Sundance Creek Post Acute: Transfer Delays Block Smoking - CA
Resident B told federal inspectors on July 23 that she preferred to be transferred to her wheelchair by 1 p.m. to participate in the facility's 1:30 p.m. smoking activity. But during her stay at Sundance Creek Post Acute, there were at least five occasions when she wasn't transferred on time.
Three of those delays happened on consecutive days in late June. On June 28, 29, and 30, Resident B missed the smoking activity entirely because no Hoyer lift was available when she needed it.
The resident explained her medical condition requires the mechanical lift for all transfers from her bed to wheelchair. When the equipment isn't available, she simply can't participate in activities she wants to attend.
CNA 1 confirmed the problem during an interview with inspectors. The aide said Resident B would get upset when she had to wait for a Hoyer lift, and wait times varied depending on how many other residents also needed the equipment. Smokers created particular bottlenecks in the schedule.
The facility's Activity Assistant verified that Resident B was absent from smoking activities on all three days in question, according to the smoker's log.
Beyond the smoking schedule, the delays affected other parts of Resident B's routine. She also preferred to be up at 9 a.m. for physical therapy sessions that started at 9:30 a.m. When the lift wasn't available, those appointments were disrupted too.
Federal inspectors found the facility violated requirements for supporting residents' activities of daily living. Regulations require nursing homes to provide appropriate care and services for residents who cannot carry out daily activities independently, including mobility and transfer assistance.
The facility's own policies, updated as recently as April 2025, state that residents should receive care and services "as appropriate to maintain or improve their ability to carry out ADLs." The policies specifically mention providing support with mobility and transfers.
Another facility policy from March 2021 promises that "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."
But for Resident B, those accommodations broke down when competing demands for the same piece of equipment left her stranded in bed while her preferred activities proceeded without her.
The smoking breaks represented more than just a nicotine habit. For many nursing home residents, scheduled activities provide structure, social interaction, and a sense of autonomy in an institutional setting. Missing three consecutive days of a preferred activity because of equipment scheduling problems suggests broader issues with care coordination.
The inspection found minimal harm to few residents, but the pattern of delays indicates systemic problems with managing transfer equipment and resident schedules. When multiple residents need the same lift at the same time, someone gets left behind.
Federal inspectors documented the violations during a complaint investigation completed on August 12, 2025. The facility now faces potential enforcement action for failing to provide timely assistance with transfers and mobility support.
For Resident B, the consequences were immediate and personal. Three days without her regular smoking break because staff couldn't coordinate a piece of equipment she needed to get out of bed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Sundance Creek Post Acute from 2025-08-12 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
SUNDANCE CREEK POST ACUTE in BANNING, CA was cited for violations during a health inspection on August 12, 2025.
Resident B told federal inspectors on July 23 that she preferred to be transferred to her wheelchair by 1 p.m.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.