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 (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 6 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 03/11/2025 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)