Mirage Post Acute

F-F554 (Resident 179)

Findings:

1. During a review of Resident 213's Admission Record, the Admission Record indicated the facility admitted

the resident on 4/16/2024, with diagnoses including fracture (a break or a crack in a bone) of left lower leg, history of falling, and dementia (a progressive state of decline in mental abilities).

During a review of Resident 213's Minimum Data Set (MDS, a resident assessment tool), dated 10/23/2024,

the MDS indicated the resident usually had the ability to make self-understood and understand others and had severe cognitive impairment (a condition that makes it difficult for a person to think, learn, remember, and make decisions). The MDS indicated the resident was dependent to requiring substantial assistance on mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily).

During a review of Resident 213's Fall Risk Observation/Assessment, dated 10/23/2024, the Fall Risk

Observation/Assessment indicated the resident was high risk for falls.

During a review of Resident 213's Care Plan (CP) regarding psychosocial-behavior, resident exhibits or is at risk for behavioral symptoms (i.e. striking out, grabbing others etc.), last revised on 12/24/2024, the CP indicated an intervention of environmental evaluation to assess room safety.

During a concurrent observation and interview on 1/14/2025, at 10:04 a.m., with the Assistant Director of Staff Development (ADSD), inside Resident 213's room, observed a side table on top of the resident fall mat at the right side of the bed. The ADSD stated there should be no furniture or equipment on top of the fall mat to prevent injury when resident fall on them.

During an interview on 1/17/2025, at 3:38 p.m., with the Director of Nursing (DON), the DON stated there should be no equipment or furniture on top of the fall mat to prevent injuries to the resident when they land

on the fall mat.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0689 During a review of the facility's recent policy and procedure (P&P) titled Homelike Environment, last reviewed

on 4/18/2024, the P&P indicated residents are provided with a safe, clean, comfortable, and homelike Level of Harm - Minimal harm or environment and encouraged to use their personal belongings to the extent possible. potential for actual harm 2. During a review of Resident 220's Admission Record, the Admission Record indicated the facility admitted Residents Affected - Few the resident on 4/28/2024, with diagnoses including type 2 diabetes mellitus (a chronic disease that occurs when the body does not produce enough insulin or does not use it properly), diabetic neuropathy (nerve damage caused by diabetes), and dysphagia (swallowing difficulties).

During a review of Resident 220's MDS, dated [DATE REDACTED], the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition (having the ability to think, learn, and remember clearly).

During a review of Resident 220's Order Summary Report, dated 12/5/2024, the Order Summary Report indicated an order for Fluocinonide External Ointment 0.05 % (Fluocinonide). Apply to rash throughout body topically (used on the outside of the body) two times a day for rash to rash throughout body Apply Fluocinonide External Ointment 0.05 % to Rash throughout body twice a day (BID).

During a concurrent observation and interview on 1/15/2024, at 10:59 a.m., with the Infection Preventionist (IP), inside Resident 220's room, observed 2 white creams on a medicine cup left at the resident's bedside.

The IP stated the medications should not be left at the bedside of the resident for safety.

During an interview and record review on 1/15/2025, at 11:10 a.m., with LVN 6, reviewed Resident 220's Order Summary Report. LVN 6 stated the white cream on two medication cups were Fluocinonide External Ointment 0.05 % (Fluocinonide) for the resident's rashes. LVN 6 stated she should have not left the medications at the bedside to prevent accidental ingestion of the medication of confused residents in the facility.

During an interview on 1/17/2025, at 3:38 p.m., with the DON, the DON stated the staff should not be leaving any medications at the bedside for resident safety. The DON stated leaving the medications at the bedside places confused residents at risk of ingesting the medication causing adverse effect on them.

During a review of the facility's recent policy and procedure (P&P) titled Self-Administration of Medications, last reviewed on 4/18/2024, the P&P indicated self-administered medications are stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer are stored on a central medication cart or in the medication room. Any medications found at the bedside that are not authorized for self-administration are turned over the nurse in charge for return to the family or responsible party.

3. During a review of Resident 471's Admission Record, the Admission Record indicated the facility admitted

the resident on 1/3/2025, with diagnoses including pneumonia (an infection/inflammation in the lungs), essential hypertension (a type of high blood pressure that develops gradually over time and has no identifiable cause), and gastro-esophageal reflux disease (GERD, a condition where stomach contents move up into the esophagus).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0689 During a review of Resident 471's MDS, dated [DATE REDACTED], the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 471's Order Summary Report, dated 1/5/2025, the Order Summary Report indicated an order for Glipizide-Metformin Oral Tablet 5-500 milligrams (mg, unit of mass or weight ) Residents Affected - Few (Glipizide-Metformin HCl). Give 1 tablet by mouth one time a day for DM. There was no order for metronidazole, cefpodoxime, and valacyclovir on the Order Summary Report of the resident.

During an interview on 1/14/2025, at 11:10 a.m., with LVN 6, LVN 6 stated the medications that she left at

the bedside were metronidazole, valacyclovir, glipizide, and cefpodoxime. LVN 6 stated she should have not left the pills at the bedside for resident safety.

During an interview on 1/17/2025, at 3:38 p.m., with the DON, the DON stated the staff should not be leaving any medications at the bedside for resident safety. The DON stated leaving the medications at the bedside places confused residents at risk of ingesting the medication causing adverse effect on them.

During a review of the facility's recent policy and procedure (P&P) titled Self-Administration of Medications, last reviewed on 4/18/2024, the P&P indicated self-administered medications are stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer are stored on a central medication cart or in the medication room. Any medications found at the bedside that are not authorized for self-administration are turned over the nurse in charge for return to the family or responsible party.

4. During a review of Resident 482's Admission Record, the Admission Record indicated the facility admitted

the resident on 1/13/2025, with diagnoses including essential hypertension (high blood pressure that does not have a clear, identifiable cause) and gastritis (a condition where the stomach lining becomes inflamed or irritated).

During a review of Resident 482's Order Summary Report, dated 1/13/2025, the Order Summary Report indicated an order for:

Baclofen Oral Tablet 5 mg (Baclofen). Give 5 mg by mouth every 12 hours for muscle spasms.

Metoprolol Tartrate Oral Tablet 50 mg (Metoprolol Tartrate). Give 50 mg by mouth two times a day for hypertension. Hold for systolic blood pressure (SBP, the pressure of blood against the artery walls when the heart has just finished contracting or pumping out blood) less than ( <)110 or pulse <60. Give with food.

