Inspection visit
Inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in
accordance with accepted professional standards.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview, and record review, the facility failed to ensure resident's medical records were accurate and
complete in accordance with the accepted professional standards and practices, for one of three sampled
residents (Resident 1), when the nursing weekly summary and the skin evaluations did not reflect the skin
changes from May 21, 2025, to May 31, 2025.
These failures could negatively impact patient care and prevent staff or representatives from being aware of
the potential changes in the resident's skin condition.
Findings:
On June 19, 2025, at 12:30 p.m., an unannounced visit was conducted to investigate a quality-of-care
concern.
Resident 1's record was reviewed. Resident 1 was admitted on [DATE] with diagnoses which included
diabetes type two (inability to process and control glucose sugar levels in the body).
A review of Resident 1's History and Physical, indicated, Resident 1 had fluctuating capacity to understand
and make decisions.
A review of Resident 1's skin/wound note, indicated:
- Dated May 21, 2025, .Resident seen by Wound NP (nurse practitioner) for sacrum pressure wound. NP
reclassified wound from unstageable to stage 4 pressure injury. New Tx (treatment) order to collagen
(medication) and therahoney (medication) .
- Dated May 28, 2025, .Resident seen by wound specialist NP with NNO (no new orders) for sacrum
wound, wound worsen continue with treatment as indicated PRN if soiled or dislodge, two new skin
condition noted upon skin assessment and treatment with new tx (treatment) orders as follow: .Right heel
DTI (deep tissue injury), cleanse with wound cleanser, pat dry, apply betadine and cover with foam dressing
.every day shift .Right lateral malleolus DTI, cleanse with wound cleanser, pat dry, apply betadine and cover
with foam dressing
A review of Resident 1's Skin & (and) Wound Evaluation, indicated:
- Dated May 19, 2025, Sacrum pressure injury unstageable presenting about 40% slough (dead tissue) and
60% with very light serous drainage (fluid from wound) noted at this time, measuring 8 L
(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 3
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
07/08/2025
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 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
(length) x9 W (width) cm (centimeters - unit of measure) with order for Medi honey (medication) and foam
dressing .
- Dated May 26, 2025, .Sacrum .Area 75.1 Length 10.8 Width 10.2 (change in size) .No c/o on wound but
c/o generalized pain when turned or reposition .Sacrum pressure wound reclassified per NP as stage 4
presenting about 40% granulation, 20% slough and 40% epithelial tissue with light serious drainage noted
with order for therahoney and collagen to wound bed .
There were no skin and wound evaluations completed and no new measurements were obtained on May
21, 2025, and May 28, 2025, as required by facility protocol .
A review of Resident 1's Nursing Weekly Summary, from May 15, 2025, to May 31, 2025, indicated the
following:
- May 15, 2025 .skin .any skin changes/breakdown? .NO (is checked) .other comments .continues tx to left
lateral foot DTI, left lateral heel DTI, and coccyx .
- May 22, 2025 skin .any skin changes/breakdown? .NO (is checked) .other comments .no new skin issues
.
- May 29, 2025 .skin .any skin changes/breakdown? .NO (is checked) .other comments NA .
- May 31, 2025 .skin any skin changes/breakdown? .NO (is checked). Other comments .continues
treatment to left lateral foot DTI, left lateral heel DTI and coccyx. No changes .
There was no documented evidence that the nursing assessments described the progressive skin changes
identified by the treatment team from May 22, 2025, to May 31, 2025.
On June 19, 2025, at 2:00 p.m., a concurrent interview and record review was conducted with the Licensed
Vocational Nurse (LVN). The treatment records (TAR), skin treatment evaluations, and progress notes of
Residents 1 were reviewed. The LVN stated any skin changes found during the evaluation of the skin and
wounds should reflect in the resident's record. The LVN stated, the treatment team performing skin and
wound evaluations should obtain two sets of measurements: one manually and one using a digital tablet.
The LVN stated when Resident 1's wound assessment was completed on May 21, 2025 and May 28, 2025,
a skin evaluation should have been completed but it was not. The LVN further stated all skin evaluations
should include both measurements and a wound description, especially when there is a change in the
wound condition.
On June 19, 2025, at 3:09 p.m. a concurrent interview and record review was conducted with the Director of
Nursing (DON), she stated the licensed nurse should document in the TAR and skin evaluation that
treatment was completed, including a description of the wound and measurements. The DON stated, the
licensed nurse should have completed a skin evaluation on May 21, 2025, when the change in skin
condition was identified. The DON stated, the weekly nursing summary for Resident 1 did not reflect the
skin changes and should have been updated to include the most current description of the skin condition
from May 21, 2025, to May 31, 2025. The DON stated if the skin condition is not documented accurately,
there was a potential risk that the resident may not receive the necessary care and treatment, and the
nursing staff and representative parities to be unaware of the changes and care provided.
(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
07/08/2025
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 0842
Level of Harm - Minimal harm
or potential for actual harm
A review of the facility policy and procedure titled, Charting and Documentation, dated 2008 indicated, .All
services provided to the resident, or any changes in the resident's medical or mental condition, shall be
documented in the resident's medical record .all observations .services performed .must be documented in
the resident's clinical record .the assessment data and/or any unusual findings obtained during the
procedure/treatment .notification of family, physician or other staff .
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555309
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
FAQ · About this visit
Common questions about this visit
What happened during the July 8, 2025 survey of SUNDANCE CREEK POST ACUTE?
This was a inspection survey of SUNDANCE CREEK POST ACUTE on July 8, 2025. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at SUNDANCE CREEK POST ACUTE on July 8, 2025?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.