer or discharge the resident from the facility as LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4RB11 Facility ID: CA240000619 If continuation sheet 1 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555309 (X3) DATE SURVEY COMPLETED 08/02/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNDANCE CREEK POST ACUTE 5800 W Wilson St Banning, CA 92220 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE specified in §483.12(a). The facility must also promptly notify the resident and, if known, the resident's legal representative or interested family member when there is a change in room or roommate assignment as specified in §483.15(e)(2); or a change in resident rights under Federal or State law or regulations as specified in paragraph (b)(1) of this section. The facility must record and periodically update the address and phone number of the resident's legal representative or interested family member. This REQUIREMENT is not met as evidenced by: Based on interview, record review, and facility document review, the facility failed to ensure the physician for one resident (Resident 1) was immediately notified of the resident's significant decline in level of consciousness (awareness) after sustaining a head injury from a fall. This failure had the potential to result in delayed provision of appropriate care and treatment which could further result in deterioration of the resident's medical condition. Findings: An unannounced visit was made to the facility on December 22, 2015, at 9:15 a.m., to investigate Resident 1's fall and head injuries. A review of Resident 1's record indicated she was admitted to the facility on November 18, 2015, with diagnoses that included diabetes mellitus (high blood sugar), physical debility, and syncope (passing out/fainting usually due FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4RB11 Facility ID: CA240000619 If continuation sheet 2 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555309 (X3) DATE SURVEY COMPLETED 08/02/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNDANCE CREEK POST ACUTE 5800 W Wilson St Banning, CA 92220 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE to low blood pressure). A review of Resident 1's incident report summary dated November 28, 2015, indicated Resident 1 was found on the floor next to her bed on November 28, 2015, at 12:15 a.m. Resident 1 sustained head injury which was characterized as a "small skin tear and bump to her left eyebrow, and with minimal bleeding." The incident report indicated Resident 1 stated she was lying in bed, tried to roll and reposition to her right side, and accidentally rolled off the bed and fell to the floor. The resident had no complaints of pain, remained alert and oriented, and was able to move all extremities without limitations until at 7 a.m. At 7 a.m., Resident 1 was noted having "mental status change" and "unable to follow commands completely." Resident 1 was transferred to the acute hospital and was found to have a "large subdural hematoma (bleeding and increased pressure on the brain)." She was intubated (insertion of a tube into the windpipe to open the airway and facilitate breathing), and was not responding." Resident 1's comprehensive admission Minimum Data Set (MDS- an assessment tool) dated November 23, 2015, indicated Resident 1's cognitive (memory/judgement) daily decision making was independent. A review of Resident 1's nursing notes dated November 23 to 28, 2015, indicated the following: a. On November 28, 2015, at 12:15 a.m., Resident 1 was found by CNA (Certified Nursing Assistant 1) "lying prone (face down) position on the floor on the right side of the bed." When asked what happened, Resident 1 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4RB11 Facility ID: CA240000619 If continuation sheet 3 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555309 (X3) DATE SURVEY COMPLETED 08/02/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNDANCE CREEK POST ACUTE 5800 W Wilson St Banning, CA 92220 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE verbalized she fell out of her bed when she was turning on her right side. Body assessed and noted skin tear with a bump on her left eyebrow with minimal bleeding. Resident 1 remained alert, oriented, and able to verbalize her needs and follow commands at that time. The physician was notified of the fall and ordered neurological checks and treatment to the laceration on the forehead. b. On November 28, 2015, at 7 a.m., Resident 1 was unable to follow commands completely. She had swelling on the left eyebrow, purplish discoloration and greenish/yellow discoloration on the left knee, and body weakness. c. On November 28, 2015, at 7:35 a.m., the on call physician (alternate for the attending physician) for Resident 1 was "made aware of overall status of the resident and suggest to send to ER (Emergency Room) for further evaluation..." The nurses documentation indicated a physician was notified 35 minutes after Resident 1 was noted as having significant change in her level of awareness including the resident's inability to follow commands completely. d. On November 28, 2015, at 7:40 a.m., "AMR (American Medical Response- an emergency transport ambulance) was called for transport. Resident remained awake with oxygen at 3 liters continuously." A review of the AMR patient (resident) care report indicated AMR personal were at resident's bedside on November 28, 2015, at 7:48 a.m. The resident was transported to the hospital