Multivitamin. Give 1 tablet by mouth one time a day for supplement.

Sucralfate Oral Tablet 1 gm (Sucralfate). Give 1 tablet by mouth two times a day for GERD.

Telmisartan Oral Tablet 40 mg (Telmisartan). Give 2 tablet by mouth one time a day for hypertension (high blood pressure) hold for SBP <110.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0689 During a concurrent observation and interview on 1/14/2025, at 2:25 p.m., with Licensed Vocational Nurse 7 (LVN 7), inside Resident 482's room, observed Resident 482's sucralfate, Telmisartan, metoprolol, MVI, and Level of Harm - Minimal harm or baclofen left at the bedside. LVN 7 stated she should have not left the medications at the bedside for potential for actual harm resident safety.

Residents Affected - Few During an interview on 1/17/2025, at 3:38 p.m., with the DON, the DON stated the staff should not be leaving any medications at the bedside for resident safety. The DON stated leaving the medications at the bedside places confused residents at risk of ingesting the medication causing adverse effect on them.

During a review of the facility's recent policy and procedure (P&P) titled Self-Administration of Medications, last reviewed on 4/18/2024, the P&P indicated self-administered medications are stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer are stored on a central medication cart or in the medication room. Any medications found at the bedside that are not authorized for self-administration are turned over the nurse in charge for return to the family or responsible party.

5. During a review of Resident 159's Admission Record, the Admission Record indicated the facility admitted

the resident on 11/23/2024, with diagnoses including collapsed vertebra (when a bone in the spine collapses), muscle weakness, and other symptoms and signs involving the musculoskeletal system ( body's support structure).

During a review of Resident 159's MDS, dated [DATE REDACTED], the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition.

During a concurrent observation and interview on 1/14/2025, at 9:59 a.m., with the ADSD, inside Resident 159's room, observed the call light of the resident was near the trash can at the right side of the bed with exposed/frayed wires on the neck of the call light button. The ADSD stated the call light cord should not have any frayed wires on them to prevent accidental electrocution of the resident. The ADSD immediately called

the Maintenance Staff to replace the call light with the frayed wires.

During an interview on 1/17/2025, at 3:38 p.m., with the DON, the DON stated there should be no exposed electrical wiring at the resident's rooms. The DON stated the frayed wires on the call light cord of the resident can cause accidental injuries like electrocution. The DON stated it is the responsibility of all staff in the facility to report potential accidents in the facility to protect the residents.

During a review of the facility's recent policy and procedure (P&P) titled Maintenance Service, last reviewed

on 4/18/2024, the P&P indicated maintenance service shall be provided to all areas of the building, grounds, and equipment. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.

43988

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0689 6. During a review of Resident 193's Admission Record, the Admission Record indicated the facility originally admitted the resident on 11/7/2023, and readmitted the resident in the facility on 7/28/2024, with diagnoses Level of Harm - Minimal harm or including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and potential for actual harm hemiparesis (weakness on one side of the body) following cerebrovascular disease (stroke, loss of blow to a part of the brain) affecting right dominant side, type 2 diabetes mellitus (a chronic disease that occurs when Residents Affected - Few the body does not produce enough insulin or does not use it properly) with foot ulcer, and generalized weakness.

During a review of Resident 193's History and Physical (H&P) dated 7/28/2024, the H&P indicated Resident 193 had fluctuating capacity to understand and make decisions.

During a review of Resident 193's MDS dated [DATE REDACTED], the MDS indicated the resident had severely impaired cognition (having the ability to think, learn, and remember clearly). The MDS indicated Resident 193 required supervision or touching assistance with eating and oral hygiene; partial/moderate assistance with mobility, upper body dressing, and personal hygiene; total assistance with lower body dressing, tub and toilet transfers; substantial/maximal assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).

During a review of Resident 193's Order Summary Report, the Order Summary Report indicated a physician's order dated 7/28/2024:

- Bedside safety mattress right and/or left side while resident in bed. Monitor for placement every shift and each opportunity that resident is observed in bed, and as needed.

During a review of Resident 193's Fall Risk Assessments dated 7/28/2024, 8/15/2024, and 10/21/2024, the Fall Risk Assessments indicated Resident 193 was a high risk for falls.

During a concurrent observation and interview on 1/15/2025 at 12:00 p.m. inside Resident 193's room with Licensed Vocational Nurse 15 (LVN 15), LVN verified Resident 193 did not have a bedside safety mattress

on the left side of the bed. LVN 1 stated Resident 193 was a high risk for falls due to poor cognition and positioning in bed. LVN 15 stated she was not sure if Resident 193 had an order for a bedside safety mattress. LVN 15 stated staff should ensure the bedside safety mattress was always at the resident's bedside per physician's order to prevent injuries from falls and monitored for placement every shift. LVN 15 stated Resident 193's bedside safety mattress should have been at the bedside for safety and to prevent the resident from getting injured during a fall.

During an interview and record review on 1/15/2025 at 12:10 p.m. with Licensed Vocational Nurse 14 (LVN 14), reviewed Resident 193's physician's order with LVN 14. LVN 14 verified Resident 193 had a physician's order for beside safety mattress dated 7/28/2024. LVN 14 stated Resident 193's bedside safety mattress should have been placed at the resident's bedside on the floor as it placed the resident at risk for incurring injury during a fall incident.

During an interview on 1/17/2025 at 5:30 p.m. with the Director of Nursing (DON), the DON stated if the staff obtained an order from the physician to place a bedside safety mattress for safety during falls, the staff should place the safety mattress at the bedside on the floor and monitor placement every shift. The DON stated Resident 193's bedside safety mattress should have been placed at the bedside. The DON stated not placing the safety mattress at the bedside placed Resident 193 at risk for getting injured in the event of a fall incident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0689 During a review of the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents, last reviewed 4/18/2024, the P&P indicated: Level of Harm - Minimal harm or potential for actual harm - Individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. Residents Affected - Few - Implementing interventions to reduce accident risks and hazards shall include the following:

a. Communicating specific interventions to all relevant staff.

b. Ensuring the interventions are implemented

c. Documenting interventions

- Monitoring the effectiveness of interventions shall include the following:

a. Ensuring the interventions are implemented correctly and consistently.

- Certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures which include bed safety and falls.

7. During a review of Resident 58's Admission Record, the Admission Record indicated the facility admitted

the resident on 11/30/2019 with diagnoses including dementia (a progressive stated of decline in mental abilities), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).

During a review of Resident 58's History and Physical (H&P) dated 12/15/2024, the H&P indicated Resident 58 did not have the capacity to understand and make decisions.

During a review of Resident 58's MDS dated [DATE REDACTED], the MDS indicated the resident had severely impaired cognition (having the ability to think, learn, and remember clearly). The MDS indicated Resident 58 required partial/moderate assistance with eating and mobility; substantial/maximal assistance with oral hygiene and upper body dressing; total assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).

During a review of Resident 58's Order Summary Report, the Order Summary Report indicated a physician's order dated 7/18/2022:

- Bedside safety mat right and/or left side while resident in bed. Monitor for placement every shift and each opportunity that resident is observed in bed and as needed.

During a review of Resident 58's Fall Risk Assessments dated 8/5/2024, 11/3/2024, and 11/29/2024, the fall risk assessments indicated Resident 58 was a high risk for falls.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0689 During a review of Resident 58's care plan on high risk for fall related to poor safety awareness, and behavioral problems initiated on 3/22/2023 and last revised on 11/6/2024 indicated bed safety mat right on Level of Harm - Minimal harm or the right and/or left while resident in bed and provide a safe environment, free of clutter, clear floors and potential for actual harm adequate lighting as a few of the interventions to prevent falls.

Residents Affected - Few During a concurrent observation and interview on 1/14/2025 at 12:37 p.m., inside Resident 58's room with Wound Coordinator (WC), observed Resident 58 lying in bed asleep with the overbed table placed on top of

the right floor mat. The WC stated she is not aware that the overbed table cannot be placed on top of the floor mat for a long period of time. The WC verified Resident 58's overbed table wheels left an indentation on

the floor affecting the integrity of the floor mat affecting resident safety in the event a fall.

During an interview on 1/17/2025 at 5:30 p.m. with the Director of Nursing (DON), the DON resident rooms should be free of clutter and the floor clear. The DON stated there should no equipment or furniture placed

on top of the floor mat for a long period of time. The DON stated Resident 58's overbed table should have not been left on top of the floor mat as it can cause injury to the resident when they fall out of the bed and hit

the table that was on the floor mat.

During a review of the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents, last reviewed 4/18/2024, the P&P indicated:

- Individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents.

- Implementing interventions to reduce accident risks and hazards shall include the following:

a. Communicating specific interventions to all relevant staff.

b. Ensuring the interventions are implemented

c. Documenting interventions

- Monitoring the effectiveness of interventions shall include the following ensuring the

interventions are implemented correctly and consistently.

- Certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures which include bed safety and falls.

8. During a review of Resident 19's Admission Record, the Admission Record indicated the facility admitted

the resident on 11/27/2021 with diagnoses including Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), pain in unspecified joint, and generalized muscle weakness.

During a review of Resident 19's History and Physical (H&P) dated 9/18/2024, the H&P indicated Resident 19 did not have the capacity to understand and make decisions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0689 During a review of Resident 19's MDS dated [DATE REDACTED], the MDS indicated the resident had severely impaired cognition (having the ability to think, learn, and remember clearly). The MDS indicated Resident 19 required Level of Harm - Minimal harm or supervision or touching assistance with eating; substantial/maximal assistance with showers, transfers, and potential for actual harm lower body dressing; partial/moderate assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). Residents Affected - Few

During a review of Resident 19's Order Summary Report, the Order Summary Report indicated a physician's order dated 10/13/2024:

- Bedside safety mat right and/or left side while resident in bed. Monitor for placement every shift and each opportunity that resident is observed in bed and as needed.

During a review of Resident 19's Fall Risk Assessments dated 9/6/2024, 10/12/2024, and 12/5/2024, the fall risk assessments indicated Resident 19 was a high risk for falls.

During a review of Resident 19's care plan (CP) indicated the following:

1. Potential for further injury/fall related to poor safety awareness, unsteady gait/balance, and weakness initiated on 11/28/2021 and last revised on 10/14/2024, the CP indicated bed safety mat right on the right and/or left while resident in bed and provide a safe environment, free of clutter, clear floors and adequate lighting as a few of the interventions to prevent falls.

2. Resident had an unwitnessed fall and is at risk for recurring falls, pain, and injury initiated on 10/14/2024,

the CP indicated bed safety mat right on the right and/or left while resident in bed and monitor for placement every shift as on the interventions to prevent further falls.

During an observation on 1/14/2025 at 12:37 p.m. inside Resident 19's room, observed Resident 19 lying in bed asleep, with oxygen concentrator (medical device that extracts oxygen from the surrounding air, concentrating it and delivering it to the patient) placed on top of the left floor mat and overbed table on top of

the right floor mat.

During a concurrent observation and interview on 1/15/2025 at 5:20 p.m. inside Resident 19's room with Licensed Vocational Nurse 9 (LVN 9), LVN 9 verified Resident 19's oxygen concentrator was placed on top of the left floor mat and the overbed table was placed on top of the right floor mat. LVN 9 stated she is not aware if there should be no equipment or furniture on top of the floor mat for long period of time. LVN 9 stated the overbed table can be unstable when moved and fall on the resident and cause injury. LVN 9 stated Resident 19 can get injured when the resident falls out of bed and hit the overbed table and oxygen concentrator. LVN 9 Resident 19's overbed table and oxygen concentrator should not have been placed on top of the floor mat for long period of time.

During an interview on 1/17/2025 at 5:30 p.m. with the Director of Nursing (DON), the DON stated there should no equipment or furniture placed on top of the floor mat for a long period of time. The DON stated Resident 19's overbed table and oxygen concentrator should have not been placed on top of the floor mats as it can cause injury to the resident when they fall out of the bed and hit the table or oxygen concentrator that was on the floor mat. The DON stated a resident's environment should be clutter free and clear of any hazards.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0689 During a review of the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents, last reviewed 4/18/2024, the P&P indicated: Level of Harm - Minimal harm or potential for actual harm - Individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. Residents Affected - Few - Implementing interventions to reduce accident risks and hazards shall include the following:

a. Communicating specific interventions to all relevant staff.

b. Ensuring the interventions are implemented

c. Documenting interventions

- Monitoring the effectiveness of interventions shall include the following ensuring the interventions are implemented correctly and consistently.

- Certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures which include bed safety and falls.

9. During a review of Resident 129's Admission Record, the Admission Record indicated the facility originally admitted the resident on 8/3/2021 and readmitted the resident on 8/16/2021 with diagnoses including dysphagia (difficulty swallowing), unspecified intellectual disabilities (a lifelong condition that limits a person's mental functioning and skills), and difficulty in walking.

During a review of Resident 129's History and Physical (H&P) dated 9/5/2024, the (H&P) indicated the resident did not have the capacity to understand and make decisions.

During a review of Resident 129's MDS dated [DATE REDACTED], the MDS indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 129 required total assistance from staff with lower body dressing, partial/moderate assistance with bathing, toileting hygiene, upper body dressing, toilet transfer, and shower transfer, and substantial/maximal assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for

an individual to thrive).

During a review of Resident 129's fall risk assessments dated 5/27/2024, 8/24/2024, and 11/23/2024, the fall risk assessments indicated the resident was a high risk for falls.

During a review of Resident 129's care plan (CP) on potential for injury or falls due to unsteady gait or balance and poor safety awareness initiated 8/4/2021 and last revised on 8/25/2023, the CP indicated the following interventions to prevent falls:

- Call light placed within reach.

- Instruct use of call light whenever in need of assistance. Instruct use of safety.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0689 During a concurrent observation and interview on 1/14/2025 at 10:38 a.m. inside Resident 129's room with Licensed Vocational Nurse 12 (LVN 12), observed Resident 129's call light was coiled and hung on the wall Level of Harm - Minimal harm or plug with the black and white wires exposed. LVN 12 the maintenance department staff is responsible in potential for actual harm ensuring the call lights are in proper working condition. LVN 12 stated she is not sure of how often and when

the maintenance staff make their rounds to check on the rooms. LVN 12 stated Resident 129's call light Residents Affected - Few should not have the black and white wires exposed as it placed the resident at risk for accidents such as electrocution due to exposed wires.

During an interview on 1/17/2025 with the DON, the DON stated the maintenance department is responsible to do room rounds and check on any defective equipment in resident rooms and replace them as needed.

The DON stated there should be no exposed electrical wiring at the resident's rooms. The DON stated Resident 129's call light should not have the black and white wires exposed as it can cause accidental injuries like electrocution. The DON stated it is the responsibility of all staff in the facility to report potential accidents in the facility to protect the residents.

During a review of the facility's recent policy and procedure (P&P) titled Maintenance Service, last reviewed

on 4/18/2024, the P&P indicated maintenance service shall be provided to all areas of the building, grounds, and equipment. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.

44244

10. During a review of Resident 179's Admission Record, the Admission Record indicated the facility admitted the resident on 8/28/2023 with diagnoses that included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (HTN-high blood pressure), and acquired absence of left toes.

During a review of Resident 179's MDS dated [DATE REDACTED], the MDS indicated the resident was able to understand others and was able to make himself understood. The MDS further indicated the resident required partial/moderate assistance from staff for bathing and dressing, required supervision for toileting and personal hygiene, and required setup or clean up assistance for eating and oral hygiene.

During a review of Resident 179's History and Physical (H&P), dated 12/3/2024, the H&P indicated the resident had fluctuating capacity to understand and make decisions.

During a review of Resident 179's Skin Rash Weekly Monitoring tool, the tool indicated on 12/6/2024 the resident had a rash throughout the body.

During a concurrent observation and interview o [TRUNCATED]

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Level of Harm - Minimal harm or potential for actual harm 44376

Residents Affected - Few Based on observation, interview, and record review, the facility failed to ensure resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections (UTI, an infection in

the bladder/urinary tract) for one of two sampled residents (Resident 481) being investigated under urinary catheters (a hollow tube inserted into the bladder to drain or collect urine) by failing to keep the urinary catheter tubing off the floor.

The deficient practices had the potential for residents to develop catheter associated urinary tract infection (CAUTI, an infection of the urinary tract caused by a tube [urinary catheter] that has been placed to drain urine from the bladder [an organ inside the body that stores urine until it can be excreted]).

Findings:

During a review of Resident 481's Admission Record, the Admission Record indicated the facility admitted

the resident on 7/20/2024, and readmitted the resident on 1/13/2025, with diagnoses including cellulitis (a bacterial infection that affects the skin and underlying tissue), benign prostatic hyperplasia (a non-cancerous condition that causes the prostate gland to enlarge) with lower urinary tract symptoms, and urinary tract infection.

During a review of Resident 481's Minimum Data Set (MDS, a resident assessment tool), dated 7/26/2024,

the MDS indicated the resident usually had the ability to make self-understood and understand others and had intact cognition (a person's mental abilities, like thinking, remembering, understanding, and reasoning, are fully functioning and not significantly impaired). The MDS indicated the resident had an indwelling urinary catheter.

During a review of Resident 481's Order Summary Report, dated 7/22/2024, the Order Summary Report indicated an order of indwelling catheter size 16 French (FR)/10 cubic centimeter (cc, a commonly used unit of volume). Diagnosis (Dx): benign prostatic hyperplasia with lower urinary tract symptoms.

During a concurrent observation and interview on 1/14/2025, at 12:28 p.m., with Registered Nurse 3 (RN 3), inside Resident 481's room, observed the urinary catheter of the resident hanging at the right side of the bed with the tubing touching the floor. RN 3 stated the urinary catheter tubing should not be touching the floor to prevent infection to the resident. RN 3 stated when the staff is doing their rounds on their residents, the staff should be proactively checking for infection control issues.

During an interview on 1/17/2025, at 3:38 p.m., with the Director of Nursing (DON), the DON stated the staff should keep the urinary catheter tubing off the floor to prevent ascending infection to the resident such as UTI.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 58 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0690 During a review of the facility's recent policy and procedure (P&P) titled Catheter Care, Urinary, last reviewed

on 4/18/2024, the P&P indicated the purpose of this procedure is to prevent catheter-associated Level of Harm - Minimal harm or complications, including urinary tract infections. Be sure the catheter tubing and drainage bag are kept off the potential for actual harm floor.

