Health inspection·January 18, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the psychosocial wellbeing of 1 out of 3 residents (Resident 1) when the facility put a screw on the window in Resident 1's room to prevent widow from opening all the way. This failure placed resident 1 at risk of depression, and a decline in psychosocial harm when Resident 1 stated he does not feel safe with screw is in the window. Findings: An unannounced visit was made to the facility on December 27, 2024, at 10:25 AM to investigate a complaint regarding Quality of Care/Treatment and Physical Environment. During a review of resident 1 ' s admission Record (general demographics), the document indicated resident 1 was admitted to the facility on [DATE], with a diagnosis to include Muscle weakness, other lack of coordination, low back pain, Encephalopathy (a group of conditions that cause brain dysfunction). During an interview with Resident 1, on December 27, 2023, at 10:45 AM, he stated he is doing well and is just concerned about the window. He states what happens if there is a fire? We could all get killed, there is no way to get out if the door or the hallway is on fire, and they cannot get to us, I do not feel safe with screw on window. During an interview with Administrator (AD) on December 27, 2023, at 10:30 AM, he stated to maintain temperature regulation for the facility all windows are secured and have a lock. There are other escape routes. He states all resident windows are secure with a screw. He stated he is not sure if it ' s in [NAME] 22 but he will have the Building director talk with me. During an interview with Building and Facilities director on December 27, 2023, at 10:35 AM, he stated that when he spoke with Life and Safety, he was told that all windows can be secured, even with a screw, to not disrupt air balance. He let me know he reached out to Life and safety to email him the policy where it states it is ok to secure windows in that manner. During an interview with DON (Director of Nursing) on December 27, 2023, at 11:00 AM, she stated she is aware all windows are secured with a screw and in case of a fire there are escape routes throughout facility. States she is not sure why there are screws om windows. (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: 555773 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 555773 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Indian Canyon Post Acute 57333 Joshua LN Yucca Valley, CA 92284 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)