Health inspection·March 11, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed for one of three sampled residents (Resident 1), to report Resident 1's total right shoulder prosthesis dislocation [the artificial component of a shoulder replacement entirely come out of their proper position], an injury of unknown source, within 2 hours to California Department of Public Health (CDPH) after the facility was made aware of the injury, for one of three sampled residents (Resident 1). This failure had potential to result in further injury for Resident 1, affecting the resident physical, emotional, and psychosocial well-being. Findings: 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 January 24, 2025, indicated Resident 1 had fluctuating capacity to make medical decisions. A review of Resident 1 Admission/readmission Evaluation/Assessment, dated January 21, 2025, indicated, .Extremities (arms and legs) .No limited ROM (range of motion - a measure of joint function and flexibility) .No Edema (swelling) Present .Resident has no wounds or skin .concerns . A review of Resident 1 Nurse's Note, dated January 27, 2025, indicated, .R (sic) (right) shoulder xray (a test used to take pictures of areas inside the body) d/t (due to) c/o (complaints of) pain and swelling . A review of Resident 1's Radiology Interpretation, dated January 27, 2025, indicated, .Right Shoulder, 2 Views .Impression .Dislodgement of the glenoid fossa portion of the right shoulder prosthesis as well as a dislocation of the total right shoulder . A review of Resident 1's eINTERACT Change in Condition Evaluation, dated January 27, 2025, indicated, .Dislodgement of glenoid fossa portion of R (sic) (right) shoulder prosthesis as well as a dislocation of the total R (right) shoulder prosthesis .Pain, swelling to R (right) shoulder .Sent to ER .Xray: New or unsuspected finding . On February 24, 2025, at 1:56 p.m., during a concurrent interview and review of Resident 1 medical records with Registered Nurse (RN) 1, she stated, any injuries of unknown source should be reported Page 1 of 6 555309 555309 03/11/2025 Sundance Creek Post Acute 5800 West Wilson Street Banning, CA 92220

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to CDPH, police, and the Ombudsman [resident's advocate who investigates and addresses complaints ensuring their rights and well-being are protected] immediately or within 2 hours after the facility became aware of the injury. RN 1 further stated it was important to report these types of injuries because they could be related to abuse. RN 1 stated on January 27, 2025, during the afternoon shift, Resident 1 was sent to the hospital due to a right shoulder prosthesis dislocation. RN 1 further stated Resident 1's right shoulder dislocation was of unknown source and a sudden event. RN 1 stated Resident 1's injury was not reported to CDPH, police, or the Ombudsman. RN 1 further stated, after the X-ray results were received on January 27, 2025, Resident 1's injury should have been reported within two hours to CDPH to ensure resident safety and prevent any further injuries or abuse. On February 24, 2025, at 3:39 p.m., during a concurrent interview and review of Resident 1's medical records with the Director of Nursing (DON), she stated, Resident 1 was transferred to the hospital on January 27, 2025, due to right shoulder dislocation and prosthesis dislodgement. The DON further stated the facility does not know how Resident 1 dislocated his right shoulder and described it as an injury of unknown source and cause. The DON stated, the facility's process for reporting injuries of unknown source requires notification to the Ombudsman, police, and CDPH within two hours of the facility becoming aware of the injury to rule out abuse. The DON stated, Resident 1's right shoulder dislocation was not reported to CDPH, the Ombudsman, or the police. The DON further stated, Resident 1's injury should have been reported for the resident safety and to rule out any possible abuse. A review of the facility policy and procedure titled, Abuse, Neglect, Exploitation or Misappropriation Reporting and Investigating, dated April 2021, indicated, . All reports of resident abuse (including injuries of unknown origin) .are reported to local, state and federal agencies .Immediately .within two hours . A review of the facility policy and procedure titled, Recognizing Signs and Symptoms of Abuse/Neglect, dated 2021, indicated, .All personnel are expected to report any signs and symptoms of abuse/neglect .immediately .Signs of physical abuse: Injuries that are non-accidental or unexplained .Fractures, dislocations or sprains . 555309 Page 2 of 6 555309 03/11/2025 Sundance Creek Post Acute 5800 West Wilson Street Banning, CA 92220