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 59 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0693 Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43988

Residents Affected - Few Based on observation, interview, and record review, the facility failed to ensure residents receiving enteral feeding (EF - also known as tube feeding, a method of supplying nutrients directly into the stomach) received appropriate care and services to prevent complications of enteral feeding for one (1) of 1 sampled resident (Resident 66) investigated under the tube feeding care area when the EF bottle did not indicate in the label

the resident's name, room number, administration rate, the date and time the bottle was started, and the initials of the nurse.

This deficient practice had the potential to result in altered nutritional status such as dehydration and malnutrition and complications associated with enteral feeding such as gastrointestinal (GI) (relating to stomach and intestines) problems such as abdominal pain and diarrhea.

Findings:

During a review of Resident 66's Admission Record, the Admission Record indicated the facility originally admitted the resident on [DATE REDACTED], and readmitted the resident on [DATE REDACTED], with diagnoses including type 2 diabetes mellitus (a chronic disease that occurs when the body does not produce enough insulin or does not use it properly) with foot ulcer, neuromuscular disorder of the bladder (lack bladder control due to a brain, spinal cord or nerve problem), and pressure ulcer (injuries to the skin and the tissue below the skin that are due to pressure on the skin for a long time) of left buttock.

During a review of Resident 66's Minimum Data Set (MDS, a resident assessment tool), dated [DATE REDACTED], the MDS indicated the resident had severely impaired cognition (having the ability to think, learn, and remember clearly). The MDS indicated Resident 66 required substantial/maximal assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 66 had a diagnosis of gastrostomy status and received tube feeding.

During a review of Resident 66's Order Summary Report, the Order Summary Report indicated the following physician's order dated [DATE REDACTED]:

- Every shift continuous gastrostomy tube (G-tube) feeding of Glucerna 1.2 formula at 75 milliliter per hour (ml/hr - a unit of measurement for 20 hours to provide 1500 ml per 1800 kilocalories (kcal - a unit of measurement). Pump to run from 1:00 p.m. to 9:00 a.m. or until dose limit is met.

During a review of Resident 66's care plan (CP) on enteral nutrition related to swallowing problem initiated

on [DATE REDACTED] indicated the following interventions:

- Enteral nutrition as ordered, monitor tolerance to enteral feeding.

- Monitor for nausea or vomiting, abdominal distention, or discomfort with each feeding or as needed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 60 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0693 During a concurrent observation and interview on [DATE REDACTED] at 9:57 a.m. inside Resident 66's room with Licensed Vocational Nurse 12 (LVN 13), LVN 13 verified Resident 66's EF bottle did not indicate the Level of Harm - Minimal harm or resident's name, room number, administration rate, start date and time, and nurse initials on the label. LVN potential for actual harm 13 stated when hanging a new EF bottle, the charge nurse is supposed to indicate in the label the resident's name, room number, administration rate, the date and time the bottle was started, and the initials of the Residents Affected - Few nurse. LVN 13 stated, Resident 66's EF bottle should have indicated in the label the resident's name, room number, administration rate, the date and time the bottle was started, and the initials of the nurse for the staff to know when it was started and ensure the formula was not expired.

During an interview on [DATE REDACTED] at 5:30 p.m. with the Director of Nursing (DON), the DON stated the staff write

in the formula bottle the resident's name, room number, administration, dated and time the formula was started, and the initials of the nurse. The DON stated charge nurse should have indicated in Resident 66's EF bottle the resident's name, room number, administration, dated and time the formula was started, and the initials of the nurse so the other nurse would be aware when the EF bottle was started and that it was not expired. The DON stated if the formula was expired it can lead to gastrointestinal complications such as intolerance of the formula, stomach pain, and diarrhea.

During a review of the facility's policy and procedure (P&P) titled, Enteral Feedings - Safety Precautions, last reviewed [DATE REDACTED], the P&P indicated a purpose to ensure safe administration of enteral nutrition. The P&P further indicated the following general guidelines on preventing errors in administration:

- Check the enteral nutrition label against the order before administration. Check the following information:

a. Resident name, ID, and room number

b. Type of formula

c. Date and time formula was prepared.

d. Route of delivery

g. Rate of administration (ml/hour).

- On the formula label document initials, date and time the formula was hung, and initial that the label was checked against the order.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 61 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43988 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure parenteral fluids (are liquids Residents Affected - Some that are administered intravenously or by injection to bypass the digestive system) were administered consistent with professional standards of practice:

1. For one (1) out of 1 sampled resident (Resident 55) investigated during a random observation when Resident 55's intravenous fluid (IVF) did not indicate the date and time it was started and the licensed nurse's initials on the label.

This deficient practice had the potential to place Resident 452 at risk for developing complications such as inflammation of the vein and infection.

2. For 1 of 1 sampled resident (Resident 111) investigated under peripheral intravenous catheter (PIVC, a thin, flexible tube that is inserted into a vein through the skin to administer fluids, medications, or blood products) by failing to:

a. Clarify with the primary physician if the midline catheter (a long, thin, flexible tube inserted into a vein in

the upper arm) was still needed in the facility.

b. Change the dressing of the midline catheter of the resident, dated 1/6/2024 on the day of observation.

c. Flush the 2 infusion ports (a small medical device that allows healthcare providers to access a vein and give fluids and medications) of the midline catheter with normal saline routinely and after accessing the infusion ports.

These deficient practices had the potential to result in Resident 111's midline catheter site to develop an infection.

Findings:

a. During a review of Resident 55's Admission Record, the Admission Record indicated the facility admitted

the resident on 7/29/2022 with diagnoses including type 2 diabetes mellitus (a chronic disease that occurs when the body does not produce enough insulin or does not use it properly), hypertension (HTN - high blood pressure), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).

During a review of Resident 55's History and Physical (H&P) dated 7/19/2024, the (H&P) indicated the resident had fluctuating capacity to understand and make decisions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 62 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0694 During a review of Resident 55's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 11/5/2024, the MDS indicated the resident had an intact cognition (mental action or process of Level of Harm - Minimal harm or acquiring knowledge and understanding). The MDS indicated Resident 55 required set up or clean up potential for actual harm assistance with eating, partial/moderate assistance with bathing, upper and lower body dressing, and ambulation; supervision or touching assistance with all other activities of daily living (ADLs - basic tasks that Residents Affected - Some must be accomplished every day for an individual to thrive).