ER at 8:08 a.m.,and she arrived at the ER at 8:12 a.m. In an interview with the Director of Nursing (DON) on April 5, 2016, at 3:45 p.m., the DON FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4RB11 Facility ID: CA240000619 If continuation sheet 4 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555309 (X3) DATE SURVEY COMPLETED 08/02/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNDANCE CREEK POST ACUTE 5800 W Wilson St Banning, CA 92220 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE was asked about the nurse's documentation indicating the physician was notified 35 minutes after Resident 1 was noted having significant change in her level of consciousness. The DON stated, "Sometimes they (nursing staff) document later, but it should have been called earlier, like, immediately." The DON confirmed there was no documentation indicating the the resident's attending physician was immediately notified when Resident 1 had shown a decline in mental awareness such as inability to follow commands completely. In a telephone interview with Registered Nurse 1 (RN 1) on July 26, 2016, at 4:45 p.m., RN 1 stated he worked on November 28, 2015, from 6:30 a.m. to 2:30 p.m. When RN 1 was asked about Resident 1's condition after the resident fell, RN 1 stated Resident 1 was not stable, was slow to respond, and complained of pain to her head at a five over 10 pain level (5/10 = moderate pain according to the facility pain scale). RN 1 stated he could not remember the time Resident 1 complained of pain to her head, or if Resident 1 was given pain medication. RN 1 was further asked about the time lapse of 35 minutes between RN 1's assessment of Resident 1 at at 7 a.m., and when RN 1 notified the physician at 7:35 a.m. regarding Resident 1's changed mental status. RN 1 stated he was gathering information and could not call the physician until he had all the information from the previous shift nurse. Registered Nurse 2 (RN 2) who was on duty at the time Resident 1 fell was not able to be interviewed. The undated facility policy and procedure titled, "Change of Condition," indicated the following guidelines: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4RB11 Facility ID: CA240000619 If continuation sheet 5 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555309 (X3) DATE SURVEY COMPLETED 08/02/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNDANCE CREEK POST ACUTE 5800 W Wilson St Banning, CA 92220 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE "Purpose: To assure the appropriate care and documentation occurs when residents experience a change of condition. Policy: Facility shall promptly notify the resident his or her attending physician and resident's legal representative of changes in resident's condition... Procedure:...2. Notify the attending physician promptly... What is a Change of Condition: ... 12. Bruises, lacerations, ... 13. Swelling or discoloration... 15. Change in level of consciousness 16. Change in Level of Functioning." The facility's policy titled, "FALLS RESIDENTS," undated, was reviewed and indicated, "...PROCEDURES:...03...The nurse will be guided by the nature, degree and seriousness of the fall in deciding the next move or action. In case of doubt, the resident is referred to the emergency room of an acute hospital.

F323 SS=G FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES CFR(s): 483.25(h)

F323 09/02/2016 The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4RB11 Facility ID: CA240000619 If continuation sheet 6 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555309 (X3) DATE SURVEY COMPLETED 08/02/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNDANCE CREEK POST ACUTE 5800 W Wilson St Banning, CA 92220 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Based on interview, record review, and facility document review, the facility failed to ensure one sampled resident (Resident 1) was free from falls and injuries when the facility did not implement care plan interventions of a perimeter mat (safety cushion device made of soft padding that absorbs and decrease the force of impact during a fall) on the floor beside the bed, and did not ensure a working bed alarm (a warning device that produces a high pitch sound to alert staff when a resident moves around or gets out of bed). The facility also failed to assess and investigate Resident 1's fall for possible causes. These failures resulted in Resident 1 falling from her bed to the floor and sustaining a laceration to her left eyebrow with bleeding and swelling. Resident 1 also had a significant change in her mental cognition with decreased level of awareness, and required hospitalization for a subdural hematoma (bleeding and increased pressure on the brain). Findings: An unannounced visit was made to the facility on December 22, 2015, at 9:15 a.m., to investigate Resident 1's fall and head injuries. A review of Resident 1's record indicated she was admitted to the facility on November 18, 2015, with diagnoses that included diabetes mellitus (high blood sugar), physical debility (weakness), and syncope (passing out/fainting). A review Resident 1's incident report summary dated November 28, 2015, indicated Resident 1 was found on the floor next to her bed on November 28, 2015, at 12:15 a.m. Resident 1 sustained head injury which was characterized FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4RB11 Facility ID: CA240000619 If continuation sheet 7 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555309 (X3) DATE SURVEY COMPLETED 08/02/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNDANCE CREEK POST ACUTE 5800 W Wilson St Banning, CA 92220 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE as "small skin tear and bump to her left eyebrow, and with minimal bleeding." The incident report indicated Resident 1 stated she was lying in bed, tried to roll and reposition to her right side, and accidentally rolled off the bed and fell to the floor. The resident had no complaints of pain, remained alert and oriented, and was able to move all extremities without limitations until 7 a.m. At 7 a.m., Resident 1 was noted having a "mental status change" and "unable to follow commands completely." Resident 1 was transferred to the acute hospital and was found to have a "large subdural hematoma. Resident 1 was intubated (insertion of a tube into the windpipe to open the airway and facilitate breathing), and was not responding." On December 22, 2015, at 9:18 a.m., the Director of Nursing (DON) was interviewed. The DON stated Resident 1 was transferred to the acute hospital via an ambulance on November 28, 2015, when the resident showed significant changes in her level of awareness. The DON stated later in the afternoon of November 28, 2015, the facility received information from the hospital that Resident 1 had a large subdural hematoma, she was verbally non-responsive, and had to be intubated. The DON stated Resident 1 remained in the hospital and passed away 12 days later. The DON was asked how Resident 1 fell and what fall precautions and interventions were in place to prevent falls and injuries. The DON stated Resident 1 had a "Tab" alarm (an electronic device that connects to a resident and alarms when the resident gets up unassisted) while in bed but the alarm did not sound when the resident rolled off the bed. When the DON was asked if a perimeter cushion pad was in place on the floor during FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4RB11 Facility ID: CA240000619 If continuation sheet 8 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555309 (X3) DATE SURVEY COMPLETED 08/02/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNDANCE CREEK POST ACUTE 5800 W Wilson St Banning, CA 92220 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the fall, the DON stated, "No, because sometimes the resident would not like the mat because it's harder for them to walk to the bathroom." The DON further stated Resident 1 had not been assessed for the use of perimeter mat. Resident 1's Nursing Home Discharge (ND) Item Set dated November 23, 2015, indicated Resident 1's cognitive (memory/judgement) daily decision making was independent. The MDS also indicated Resident 1 required extensive assistance of one person for bed mobility, transfers, ambulation (walking), and toileting. A review of Resident 1's nursing notes dated November 23 to 28, 2015, indicated the following documentation: a. On November 23, 2015, at 10:52 a.m., during transfer from wheelchair to bed while working with a Physical Therapist, Resident 1 became unconscious, unresponsive, and slumped forward onto the bed. Resident 1 was sent to the hospital for further evaluation and treatment. The resident returned to the facility on November 26, 2015, with a diagnoses of syncope and collapse. b. On November 28, 2015, at 12:15 a.m., Resident 1 was found by Certified Nursing Assistant 1 (CNA 1) to be "lying prone (face down) position on the floor on the right side of the bed." When Resident 1 was asked what happened, Resident 1 verbalized she fell out of her bed when she was turning on her right side. Body assessed and noted skin tear with a bump on her left eyebrow with minimal bleeding. Resident 1 remained alert, oriented, and able to verbalize her needs and follow commands. The physician was notified of the fall and ordered neurological checks, and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4RB11 Facility ID: CA240000619 If continuation sheet 9 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555309 (X3) DATE SURVEY COMPLETED 08/02/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNDANCE CREEK POST ACUTE 5800 W Wilson St Banning, CA 92220 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE treatment to the laceration on the forehead. c. On November 28, 2016, at 7 a.m., Resident 1 was unable to follow command completely, had swelling on the left eyebrow, purplish discoloration and greenish/yellow discoloration on the left knee, and body weakness. d. On November 28, 2016, at 7:35 a.m., the on-call physician (alternate for the attending physician) for Resident 1 was "made aware of overall status of the patient (resident) and suggest to send to ER (Emergency Room) for further evaluation..." The nurse's documentation indicated the physician was notified 35 minutes after Resident 1 was noted having a significant change in her level of awareness including the resident's inability to follow commands completely. e. On November 28, 2015, at 7:40 a.m., "AMR (American Medical Response- an emergency transport ambulance) was called for transport." Resident remained awake with oxygen at 3 liters continuously. f. On November 28, 2015, at 7:50 a.m., Resident 1 was transported to the hospital. A review of the AMR personnel report indicated Resident 1 was transported to the ER at 8:08 a.m. with primary and secondary impression of, "Trauma- Head injury; Neurological- Altered mentation." A review of Resident 1's ER initial assessment and progress notes