Inspection·January 3, 2025

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. 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 provide showers on scheduled shower days and bed baths on non-shower days, for one of three sampled residents (Resident A). This failure had the potential to negatively affect the resident ' s physical, emotional, and social well-being which included skin infections, body odor, and discomfort. Residents Affected - Few Findings: Resident A ' s record was reviewed. Resident A was admitted to the facility on [DATE], with diagnoses which included bilateral lower extremities contractures (both legs experienced shortening of muscles leading to restricted movements) and history of cerebrovascular accident (stroke) with left-sided deficits (loss or impairment of function on the left side). A review of Resident A ' s care plan dated July 5, 2024, indicated, .ADL (activities of daily living)/Mobility: Resident .is at risk for ADL/mobility decline and requires assistance related to .HEMIPLEGIA (paralysis on one side of the body) AND HEMIPARESIS (weakness on one side of the body) .MUSCLE WEAKNESS .muscle wasting and Atrophy (gradual wasting away or decrease in size of a body part or tissue) .Encourage to participate in ADLs to promote independence .Monitor for .declines in ability to participate in ADLs . On December 18, 2024, at 10:21 a.m., Certified Nursing Assistant (CNA) 2 was interviewed. CNA 2 stated, residents were provided showers three to four times a week. CNA 2 stated, resident could be provided daily showers if the residents requested them. CNA 2 stated, if a resident refused a shower, she would offer the resident a bed bath. CNA 2 stated, if the resident refused twice, she would report this to the charge nurse. On December 18, 2024, at 11 am., CNA 4 was interviewed. CNA 4 stated, she was familiar with Resident A. CNA 4 stated, Resident A was dependent on all activities of daily living. CNA 4 stated residents were given bed bath if there was no scheduled shower. CNA 4 stated if a resident refused shower, it would be documented, and a bed bath would be provided according to facility protocol. On December 18, 2024, at 3:16 p.m., Licensed Vocational Nurse (LVN) 2 was interviewed. LVN 2 stated, she cared for Resident A. LVN 2 stated Resident A was non-verbal and required assistance with showering. LVN 2 stated Resident A preferred bed bath. A review of Resident A's Documentation Survey Report, for July 2024 and August 2024, indicated that on July 25, August 1, and August 5, 2024, Resident A's scheduled shower days, the resident received (continued on next page) 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. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 555309 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 01/03/2025 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)