Inspection·July 9, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 assess and monitor one of four sampled residents (Resident 1) for signs and symptoms of circulatory insufficiency (decrease blood flow) in the right lower leg after testing positive for deep vein thrombosis (DVT - a blood clot). Residents Affected - Few This failure had the potential to result in staff being unable to detect worsening circulatory insufficiency. Findings: A review of Resident 1's admission Record, indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included diabetes (high blood sugar), end stage renal disease (kidney failure) and hemodialysis (special procedure done to remove wastes and excess fluids from the body). A review of Resident 1's History and Physical, dated April 6, 2025, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1's Radiology Results Report, dated May 1, 2025, indicated, .Venous Lower Extremity Unilat (unilateral - one side) .Interpretation .Significant findings .there is a clot in the right popliteal vein possibly chronic . A review of Resident 1's care plan indicated: - .Diabetes: Resident has a diagnosis of diabetes and is at risk for complications manifested by .peripheral vascular disease (decreased blood flow to lower extremities), skin breakdown .Interventions .monitor for skin changes or breakdown . - .Resident noted with right calf pain .5/1/25 .Venous Lower extremity unilateral US (ultrasound - medical tool that uses sound waves to produce images of the inside of the body) result: Chronic clot in the right popliteal vein (vein of the lower leg), MD (doctor) notified .potential for circulatory impairment (blood flow) manifested by pain, discoloration, swelling to R (right) foot .Interventions .Monitor for swelling, increasing to severe pain, discoloration and unable to move lower extremity . A further review of Resident 1's records did not indicate any documentation that Resident 1's right leg was assessed and monitored. A review of Resident 1's Change of Condition , dated May 9, 2025, indicated, .Resident noted with (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 2 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 07/09/2025 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)