Other·November 14, 2017

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 the investigation of one entity reported incident. Entity reported incident number: CA00513944 Representing the California Department of Public Health: Surveyor 36779, 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. One deficiency was issued for entity reported incident number: CA00513994

F225 SS=D INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS CFR(s): 483.12(a)(3)(4)(c)(1)-(4)

F225 11/20/2017 483.12(a) The facility must(3) Not employ or otherwise engage individuals who(i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; (ii) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or (iii) Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, 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: QG3211 Facility ID: CA240000619 If continuation sheet 1 of 6 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 10/26/2017 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 neglect, exploitation, mistreatment of residents or misappropriation of resident property. (4) Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff. (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in longterm care facilities) in accordance with State law through established procedures. (2) Have evidence that all alleged violations are thoroughly investigated. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QG3211 Facility ID: CA240000619 If continuation sheet 2 of 6 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 10/26/2017 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 taken. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to report an allegation of sexual abuse for one of three sampled residents (Resident 1) to the California Department of Public Health (CDPH) within 24 hours of becoming aware of the alleged abuse. This failure had the potential to place Resident 1, and other residents of the facility, at risk of possible abuse not being reported timely to the state agency so that necessary corrective actions could be taken depending on the results of the investigation. Findings: On December 13, 2016, at 9:50 a.m., an unannounced visit was made to the facility to investigate the allegation of abuse made by Resident 1. A review of the facility's, "Summary of Event," dated December 12, 2016, addressed to CDPH, indicated Resident 1 made an allegation to facility staff on December 9, 2016, at approximately 5:45 p.m., that she was raped by a male staff member. The report indicated Resident 1 stated the rape occurred on December 4, 2016 (no time specified). However, Resident 1 did not report her allegation to anyone until December 9, 2016. An updated report dated December 20, 2016, addressed to the CDPH, indicated the facility staff investigated Resident 1's allegation of sexual abuse and was not able to substantiate it based on their investigation. The report further indicated, "Video review (from surveillance camera) revealed no conclusive info as to who entered [Resident 1's room] on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QG3211 Facility ID: CA240000619 If continuation sheet 3 of 6 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 10/26/2017 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 certain times since [Resident 1's room] door is located at the blind area of the camera." An interview was conducted with the Administrator on December 13, 2016, at 9:50 a.m. The Administrator stated he was notified on December 9, 2016, at 5:45 p.m., of Resident 1's allegation of sexual abuse. The Administrator stated Resident 1 gave a lot of detail about the alleged sexual abuse. However, Resident 1 was confused sometimes and the Administrator did not think it happened. The Administrator stated during his initial interview with Resident 1, she first alleged the rape occurred at 3 a.m. (the morning of December 5, 2016). The Administrator stated during other interviews with Resident 1, Resident 1 stated the rape occurred on December 4, 2016, around 10:30 p.m. The Administrator stated he notified CDPH on December 12, 2016. The Administrator stated he did not know why he did not notify CDPH sooner, and stated he should have notified CDPH within 24 hours of becoming aware of Resident 1's allegation of sexual abuse. An interview was conducted with the Social Services Director (SSD) on December 13, 2016, at 9:50 a.m. The SSD stated a police officer came to the facility on December 9, 2016, to speak with Resident 1. The SSD stated the police officer was told by Resident 1 that the rape did not occur at the facility, and the rape occurred at a park. An interview was conducted with Resident 1 on December 13, 2016, at 10:30 a.m. Resident 1 was alert and able to answer simple questions. Resident 1 was not able to clearly articulate conversations. Resident 1 was able to describe a sexual event but was not able to give an exact description or name of the alleged perpetrator. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QG3211 Facility ID: CA240000619 If continuation sheet 4 of 6 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 10/26/2017 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 Resident 1's record was reviewed. Resident 1 was admitted to the facility on May 16, 2016, and readmitted on September 25, 2016. Resident 1 had diagnoses including weakness, diabetes, and seizures (abnormal electrical activity in the brain). Review of the nursing progress note dated December 9, 2016, at 5:45 p.m., by a Licensed Vocational Nurse (LVN 1) indicated, "...Resident verbalized allegations that someone sexually assaulted her while changing her a few nights ago..." A nursing progress note dated December 10, 2016, at 3:04 p.m., by the Social Services Designee indicated, "...Ombudsman notified...and Administrator aware..." There was no documented evidence that the facility notified CDPH within 24 hours of the allegation. During observation of the facility's video surveillance camera recording dated December 4, 2016, between the hours of 10:15 p.m. to 11 p.m., the video tape did not clearly show Resident 1's bedroom door, and did not show staff going in and out of the room due to the position of the camera. Staff were viewed going down the hallway away from Resident 1's door, but there was no clear visual picture of staff entering and exiting the resident's bedroom. The facility's undated policy titled, "Abuse Prohibition Program," indicated, "...Reporting...The agency mandated by your state (CDPH) must be notified within 24 hours of suspected abuse..." The facility's undated policy titled, "Resident Abuse, Neglect, or Mistreatment," indicated "...Procedure...3. The Administrator or designee will notify the resident's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QG3211 Facility ID: CA240000619 If continuation sheet 5 of 6 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 10/26/2017 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 representative, and any State (CDPH) or Federal agencies of allegation within 24 hours..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QG3211 Facility ID: CA240000619 If continuation sheet 6 of 6