During a review of Resident 55's Order Summary Report, the Order Summary Report indicated a physician's order dated 1/14/2025:

- Sodium Chloride Intravenous Solution 0.9% (NS - a solution often used to restore blood volume and provide hydration in cases of dehydration, low blood volume, or fluid loss due to bleeding or burns). Use 75 milliliter per hour (ml/hr) intravenously every shift for electrolyte imbalance (a condition that occurs when certain mineral levels in the blood get too high or too low when a person lose a large amount of body fluids such as sweating or vomiting) for 1 liter only.

During a concurrent observation and interview on 1/15/2024 at 9:13 a.m. inside Resident 55's room with Registered Nurse 3 (RN 3), observed a bag of Sodium Chloride Intravenous Solution infusing at 75 ml/hr via pump and did not indicate on the label the start date and time and initials of the licensed nurse. RN 3 stated licensed nurses are supposed to indicate in the label the date and time the infusion was started and the initials of the licensed nurse who started it. RN 3 stated he was the one who started Resident 55's infusion. RN 3 stated he should have indicated in the label the date and time he started the infusion and his initials. RN 3 stated the purpose of indicating the date and time and initials of the licensed nurse is so all the staff would be aware of when it was started which can lead to complications.

During an interview on 1/17/2025, at 3:38 p.m., with the Director of Nursing (DON), the DON stated when administering intravenous solutions, the licensed nurses should indicate in the label the date and time the bad was started and indicate the initials of the licensed nurse. The DON stated the licensed nurse who started the infusion should have indicated in Resident 55's intravenous solution bag the date and time it was started and the licensed nurse's initials to ensure all staff are aware of when the IV was started to prevent complications and to ensure the infusion was accurate.

During a review of the facility's policy and procedure (P&P) titled, Peripheral I.V.: Continuous Infusion, last reviewed 4/18/2024, the P&P indicated a purpose to infuse liquids and electrolytes through a cannula directly

in the vein to replace water and electrolyte losses from the body and provide a vehicle for the administration of medications. The P&P further indicated to label the administration set and container with time, date, and initials of the nurse.

44376

b. During a review of Resident 111's Admission Record, the Admission Record indicated the facility admitted

the resident on 1/18/2023, and readmitted the resident on 12/14/2024, with diagnoses including cellulitis (a bacterial infection that affects the skin and underlying tissue) of left lower limb and peripheral vascular disease (PVD, a slow and progressive disorder of the blood vessels).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 63 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0694 During a review of Resident 111's MDS dated [DATE REDACTED], the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition (a participant who has sufficient Level of Harm - Minimal harm or judgment, planning, organization, self-control, and the persistence needed to manage the normal demands potential for actual harm of the participant's environment). The MDS indicated the resident had intravenous (IV, within a vein) medications. Residents Affected - Some

During a review of Resident 111's Order Summary Report, the Order Summary Report indicated an order for:

12/16/2024 Flush each lumen (infusion ports) with 3 cubic centimeters (cc, a unit of measurement for volume) of 0.9% sodium chloride (NaCl, mixture of water and salt) before and after each meds.

1/16/2025 Central Line Care- change transparent dressing and injection cap/extension every 7 days and if needed (PRN) if integrity is compromised as needed and every day and evening shift every 7 day(s).

During a review of Resident 111's Care Plan (CP) titled Vascular Access: Resident is at risk for complications due to the presence of a midline for treatment if long term IV antibiotic therapy, last revised on 12/16/2024, the CP indicated an intervention to flush IV access per physician orders and keep IV site dressing dry and intact.

During a concurrent observation and interview on 1/14/2025, at 12:20 p.m., with the Registered Nurse 4 (RN 4), inside Resident 11's room, observed Resident's midline catheter with transparent dressing dated 1/6/2025, soaked with bloody drainage and the infusion ports had bloody backflow. RN 4 stated the dressing should be changed every 7 days and PRN. RN 4 stated the dressing should have been changed on 1/13/2025. RN 4 also stated the infusion ports should be flushed routinely and before and after medications were administered on the ports. RN 4 stated it was important to keep the dressing clean and dry, ports flushed without blood backflow to prevent infection and to keep the line patent and intact.

During an interview on 1/17/2025, at 3:38 p.m., with the DON, the DON stated the dressing of the midline catheter should be changed every 7 days or PRN when soiled to prevent infection and the infusion ports should be flushed routinely, before and after administering medications to prevent clogging of the line.

During a review of the facility's recent policy and procedure (P&P) titled, Guidelines for Preventing Intravenous Catheter -Related Infections, last reviewed 4/18/2024, the P&P indicated the purpose of this procedure is to maximally reduce the risk of infection associated with indwelling intravenous (IV) catheters. Change TSM dressings on CVADs every 5-7 days or PRN if damp, loosened, or visibly soiled. This does not require a physician's order. Replace transparent dressings on tunneled or implanted CVCs every 5-7 days unless the dressing is loose or soiled.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 64 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0700 Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed Level of Harm - Minimal harm or consent; and (4) Correctly install and maintain the bed rail. potential for actual harm 44244 Residents Affected - Some Based on observation, interview, and record review the facility failed to ensure the safe and appropriate use of side rails (SR, adjustable rigid plastic or metal bars attached to the bed that may be positioned in various locations on the bed; upper or lower, either or both sides) for one of nine sampled residents (Resident 39) reviewed under the Restraints care area by failing to:

1. Attempt to use appropriate alternatives prior to installing bilateral lower (at the leg area) SRs.

2. Conduct an assessment including the risk for entrapment (occurs when a resident is caught between the mattress and bed rail or within the bed rail itself) from bilateral lower SRs use.

3. Review the risk and benefits of bilateral lower SRs with the resident or resident representative and obtain informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered).

These deficient practices had the potential to result in psychosocial harm, physical harm from entrapment and death of residents.

Findings:

During a review of Resident 39's Admission Record, the Admission Record indicated the facility admitted the resident on 6/4/2024 with diagnoses that included osteomyelitis (inflammation of bone or bone marrow, usually due to infection) of vertebra (bones of spine), sacral and sacrococcygeal region (base of spine at the tailbone), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (partial paralysis or weakness on one side of the body) following cerebral infarction (CVA-stroke, loss of blood flow to a part of the brain) affecting the right dominant side, cognitive communication deficit (trouble communicating due to problems with thinking skills), and depression.