F 0610 Respond appropriately to all alleged violations. 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 for one of three sampled residents (Resident 1), to investigate how Resident 1's right shoulder prosthesis became dislocated [the artificial component of a shoulder replacement entirely come out of their proper position]. Residents Affected - Few This failure had potential to result in further harm for Resident 1, affecting the resident physical, emotional, and psychosocial well-being. Findings: 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 January 24, 2025, indicated Resident 1 had fluctuating capacity to make medical decisions. A review of Resident 1 Admission/readmission Evaluation/Assessment, dated January 21, 2025, indicated, .Extremities (arms and legs) .No limited ROM (range of motion - a measure of joint function and flexibility) .No Edema (swelling) Present .Resident has no wounds or skin .concerns . A review of Resident 1 Nurse's Note, dated January 27, 2025, indicated, .R (sic) (right) shoulder xray (a test used to take pictures of areas inside the body) d/t (due to) c/o (complaints of) pain and swelling . A review of Resident 1s Radiology Interpretation, dated January 27, 2025, indicated, .Right Shoulder, 2 Views .Impression .Dislodgement of the glenoid fossa portion of the right shoulder prosthesis (a device designed to replace or make a part of the body work better) as well as a dislocation of the total right shoulder . A review of Resident 1's eINTERACT Change in Condition Evaluation, dated January 27, 2025, indicated, .Dislodgement of glenoid fossa portion of R (sic) (right) shoulder prosthesis as well as a dislocation of the total R (right) shoulder prosthesis .Pain, swelling to R (right) shoulder .Sent to ER .Xray: New or unsuspected findings . On February 24, 2025, at 1:56 p.m., during a concurrent interview and review of Resident 1's eINTERACT change in condition evaluation with Registered Nurse (RN) 1, she stated, Resident 1 was sent out to the hospital on January 27, 2025, during the afternoon shift due to a right shoulder prosthesis [artificial shoulder joint] dislocation. RN 1 further stated Resident 1's right shoulder prosthesis dislocation was from an unknown source and a sudden event. On February 24, 2025, at 3:39 p.m., during a concurrent interview and review of Resident 1's eINTERACT change in condition evaluation with the Director or Nursing (DON), she stated, the facility's process for injuries of unknown source requires an investigation once the facility becomes aware of the injury, in order to determine the cause and rule out possible abuse. The DON stated on January 27, 2025, Resident 1 was transferred to the hospital due to a right shoulder prosthesis dislocation and dislodgement. The DON further stated the facility did not know how 555309 Page 3 of 6 555309 03/11/2025 Sundance Creek Post Acute 5800 West Wilson Street Banning, CA 92220

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 1 dislocated his right shoulder prosthesis. The DON stated, Resident 1 had no falls or injuries, swelling, or right shoulder pain upon admission and that Resident 1's injury first appeared six days later. The DON stated, it was an injury of unknown source and cause. The DON stated Resident 1's injury was not investigated by the facility and the incident should have been investigated. A review of the facility policy and procedure titled, Abuse, Neglect, Exploitation or Misappropriation Reporting and Investigating, dated April 2021, indicated, . All reports of resident abuse (including injuries of unknown origin) .are reported to local, state and federal agencies .and thoroughly investigated by facility management .The administrator or his/her designee, provide the appropriate agencies .a written report of the findings of the investigation within five working days of the occurrence of the incident . 555309 Page 4 of 6 555309 03/11/2025 Sundance Creek Post Acute 5800 West Wilson Street Banning, CA 92220

