Mirage Post Acute failed to develop person-centered care for Resident 7, who refused to leave her room despite the ongoing ceiling leak. Instead, staff relied on a generic care plan that made no mention of the water damage or safety monitoring requirements.
The facility's Minimum Data Set Nurse Assistant reviewed Resident 7's care plan on November 21 and acknowledged its inadequacy. The plan included only broad interventions like "encourage active participation of care" and "monitor the effectiveness of safety equipment."
"The care plan was generalized and did not indicate hourly rounding to check and observe for the progression of leaks if improving or not," the nurse assistant told inspectors. She said the plan failed to address whether "Resident 7 was safe and feels safe inside the room."
The Director of Nursing agreed the approach violated federal requirements. "Resident 7's Care Plan should be person centered or individualized to address her safety inside the room that had a leaking ceiling," she told inspectors on November 21.
Three days later, the same director elaborated on the safety risks. She said the care plan should have included "an intervention that Resident 7 was being checked hourly to check for her safety."
Without proper monitoring, the director warned, "there might be a delay in room change and placing Resident 7's safety at risk."
The facility's own policies, last reviewed in July 2025, require staff to provide "person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences." The Director of Nursing admitted to inspectors that "the policy for person-centered care was not followed."
Federal regulations mandate comprehensive care plans with "measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs." The plans must describe specific services needed to maintain each resident's "highest practicable physical, mental, and psychosocial well-being."
When residents refuse recommended care, facilities must still document the refusal and develop alternative approaches. The regulations specify that interventions should "address the underlying source(s) of the problem area(s), not just symptoms or triggers."
Mirage Post Acute's generic approach fell short of these requirements. While Resident 7 had the right to remain in her room, the facility failed to create safety protocols for monitoring both the leak's progression and the resident's wellbeing in the compromised environment.
The inspection narrative doesn't specify how long the ceiling had been leaking or what caused the water damage. It also doesn't indicate whether the facility eventually moved the resident or developed an appropriate care plan.
The violation carried a minimal harm designation, affecting few residents. But the case illustrates how facilities can fail vulnerable residents even when following their preferences about care and living arrangements.
Resident 7's situation required balancing her autonomy with safety concerns. Federal inspectors found the facility tilted too far toward generic compliance rather than individualized protection.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mirage Post Acute from 2025-11-24 including all violations, facility responses, and corrective action plans.