During a review of Resident 39's Minimum Data Set (MDS - resident assessment tool) dated 12/11/2024, the MDS indicated the resident was able to understand others and was able to make herself understood. The MDS further indicated the resident required partial/moderate assistance from staff for toileting and required substantial/maximal assistance for bathing, dressing, personal hygiene, and mobility while in bed.

During a review of Resident 39's History and Physical (H&P), dated 6/7/2024, the H&P indicated the resident did not have the capacity to understand and make decisions.

During a review of Resident 39's Order Summary Report, the report indicated an order for two, top quarter SRs up for mobility/enabler (safety), every shift, dated 6/4/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 65 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0700 During a review of Resident 39's Nursing Bed Rail Observation Assessment, dated 6/4/2024, the assessment indicated informed consent was received by the resident's representative after a discussion Level of Harm - Minimal harm or regarding the risk and benefits of the use of the recommended left and right upper SRs that did not impede potential for actual harm the resident's freedom of movement.

Residents Affected - Some During a concurrent observation and interview on 1/14/2025 at 12:14 p.m., with Resident 39, Resident 39 lay

in bed with four SRs (bilateral upper and bilateral lower) in the raised position. Observed Certified Nursing Assistant 6 (CNA 6) entered the resident's room, spoke to the resident, and then exited. Resident 39 stated

the staff puts the SRs up and she cannot remove them.

During an interview on 1/14/2025 at 12:22 p.m. with CNA 6, CNA 6 stated Resident 39 must have four SRs up to prevent her from falling out of the bed because the resident leans to the left and moves her feet.

During an observation on 1/15/2025 at 7:45 a.m., observe Resident 39 in bed with fours SRs in the raised position.

During a concurrent observation, interview, and record review on 1/16/2025 at 9:19 a.m., with CNA 6 and Licensed Vocational Nurse 13 (LVN 13), LVN 13 reviewed Resident 39's physician orders. Observed LVN 13 at Resident 39's room entry. Observed Resident 39 with four SRs in the raised position. LVN 13 stated she did not know why Resident 39 had four SRs up because the resident had a physician's order for only two SRs. LVN 13 stated CNA 6 was also caring for Resident 39 and CNA 6 did not mention the resident needed four SRs. CNA 6 approached LVN 13 and stated Resident 39 requested to have the four SRs in the raised position to prevent falls. LVN 13 stated SRs should not be used as a fall prevention strategy. LVN 13 stated there was no need for Resident 39 to have four SRs in the raised position. LVN 13 stated CNA 6 should have communicated that Resident 39 requested to have the four SRs up because there is a process to follow for the use of SRs. LVN 13 stated if the resident requested four SRs, the physician should be notified and the resident should be assessed for safety.

During a concurrent interview and record review on 1/16/2025 at 9:48 a.m., with Licensed Vocational Nurse 14 (LVN 14), LVN 14 reviewed Resident 39's physician orders, Care Plans, and Nursing Bed Rail

Observation Assessment, dated 6/4/2024. LVN 14 stated Resident 39 had an order, was care planned, and assessed and consented for the use of two upper SRs only. LVN 14 stated there was no documentation to indicate the resident requested to have four SRs. LVN 14 stated if Resident 39 requested for four SRs, then

the resident needed to be re-evaluated. LVN 14 stated the importance of the safety evaluation is to make sure the resident would not become confined or trapped in the SRs. LVN 14 stated a bolster mattress (designed to prevent residents from falling out of bed) could be used to provide a feeling of security for the resident instead of using four SRs that pose more of a risk. LVN 14 stated when CNA 6 placed Resident 39's four SRs in the raised position there was a potential that the resident's limbs could become wedged between

the mattress and SRs causing bruising or injury.

During a follow up interview on 1/16/2024 at 12:27 p.m. with LVN 14, LVN 14 stated Resident 39 did not have the capacity to consent for the use of four SR's so the resident's representative was called. LVN 14 stated the representative did not consent to the use of four SRs.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 66 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0700 During a concurrent interview and record review on 1/17/2025 at 12:10 p.m. with the Director of Nursing (DON), the DON reviewed the facility policy and procedures regarding SRs. The DON stated some beds in Level of Harm - Minimal harm or the facility have lower SRs that cannot be removed from the bed. The DON stated CNA 6 saw the lower SRs potential for actual harm and placed them up for Resident 39. The DON stated there is a process for the use of SRs that includes an interdisciplinary meeting to determine the safety of SR use and to explain the risk and benefits of the SRs to Residents Affected - Some the resident and representative. The DON 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 DON stated the facility policy for SRs was not followed.

During a review of the facility P&P titled, Bed Safety and Bed Rails, last reviewed 4/18/2024, the P&P indicated resident beds meet the safety specifications established by the Hospital Bed Safety Workgroup.

The use of bed rails is prohibited unless the criteria for use of bed rails have been met. The resident's sleeping environment is evaluated by the interdisciplinary team. Consideration is given to the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family. Bed rails are adjustable metal or rigid plastic bars that attach to the bed. The use of bed rails or SRs is prohibited unless the criteria for the use of bed rails have been met, including attempting alternatives, interdisciplinary evaluation, resident assessment, and informed consent. Prior to the installation or use of a side or bed rail, alternatives to the use of side or bed rails are attempted. Alternatives may include roll guards, foam bumpers, lowering the bed, and the use of a concave mattress to reduce rolling off the bed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 67 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm 38552

Residents Affected - Some Based on observation interview, and record review, the facility failed provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for one of one sampled resident (Resident 37) and one of three medication carts (Station 1 Cart B) investigated under the Medication Storage and Labeling task by:

1. Failing to administer Resident 37's Jardiance (hypoglycemic medication-lowers blood sugar levels) and metformin (hypoglycemic medication) medications as ordered by the physician.

This deficient practice placed Resident 37 at risk for causing complications and delay in the necessary care and services the resident needs.

2. Failing to ensure licensed nurses completed the incoming and outgoing Floor Narcotic (opioid [a class of drug to reduce moderate to severe pain]) Release (a form signed by the incoming and outgoing licensed nurse after reconciling narcotic medications) on 1/14/2025 for Station 1 Cart B.

This deficient practice had the potential to result in increase opportunity for medication diversion (the transfer of a medication from a lawful to an unlawful channel of distribution or use).

Findings:

During a review of Resident 37's Admission Record, the Admission Record indicated the facility admitted the resident on 6/23/2015 with diagnoses including type II diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), multiple sclerosis (MS-a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord), and rheumatoid arthritis (a chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility).

