Health inspection·May 1, 2025

F 0609 .will continue to monitor . Level of Harm - Minimal harm or potential for actual harm A review of Resident 1's Progress Notes, dated March 28, 2025, at 3 a.m., indicated .resident resting in bed .no c/o (complaint of) pain or discomfort at this time .no acute distress noted .call light within reach . Residents Affected - Few 2. A review of Resident 2's admission Record, indicated, Resident 2 was admitted to the facility on [DATE], with diagnoses which included Schizoaffective disorder, bipolar type (a mental health condition). A review of Resident 2's History and Physical, dated January 15, 2025, indicated Resident 2 had capacity to understand and make decisions. A review of Resident 2's Minimum Data Set (an assessment tool) dated March 31, 2025, indicated a BIMS score of 9 (moderate cognitive impairment). A Review of Resident 2's Progress Notes, dated March 28, 2025, at 10:08 p.m., indicated .at 2200 (10 p.m.) (Resident 3) informed this LVN that she witnessed (Resident 2) going into room [ROOM NUMBER]. When (Resident 2) entered the room, she hit (Resident 1) in the (resident's room) in the head and proceeded to leave the room. CNAs and other staff members redirected (Resident 2) back to her room. This nurse evaluated (Resident 1) after she was hit and had little to no pain after (Resident 2) had hit her. Will continue to watch resident for this behavior . A review of Resident 2's Progress Notes, dated March 29, 2025, at 3:00 a.m., indicated .(Resident 2) sitting on wheelchair at the station. No s/sx (sign and symptoms) of agitation at this time. No reports of pain or discomfort. No acute distress noted. Kept the environmental calm and quiet . A review of Resident 2's Progress Notes, dated March 29, 2025, at 8:00 a.m., indicated .(Resident 2) has been wheeling herself around facility, calmly asking for breakfast and coffee. Educated her of breakfast times and resident went back to her room. Will continue to monitor and follow POC . A further review of Residents 1 and 2's record indicated, there was no documented evidence that the facility reported the alleged abuse to CDPH or facility Ombudsman on March 28, 2025, at 10 p.m. On April 4, 2025, at 12:55 p.m. an interview was conducted with Resident 3. Resident 3 stated on March 28, 2025, at approximately 10 p.m., she was in her room and observed Resident 1, who was sitting in her wheelchair and facing the window, when Resident 2 entered Resident 1's room and hit her on the back of the head. Resident 3 stated, she went to check on Resident 1, who appeared tearful and scared. Resident 3 stated, she assisted Resident 1 to the nurses' station and reported the incident to the Licensed Vocational Nurse (LVN) 1. On April 4, 2025, at 1:15 p.m., a concurrent observation and interview were conducted with Resident 1. Although nonverbal, Resident 1 was able to communicate in writing. Resident 1 wrote that Resident 2 had hit her on the head at night. Resident 1 also wrote that she was scared. Resident 1 indicated that Resident 3 witnessed the incident and helped her report the incident to the staff. On April 4, 2025, at 1:47 p.m., an interview was conducted with LVN 1. LVN 1 stated, she was assigned to both Residents 1 and 2 on the evening shift of March 28, 2025. LVN 1 stated, at 10 p.m., Resident 3 brought Resident 1 to the nurse's station and reported the witnessed incident. LVN 1 stated, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555309 If continuation sheet Page 2 of 3 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 05/01/2025 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)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few she informed Registered Nurse (RN 1) and relied on RN 1 for direction and did not receive further assistance. LVN 1 stated, the incident was a physical abuse and should have been reported to CDPH within two hours. LVN 1 stated, the failure to report in a timely manner could have exposed Resident 1 to further abuse and emotional distress. On April 4, 2025, at 2:15 p.m., an interview was conducted with RN 1. RN 1 stated, she was informed of the incident by LVN 1 around 10 p.m. RN 1 stated, she assumed LVN 1 would handle the reporting of the alleged abuse to CDPH. RN 1 stated, she should have followed up and ensured the report was made within the required timeframe to CDPH, the Ombudsman, law enforcement, the physician, and the resident's representative. On April 4, 2025, at 4:02 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated she was first informed of the incident on March 29, 2025, at approximately 9:50 a.m. by LVN 2. The DON stated, the incident between Residents 1 and 2 should have been reported to CDPH and other required entities within two hours of staff awareness. The DON stated, all staff are mandated reporters and must report allegations of abuse promptly to ensure resident safety and prevent emotional or physical harm. A review of the facility policy and procedure titled, Abuse, Neglect, Exploitation or Misappropriation Reporting and Investigation, dated September 2022, indicated, . All reports of resident abuse .are reported to local, state, and federal agencies .immediately .within two hours of an allegation involving abuse or result in serious bodily injury . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555309 If continuation sheet Page 3 of 3