F 0623 Level of Harm - Minimal harm or potential for actual harm Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed for one of three sampled residents (Resident 1) to: Residents Affected - Few 1. Provide the resident and or resident representative a written copy of the transfer or discharge. This failure had the potential to deny the resident the opportunity to understand the reasons for the transfer and the right to appeal, and other pertinent information related to the discharge process; and 2. Ensure a copy of the transfer or discharge notice was sent to the representative of the Office of the State Long-Term Care Ombudsman (LTC Ombudsman - an advocate for residents of nursing homes to protect residents' rights and ensure quality care). This failure had the potential to delay advocacy and oversight of Resident 1's discharge plan, impacting continuity of care and resident rights. Findings: 1. 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 January 24, 2025, indicated Resident 1 had fluctuating capacity to make medical decisions. A review of Resident 1's Physician Order, dated January 27, 2025, indicated, .Send to ER (emergency room) for eval (sic) (evaluation) and treatment . A review of Resident 1's eINTERACT Transfer Form, dated January 27, 2025, indicated, .Sent to (name of hospital) .Reasons: Dislodgement and dislocation of R (sic) (right) shoulder prosthesis (a device designed to replace or make a part of the body work better) . Further review of Resident 1's medical records indicated, no documented evidence that Resident 1 was provided a written copy of the transfer or discharge. On February 24, 2025, at 1:56 p.m., during a concurrent interview and review of Resident 1's notice of transfer or discharge record with Registered Nurse (RN) 1, RN 1 stated for transfers to an acute hospital, the licensed nurse would provide the resident with the paperwork and the notice of transfer or discharge. RN 1 stated, Resident 1 was transferred to acute on January 27, 2025, and there was no documentation indicating Resident 1 was provided a written notice of transfer or discharge. On February 24, 2025, at 3:39 p.m., during a concurrent interview and review of Resident 1's notice of transfer or discharge record with the Director of Nursing (DON), she stated when residents are transferred or discharged from the facility, the resident should be provided with the written copy of the notice of transfer or discharge. The DON stated, Resident 1 was not provided the notice of transfer or discharge. 555309 Page 5 of 6 555309 03/11/2025 Sundance Creek Post Acute 5800 West Wilson Street Banning, CA 92220

F 0623 Level of Harm - Minimal harm or potential for actual harm A review of the facility policy and procedure titled, Transfer or Discharge Notice, dated 2021, indicated, .Notice of transfer is provided to the resident and representative as soon as practicable before the transfer .Notices are provided in a form and manner that the resident can understand .Nursing notes will include documentation of appropriate orientation and preparation of the resident prior to transfer or discharge . Residents Affected - Few 2. 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 January 24, 2025, indicated Resident 1 had fluctuating capacity to make medical decisions. A review of Resident 1's Physician Order, dated January 27, 2025, indicated, .Send to ER (emergency room) for eval (sic) (evaluation) and treatment . A review of Resident 1's eINTERACT Transfer Form, dated January 27, 2025, indicated, .Sent to (name of hospital) .Reasons: Dislodgement and dislocation of R (sic) (right) shoulder prosthesis (a device designed to replace or make a part of the body work better) . Further review of Resident 1's medical records indicated, there was no documented evidence the facility mailed or faxed a copy of the transfer or discharge notice to the LTC Ombudsman after Resident 1 was discharged from the facility on January 27, 2025. On February 24, 2025, at 3:39 p.m., during a concurrent interview and review of Resident 1's notice of transfer or discharge record with the Director of Nursing (DON), she stated when residents are transferred or discharged from the facility, the Social Service Director (SSD) is responsible for sending the discharge notice to the LTC Ombudsman the same day or the next business day. The DON stated Resident 1 was transferred to the hospital on January 27, 2025, and the discharge notice was not sent to the LTC Ombudsman. The DON further stated the SSD should have sent the notice to the Ombudsman. On February 24, 2025, at 3:39 p.m., during a concurrent interview and review of Resident 1's notice of transfer or discharge record with the SSD, he stated for residents who transferred or discharged from the facility, the LTC Ombudsman is sent a letter to notify of the resident discharge the same day or the next business day. The SSD further stated Resident 1 was transferred to the hospital on January 27, 2025, and he did not send the discharge notice to the LTC Ombudsman. The SSD stated if a resident is transferred to the hospital, the hospital will send the notice. The SSD stated he should have sent the notice to ensure the LTC Ombudsman was made aware and able to advocate for Resident 1's care. A review of the facility policy and procedure titled, Transfer or Discharge Notice, dated 2021, indicated, .Notice of transfer is provided .to the long-term care ombudsman when practicable .If discharge is initiated by the facility .to the hospital .The facility will send a copy of the discharge notice to a representative of the office of the state LTC Ombudsman . 555309 Page 6 of 6