dated November 28, 2015, at 9:15 a.m., indicated Resident 1 had a swelling and hematoma on the left eye area, had decreased level of consciousness, confused, disoriented to place and time, was not following commands, and her eye pupils were unequal. Resident 1 was intubated due to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4RB11 Facility ID: CA240000619 If continuation sheet 10 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555309 (X3) DATE SURVEY COMPLETED 08/02/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNDANCE CREEK POST ACUTE 5800 W Wilson St Banning, CA 92220 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE changed mental awareness. At 11 p.m., Resident 1 was transferred to another acute hospital due to needing a higher level of care. Review of Resident 1's Computed Tomography (CT scan/x-ray) of the head indicated Resident 1 had a "Large left subdural hematoma." On December 23, 2015, at 10:45 a.m., CNA 1 was interviewed by telephone. CNA 1 stated she was assigned to care for Resident 1 on November 27, 2016 from 10:30 p.m. until November 28, 2015, at 6:30 a.m. CNA 1 was asked to describe how Resident 1 fell. CNA 1 stated she was walking on the hallway at approximately 12 a.m. when she heard a faint voice calling for help repeatedly. CNA 1 found Resident 1 lying on the floor on the left side of the bed by the window. CNA 1 stated Resident 1 was bleeding from her forehead. CNA 1 stated the nurse applied a bandage to Resident 1's forehead to stop the bleeding. CNA 1 stated Resident 1 complained of a headache after the fall but was not sure what time that was. When CNA 1 was asked about fall preventive measures or devices that were in place for Resident 1, CNA 1 stated Resident 1 had a bed alarm but the alarm did not sound after Resident 1 rolled off the bed. CNA 1 further stated Resident 1's bed was at a low position, and there was no perimeter mat or cushion on the floor. Registered Nurse 2 (RN 2) who was on duty at the time Resident 1 fell was not able to be interviewed. A review of Resident 1's care plan to prevent falls and injuries initiated November 19, 2015, included the use of low bed for safety; bed alarm for safety; and a perimeter mat on the floor for safety. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4RB11 Facility ID: CA240000619 If continuation sheet 11 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555309 (X3) DATE SURVEY COMPLETED 08/02/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNDANCE CREEK POST ACUTE 5800 W Wilson St Banning, CA 92220 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Further review of Resident 1's record did not indicate documentation of a fall risk assessment and post-fall assessment to determine and analyze the cause of the fall. There was no interdisciplinary team (IDT) assessment or investigation why the bed alarm did not sound when Resident 1 rolled off the bed, and why a perimeter floor mat was not in place. In an interview with the DON and the Quality Assurance Registered Nurse (QA-RN) on April 5, 2016, at 3:45 p.m., they were asked if there was an IDT assessment or investigation to analyze and determine the cause of Resident 1's fall. The DON stated no investigation was done to determine the cause of the fall. The DON confirmed there was no perimeter mat on the floor, and could not explain why the bed alarm did not sound at the time of the fall. In a telephone interview with RN 1 on July 26, 2016, at 4:45 p.m., RN 1 stated he worked on November 28, 2015, from 6:30 a.m. to 2:30 p.m. When RN 1 was asked about Resident 1's condition after the resident fell, RN 1 stated Resident 1 was not stable, was slow to respond, and complained of pain to her head at a five over 10 pain level (5/10 = moderate pain according to the facility pain scale). RN 1 stated he could not remember the time Resident 1 complained of pain to her head. RN 1 was further asked about the time lapse of 35 minutes between RN 1's assessment of Resident 1 at 7 a.m., and when RN 1 notified the physician at 7:35 a.m. regarding Resident 1's changed mental status. RN 1 stated he was gathering information and could not call the physician until he had all the information from the previous shift nurse. The facility's policy and procedure titled, "Fall FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4RB11 Facility ID: CA240000619 If continuation sheet 12 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555309 (X3) DATE SURVEY COMPLETED 08/02/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNDANCE CREEK POST ACUTE 5800 W Wilson St Banning, CA 92220 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Prevention Program," dated November 15, 2015, indicated, "POLICY: Each resident shall be assessed for propensity for falls, and each resident shall be with adequate supervision and assistance devices to prevent accidents. PROCEDURES: ...11.) Residents assessed to be high risk for fall and appropriate for the use of wheelchair alarms, bed alarms, (a) perimeter mat will be ordered. The facility's policy titled, "FALLS RESIDENTS," undated, was reviewed and indicated, "...PROCEDURES:...08. Proper actions following a fall include:..Determining what may have caused or contributed to the fall; Addressing the factors for the fall; and Revising the resident's plan of care and or facility practices, as needed, to reduce the likelihood of another fall." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4RB11 Facility ID: CA240000619 If continuation sheet 13 of 13