Health inspection·August 12, 2025

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to make reasonable accommodations to meet the needs and preferences of two residents (Residents A and B) who required Hoyer lift (a mechanical device used to transfer residents who cannot bear weight) for transfers. This failure resulted in delays, missed activities, and disruption of established daily routines for two of three sampled residents (Residents A and B).Findings:On July 22, 2025, at 12:14 p.m., during an interview with Resident A, he stated everybody is fighting over two Hoyer lifts. Resident A stated, two Hoyer lifts were not enough to service more than 100 residents.1.A review of Resident A's admission Record indicated Resident A was admitted to the facility May 26, 2019, with diagnoses which included morbid obesity (extremely overweight), and chronic pain syndrome (persistent pain lasting longer than 3 months, often significantly impacting daily life and potentially leading to disability).On July 22, 2025, at 1:53 p.m., during an interview with Certified Nurse Assistant (CNA) 1, CNA 1 stated at least ten residents in the East station require a Hoyer lift for transfers. CNA 1 stated the facility needs four or five Hoyer lifts at that station to accommodate smokers who want to smoke at the same time.On July 22, 2025, at 1:58 p.m. during an interview with the Maintenance Supervisor (MS), the MS stated there were three functioning Hoyer lifts in the facility, one was disabled, and no replacement parts were available. On July 22, 2025, at 4:33 p.m. during another interview with Resident A, he stated it is hard for us to wait to be transferred and it screws up our daily routines. Resident A stated his routine is to be up at 10 a.m. daily and back to bed at 11:30 a.m. Resident A stated, this has happened more than once and sometimes he was told there was no available Hoyer lift and had to wait until other residents were finished. A review of Resident A's care plan dated February 18, 2025, indicated .Focus : Self Care Deficit at risk for poor hygiene R/T (related to) DX (diagnosis) - chronic pain syndrome.Needs total with 2 persons assistance with transfer .Intervention.CNA May sit up resident in wheelchair with Hoyer lift for transfer every day shift .On July 23, 2025, at 11:54 a.m., during an interview with CNA 2, CNA 2 stated she was regularly assigned to Resident A. CNA 2 stated it was facility practice to accommodate resident preferences. CNA 2 stated Resident A required the Hoyer lift for transfers and preferred to be up by 10 a.m., and 30 minutes earlier on shower days. CNA 2 stated, it often took longer than that to transfer him because there was no available Hoyer lift, requiring her to wait until other CNAs were finished. 2. A review of Resident B's admission Record, indicated Resident B was admitted to the facility on [DATE], with diagnoses which included hemiplegia (one sided paralysis) and hemiparesis (muscle weakness restricted to one side) following cerebral infarction (disrupted blood flow to the brain).A review of Resident B's care plan dated February 7, 2025, with target date of August 6, 2025, indicated Focus : ADL (activity of daily living)/Mobility: Resident has actual ADL/Mobility decline and requires assistance related to Dx of (L)left sided weakness s/p (status post) CVA (cerebrovascular accident -stroke) Intervention.Transfer.Use EZ (another brand) lift during transfer for safety every Residents Affected - Few Page 1 of 2 555309 555309 08/12/2025 Sundance Creek Post Acute 5800 West Wilson Street Banning, CA 92220

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few shift,,,On July 23, 2025, at 12:43 p.m., during an interview with CNA 1, CNA 1 stated Resident B preferred to be up at 9 a.m., for physical therapy at 9:30 a.m. and on other days at 1 p.m. to attend the 1:30 p.m. smoking schedule. CNA 1 stated Resident B would get upset when she had to wait for a Hoyer lift, and this wait time varied depending on how many other residents also needed the lift, especially smokers. On July 23, 2025, at 1:23 p.m., during an interview, Resident B stated she needed the Hoyer lift for transfers due to her medical condition. Resident B stated she preferred to be up by 1 p.m. to participated in the 1:30 p.m. smoking activity. Resident B stated in her stay at the facility, there were at least five occasions when she was not transferred to her wheelchair on time, including three occasions in the previous month (June 28, 29, and 30, 2025) when she missed the smoking activity entirely due to the unavailability of a Hoyer lift. On July 23, 2025, at 4:55 p.m. in a concurrent interview and record review of Smoker's Log with Activity Assistant (AA), AA stated Resident B did not attend smoking on June 28, June 29 & June 30, 2025.A review of facility policy and procedure titled, Activities of Daily Living (ADL), Supporting, dated April 2025, indicated, Residents are provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out ADLs.Appropriate care and services are provided for residents who are unable to carry out ADLs independently.in accordance with the plan of care, including appropriate support and assistance with.mobility.transfer.A review of the facility titled Accommodation of Needs, dated March 2021, indicated .The resident's individual needs and preferences are accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered . 555309 Page 2 of 2