That was just one of multiple safety violations federal inspectors documented during a January 17 inspection at Mirage Post Acute, where staff repeatedly left medications unattended, placed furniture on fall safety mats, and failed to maintain basic infection control standards.
The medication incident involved Resident 220, who had intact cognition and could understand staff clearly. Licensed Vocational Nurse 6 had left two white creams containing Fluocinonide External Ointment 0.05% in medicine cups at the resident's bedside. The topical medication was ordered twice daily for rashes throughout the resident's body.
When the facility's Infection Preventionist discovered the medications during rounds, she immediately noted "the medications should not be left at the bedside of the resident for safety."
But the problem extended far beyond a single incident. Inspectors found similar medication lapses with three other residents on the same day.
Medications Left Unattended
In Resident 471's room, inspectors observed multiple medications left at the bedside: sucralfate, Telmisartan, metoprolol, multivitamin, and baclofen. The resident had been admitted just four days earlier with pneumonia, high blood pressure, and gastro-esophageal reflux disease.
Licensed Vocational Nurse 7, who had left the medications, acknowledged "she should have not left the medications at the bedside for resident safety."
The facility's own policy explicitly prohibits this practice. According to the Self-Administration of Medications policy, any medications found at bedsides that aren't authorized for self-administration "are turned over the nurse in charge for return to the family or responsible party."
Director of Nursing staff told inspectors that leaving medications at bedsides "places confused residents at risk of ingesting the medication causing adverse effect on them."
Fall Safety Equipment Compromised
Perhaps more alarming were the violations involving fall prevention equipment designed to protect the facility's most vulnerable residents.
Resident 213, who had severe cognitive impairment and was classified as high risk for falls, had a side table placed directly on top of the fall mat beside the bed. The resident's care plan specifically called for "environmental evaluation to assess room safety" due to behavioral symptoms including striking out and grabbing others.
When the Assistant Director of Staff Development discovered the violation, she stated "there should be no furniture or equipment on top of the fall mat to prevent injury when resident fall on them."
The same problem appeared in multiple rooms. Resident 58, who had Alzheimer's disease and severe cognitive impairment, had an overbed table placed on the right floor mat. The table's wheels had left an indentation on the mat, "affecting the integrity of the floor mat affecting resident safety in the event a fall."
In Resident 19's room, inspectors found both an oxygen concentrator on the left floor mat and an overbed table on the right mat. The resident had Alzheimer's disease and was considered high risk for falls.
Licensed Vocational Nurse 9 admitted she wasn't aware equipment shouldn't be placed on floor mats long-term, but acknowledged "the overbed table can be unstable when moved and fall on the resident and cause injury."
Electrical Hazards in Patient Rooms
The safety violations extended to basic maintenance issues that posed electrocution risks.
In Resident 159's room, inspectors found a call light with "exposed/frayed wires on the neck of the call light button." The Assistant Director of Staff Development immediately called maintenance staff to replace the dangerous equipment, noting the frayed wires could cause "accidental electrocution of the resident."
A similar hazard existed in Resident 129's room, where the call light had "black and white wires exposed." Licensed Vocational Nurse 12 acknowledged this "placed the resident at risk for accidents such as electrocution due to exposed wires."
Infection Control Failures
Inspectors also documented serious infection control violations that could lead to catheter-associated urinary tract infections.
Resident 481, who had an indwelling urinary catheter due to benign prostatic hyperplasia, had catheter tubing "touching the floor." Registered Nurse 3 immediately recognized the problem, stating "the urinary catheter tubing should not be touching the floor to prevent infection to the resident."
The facility's own Catheter Care policy emphasizes that catheter tubing and drainage bags must be "kept off the floor" to prevent complications.
Another resident, identified as Resident 111, had a midline catheter with a transparent dressing that was overdue for changing. The dressing, dated January 6, was "soaked with bloody drainage and the infusion ports had bloody backflow" when inspectors observed it on January 14.
Registered Nurse 4 admitted "the dressing should have been changed on 1/13/2025" and noted the importance of keeping "the dressing clean and dry, ports flushed without blood backflow to prevent infection."
Medication Management Breakdowns
The facility's medication management system showed significant gaps that affected diabetic residents' care.
Resident 37, who had been at the facility since 2015 with Type II diabetes, experienced repeated problems getting prescribed medications. The resident told inspectors that during one shift, "her medication nurse could not find her metformin medication and she complained about it."
Licensed Vocational Nurse 1 acknowledged not administering the resident's Jardiance diabetes medication because "it was not available" and admitted to missing metformin doses on two separate days.
When inspectors reviewed the resident's Medication Administration Record, they found missing signatures for both Jardiance and metformin on multiple dates, with no documentation explaining why doses weren't given.
Registered Nurse 2 explained that when diabetic medications aren't administered as scheduled, "resident could potentially experience hyperglycemia symptoms such as cold, clammy skin, frequent urination, and/or altered level of consciousness."
Tube Feeding Safety Compromised
The facility also failed to properly label enteral feeding bottles, creating risks for residents receiving nutrition through feeding tubes.
Resident 66's feeding bottle lacked essential safety information including the resident's name, room number, administration rate, start date and time, and nurse initials. Licensed Vocational Nurse 13 acknowledged that proper labeling helps staff "know when it was started and ensure the formula was not expired."
The Director of Nursing explained that expired formula "can lead to gastrointestinal complications such as intolerance of the formula, stomach pain, and diarrhea."
Side Rail Violations
In one of the most serious safety violations, staff improperly used four side rails on Resident 39's bed without proper assessment or consent. The resident had a physician's order for only two upper side rails, but Certified Nursing Assistant 6 had raised all four rails.
When questioned, the CNA claimed "Resident 39 must have four side rails up to prevent her from falling out of the bed because the resident leans to the left and moves her feet."
However, Licensed Vocational Nurse 14 noted that using unauthorized side rails created "a potential that the resident's limbs could become wedged between the mattress and side rails causing bruising or injury."
The facility's policy requires attempting alternatives before using side rails, conducting safety assessments, and obtaining informed consent. None of these steps were followed.
Systemic Problems
The Director of Nursing acknowledged that the facility's policies weren't being followed. Regarding the side rail incident, she stated "this process was not followed by CNA 6 for Resident 39 and could have potentially resulted in entrapment and injury of the resident."
The violations affected residents with various conditions including diabetes, dementia, Alzheimer's disease, and those recovering from strokes. Many had severe cognitive impairments and required substantial assistance with daily activities, making them particularly vulnerable to the safety lapses inspectors documented.
The facility's own policies addressed each violation area, from medication safety to fall prevention to infection control. However, the inspection revealed a consistent pattern of staff failing to follow established procedures designed to protect resident safety and well-being.
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.