Resident 179 sat in bed on January 14, 2025, when federal inspectors arrived at Mirage Post Acute and found the clear plastic cups containing various topical medications. The resident, who had been admitted in August 2023 with diabetes, hypertension, and missing left toes, told inspectors the nurse "sometimes leaves the ointments for him to apply himself."
His arms, legs, and torso were covered with raised red pustules in various stages of healing.
Licensed Vocational Nurse 4 confirmed the resident had a body rash that treatment nurses were supposed to care for. But Treatment Nurse 1 told inspectors she never leaves medications for residents to self-apply because Resident 179 "was not care planned for medication self-administration."
The confusion deepened when Certified Nursing Assistant 2 said she didn't see the medication cups during her shift, suggesting "maybe the resident hid the cups from her." She knew the resident kept tubes of ointment from his family in his nightstand but couldn't identify whether the surveyor had observed facility medications or the resident's personal supplies.
Two days later, Treatment Nurse 1 watched Resident 179 apply hydrocortisone cream to his left arm. She observed two tubes of hydrocortisone cream and a tube labeled Barmicil Compuesto on his bedside table. She left the room without removing any medications.
Resident 179 told inspectors he had three tubes of creams provided by his family that he applied himself, and that "facility staff knows that he applies the creams by himself and that he stores them in his room."
The Wound Coordinator, who had been treating the resident's recurring rash, said the resident had been seen by a dermatologist. But when she reviewed the resident's medical records, she found no physician's order for hydrocortisone cream or Barmicil Compuesto. The resident had never been assessed for safe self-administration of any medication.
"The resident should not be applying those medications," the Wound Coordinator told inspectors. She explained that if staff knew the resident wanted to self-administer topical medications, they should have notified the licensed nurse to ensure the physician agreed and that a self-administration assessment was completed.
Without proper oversight, she said, the resident's self-medication "may be a contributing factor as to why the resident's rash does not completely heal because the resident may be allergic to the ointments and creams he is self-administering."
Director of Nursing confirmed that medications should never be left at a resident's bedside, even for residents approved for self-administration. He had just learned that Resident 179 was self-administering medications with staff knowledge. The resident told him the medications were sent by family from another country.
"The licensed nurses and physician need to be aware of all the medications a resident is taking, document the administration in the MAR, and keep the medication locked up so it isn't available to other residents," the Director of Nursing said.
The facility's own policy requires that residents undergo comprehensive assessment by an interdisciplinary team before being approved for self-medication. The team must determine whether the resident can read medication labels, follow directions, understand timing and side effects, and safely store medications.
For approved self-administering residents, medications must be stored securely and administration must be documented. Any unauthorized medications found at bedside should be returned to family or responsible parties.
The medication safety violations were part of a broader pattern of care failures discovered during the January inspection. Federal inspectors found that five residents lacked accessible call lights, including one resident who hadn't had a call light for months despite care plans requiring them to be within reach.
Resident 49, who has dementia and bilateral leg amputations, had no call light at all. The metal wall plate behind his bed had adapter pieces but no cords attached. Staff said he breaks call lights, but maintenance had never been notified to replace the missing device.
"All residents should have a call light in case they need anything," said Certified Nursing Assistant 2, who regularly cared for Resident 49. She had reported the missing call light to charge nurses because "it concerned her that the resident may not get assistance."
Licensed Vocational Nurse 4 found the resident without a call light during medication rounds but failed to notice the missing device. "When residents are not provided a call light, the resident's safety is compromised because there may be delay in responding to the resident," she acknowledged.
The inspection also revealed widespread use of physical restraints without proper documentation. Ten residents had beds placed against walls, wedge pillows tucked under sheets, or other restrictive devices without required physician orders, informed consent, or safety assessments.
Resident 264 had a wedge pillow tucked under the sheet to prevent getting out of the right side of the bed. Staff acknowledged this was a restraint but had no physician order, consent, or care plan for its use.
Multiple residents had beds positioned against walls to prevent falls, but the facility failed to obtain informed consent or complete restraint assessments. Licensed Vocational Nurse 5 reviewed medical records for several residents and confirmed the missing documentation.
"It was important to have a physician's order, informed consent, restraint assessment, and care plan on the use of bed against the wall to ensure its safe use," she told inspectors.
The Director of Nursing said staff should obtain all required approvals and assessments before using any restraints. The facility's policy clearly defines physical restraints as devices residents cannot easily remove that restrict movement or access to their bodies.
In Resident 109's bathroom, hot water from the sink faucet measured only 85 to 86 degrees Fahrenheit after running for five minutes. Maintenance Staff 1 said hot water should reach 105 to 120 degrees to provide comfortable washing temperature. The facility's policy requires water temperatures in that range to prevent resident discomfort.
The facility also failed to properly screen Resident 164 for mental health conditions before admission. Despite having a diagnosis of schizophrenia, the resident's PASARR screening indicated no mental disorder. The Director of Admissions acknowledged she should have checked the admission record and coded the screening accurately to ensure proper care and services.
Three residents lacked required care plans for significant medical needs. Resident 249 had no care plans for antidepressant and anti-anxiety medications despite being on high-risk drug classes. Resident 481 had no care plan for his indwelling urinary catheter or for his bed being placed against the wall as a restraint.
The inspection found additional nursing practice violations, including failure to rotate insulin and blood thinner injection sites for seven residents. This practice can cause bruising, abnormal fat distribution, and protein buildup in the skin.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mirage Post Acute from 2025-01-17 including all violations, facility responses, and corrective action plans.