Health inspection·October 24, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few medical records with the SSA 1, he stated, any allegation of abuse should be reported to CDPH, Ombudsman, police within two hours after the facility was made aware. SSA 1 further stated missing funds from a resident ' s bank card would be considered financial abuse. SSA 1 stated on October 9, 2024, around 2 p.m., Resident 1 reported to him that his bank card and about 600 dollars were missing. SSA 1 further stated he did not report the abuse allegation to CDPH and the incident was reported on October 10, 2024 at 3:16 p.m (25 hours later). SSA 1 stated he should have reported the abuse incident immediately within two hours to CDPH on October 9, 2024, after he was made aware of the abuse allegation. SSA 1 further stated, it was important to report abuse immediately to ensure the resident ' s safety and prevent any further abuse. On October 24, 2024, at 2:45 p.m., during a concurrent interview and review of Resident 1 ' s medical records with the Director of Nursing (DON), she stated, all facility staff are mandated reporters and any type of abuse, including allegations or suspicion of financial abuse should be reported to CDPH, ombudsman, the police within two hours. The DON further stated any resident reports of theft or loss of finances was considered financial abuse. The DON stated on October 9, 2024, Resident 1 reported to SSA 1 that he had missing finances. The DON further stated the abuse incident was not reported to CPDH until October 10, 2024 (25 hours after the allegation was made). The DON stated SSA 1 should have reported the abuse incident to CDPH within two hours on October 9, 2024. The DON further stated it was important to report any allegation or suspicion of abuse to ensure the safety of the resident and prevent any further abuse. A review of the facility policy and procedure titled, Abuse Prevention, dated December 31, 2015, indicated, .All employees .are mandated reporter .The facility is required to report all allegations of abuse, including .misappropriation of resident property .even if no reasonable suspicion within 2 hours . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555309 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 555309 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sundance Creek Post Acute 5800 West Wilson Street Banning, CA 92220 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 ensure for one of three sampled residents (Resident 1) was monitored after an allegation of financial abuse. Residents Affected - Few This failure had the potential to affect Resident 1 ' s emotional and psychosocial wellbeing. Findings: On October 24, 2024, at 9 a.m., an unannounced visit to the facility was conducted to investigate a misappropriation of property issue. A review of Resident 1's admission Record, indicated, Resident 1 was admitted to the facility on [DATE]. A review of Resident 1's History and Physical, dated October 4, 2024 indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1 ' s (city name) Police Department CAD Incident Report (police report), dated October 9, 2024 at 2:05 p.m., indicated, .Incident type: Theft .Caller Name: (Social Service Assistant [SSA] 1 ' s name) .Incident Comments: RP (sic) (Reporting Party) is Social Worker advised (Resident 1 ' s name) family member took his wallet .Patient is now saying his cash and cards are missing . A review of Resident 1s Social Service Notes, dated October 9, 2024, indicated the following: - .Police report opened for theft of resident ' s finances .(police case number). - .Resident came to SS (social service) to report missing finances .SSA called (city name) PD (police department) to make a claim regarding the claims from resident. A review of Resident 1 ' s Progress Notes, indicated Resident 1 was not assessed and monitored after the allegation of a misappropriation of property incident. On October 24, 2024, at 11:06 a.m., during a concurrent interview and review of Resident 1 medical records with the Social Service Director (SSD), he stated residents involved in any abuse allegation should be monitored for psychosocial wellbeing for 72 hours. The SSD stated on October 9, 2024, Resident 1 reported an allegation of financial abuse, and Resident 1 was not monitored for psychosocial wellbeing after the abuse allegation. The SSD further stated Resident 1 should have been monitored after the abuse allegation to ensure there were no negative psychosocial effects from the incident. On October 24, 2024, at 2:45 p.m., during a concurrent interview and review of Resident 1 medical records with the Director of Nursing (DON), she stated, Resident 1 was not assessed and monitored after the alleged financial abuse incident on October 9, 2024. The DON stated residents involved in an abuse allegation should be monitored for 72 hours for any negative effects. The DON further stated, it was important to assess and monitor a resident after an abuse allegation to determine any emotional, psychosocial effects. The DON stated her expectation was there should be a 72-hour monitoring and documentation of the involved resident after an abuse incident or allegation. The DON further (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555309 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 555309 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sundance Creek Post Acute 5800 West Wilson Street Banning, CA 92220 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete stated, Resident 1 should have been assessed and monitored for emotional distress and any changes in behavior. The DON stated, the facility did not have a specific policy related to the 72-hour monitoring but it was the facility ' s standard practice to monitor residents for 72 hours after any abuse allegations with the monitoring documented in the resident ' s medical records. A review of the facility's policy and procedure titled, .Abuse Prevention, dated December 31, 2015, indicated, .Where the circumstance of the alleged violation warrants .The Director of Nursing Services or designee shall initiate a physical and mental assessment of the resident .and document in the medical record . Event ID: Facility ID: 555309 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 555309 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sundance Creek Post Acute 5800 West Wilson Street Banning, CA 92220 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 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when staff was observed not performing hand hygiene upon entry and exit of two transmission-based precaution (TBP - an infection control measure use in healthcare to prevent the spread of infection and diseases) rooms. Residents Affected - Few This failure had the potential to increase the spread of pathogens (germs) and infections by staff to facility residents. Findings: On October 24, 2024, at 9:43 a.m., during a concurrent observation and interview in the hallway outside Resident 8's and Resident 9's rooms, a Droplet Precaution (a type of TBP) sign was observed outside the room doors. The Physical Therapy Assistant (PTA) was observed to not perform hand hygiene when exiting Resident 9's room and when entering and exiting Resident 8's room. The PTA stated droplet precaution requires facility staff and visitors to wear a mask and wash hands before entering and upon exiting the room. The PTA stated he did not perform hand hygiene when he exited Resident 9's room and when he entered and exited Resident 8's room. The PTA further stated he should have washed his hands to prevent the spread of pathogens and infections to facility residents. A review of the facility signage titled, Droplet Precaution, dated November 20, 2020, indicated, .Everyone Must: Clean their hands, including before entering and when leaving the room . On October 24, 2024, at 2:11 p.m., during an interview with the Infection Preventionist (IP), he stated the staff should perform hand hygiene when entering and exiting a resident's room. The IP further stated hand hygiene was important and the primary method to prevent the spread of infection and disease to facility residents. The IP stated the PTA should have performed hand hygiene prior to entering and exiting both Resident 9's and Resident 8's rooms. A review of the facility Policy and Procedure titled, Handwashing/Hand Hygiene, dated 2021, indicated, .The facility considers hand hygiene as the primary means to prevent the spread of health care associated infections .All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infection to .residents . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555309 If continuation sheet Page 5 of 5