During a review of Resident 37's Minimum Data Set (MDS-a resident assessment tool), dated 10/11/2024,

the MDS indicated the resident had the ability to make self understood and had the ability to understand others. The MDS indicated the resident is taking a hypoglycemic one of the high-risk drug classes.

During a review of Resident 37's Order Summary Report, the Order Summary Report indicated:

- Jardiance (empagliflozin) oral tablet 10 milligram (mg-a unit of measurement) give (1) tablet by mouth in the morning for diabetes, dated 12/8/2024.

- Metformin hydrochloride (HCl) tablet 1000 mg, give 1000 mg by mouth in the morning related to type 2 diabetes mellitus without complications with meal, dated 1/4/2023.

- Metformin HCl tablet 500 mg, give 500 mg by mouth in the evening related to type 2 diabetes mellitus without complications, dated 1/4/2023.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 68 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0755 During a review of Resident 37's care plan focusing on medication-hypoglycemic, initiated date 1/16/2025,

the care plan indicated the goals of no sign/symptoms of hyperglycemia: flushed skin, dry skin, drowsiness, Level of Harm - Minimal harm or nausea, vomiting, abdominal pain, and increased respirations. The care plan indicated to administer potential for actual harm medications as ordered which included Jardiance oral tablet daily and metformin HCl tablet 1000 mg in the morning and 500 mg in the evening. Residents Affected - Some

During an interview of Resident 137 pm 1/15/2025 at 9:28 a.m., Resident 37 stated during the 3 p.m. to 11 p. m. shift on 1/14/2025 her medication nurse could not find her metformin medication and she complained about it and later they were able to find it and gave her metformin.

During a concurrent observation and interview on 1/16/2025 at 6:40 a.m., inspected Station 1 Cart B with Licensed Vocational Nurse 1 (LVN 1). LVN 1 stated she has completed medication administration for Resident 37 for medications scheduled at 6:30 a.m. LVN 1 stated she did not administer Jardiance because

it was not available. LVN 1 stated Resident 37 last received Jardiance on 1/12/2025 and she submitted the refill request on 1/15/2025 and has not been delivered yet. LVN 1 stated Resident 37's metformin is in the cart, and she administered it 1/16/2025 and 1/15/2025. LVN 1 stated she did not administer metformin on 1/13/2025 and 1/14/2025. LVN 1 stated Resident 37 requested for her supervisor and Registered Nurse 1 (RN 1) spoke to the resident about her 6:30 a.m. scheduled medications.

During an interview with LVN 1 on 1/16/2025 at 7:38 a.m., LVN 1 stated she was told by RN 1 that their pharmacy has ran out of Jardiance and that Resident 37's Jardiance medication would not be delivered until 1/20/2025.

During an interview on 1/16/2025 at 10 a.m., Resident 37 stated she had problems with her medications again that morning when the medication nurse would not give her (Resident 37) medication, Jardiance. Resident 37 she complained about it and she spoke to RN 1. RN 1 was able to find the resident's Jardiance and administered to Resident 37. Resident 37 stated it was an ongoing issue with her medications and the facility is not doing anything about it.

During a concurrent observation and interview on 1/16/2025 at 10:20 a.m., re-inspected Station 1 Cart B, with LVN 15. LVN 15 stated she completed medication administration for Resident 37. Requested to see the bubble packs (packaging that have a preformed plastic pocket or shell where a product sits securely in place) scheduled during the morning medications. LVN 15 stated Jardiance bubble pack was in her drawer, but she did not administer it because it is scheduled for 6:30 a.m. and not during her shift, 7 a.m. to 3 p.m. shift. LVN 15 stated she did not put it there and it should be placed in the 11 p.m. to 7 a.m. drawer.

During an interview on 1/16/2025 at 1:23 p.m., with Registered Nurse 2 (RN 2), RN 2 stated she did not receive report from RN 1 about Resident 37's medication concerns that morning. RN 2 stated if the resident's medication needed follow-up, she would follow-up with pharmacy and ensure the resident's medication be delivered on time.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 69 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0755 During a concurrent interview and record review of Resident 37's Medication Administration Record (MAR) 1/2025, on 1/16/2025 at 1:36 p.m., with RN 2, RN 2 stated Resident 37's Jardiance and metformin did not Level of Harm - Minimal harm or have initials on 1/6/2025 and 1/14/2025. RN 2 stated there were no documentation in the nursing potential for actual harm progress/narrative notes about the metformin and Jardiance on 1/6/2025, 1/13/2025, and 1/14/2025 of any explanation why the doses were not administered. RN 2 stated medications should be administered on time Residents Affected - Some and as ordered. RN 2 stated when Resident 37's hypoglycemic medications are not administered as scheduled and as ordered, resident could potentially experience hyperglycemia symptoms such as cold, clammy skin, frequent urination, and/or altered level of consciousness.

During a concurrent interview and record review of Resident 37's MAR for 1/2025, on 1/17/2025 at 7:01 a.m., with RN 1, RN 1 stated Resident 37 likes things done a certain way, and he (RN 1) administered Jardiance

on 1/16/2025 and 1/14/2025. RN 1 stated he also administered Resident 37's metformin on 1/14/2025 but he did not sign the MAR. RN 1 stated he has access to the electronic MAR and he should have charted (documented) the MAR after he administered the medications to Resident 37. RN 1 stated the purpose of documentation is to make sure the resident is receiving the proper care including the medications.

During an interview on 1/17/2025 at 4:19 p.m., with the Director of Nursing (DON), the DON stated medications are administered as ordered by the physician because it is part of the six patient rights. The DON stated when residents do not receive their medication, the resident could have an adverse effect and is

a medication error. The DON stated when the licensed nurse does not document on the resident's MAR when the medication was given,

then it was not done, and the medication was not given.

During a review of the facility's policy and procedure (P&P) titled, Administering Medications, last reviewed

on 4/18/2024, the P&P indicated medications are administered in a safe and timely manner, and as prescribed. The P&P indicated medications are administered in accordance with prescriber orders, including any required time frame. The P&P indicated as required or indicated for a medication, the individual administering the medication records in the resident's medical record the signature and title of the person administering the drug.

b. During a concurrent interview and record review of the facility's Floor Narcotic Release form 1/2025, on 1/16/2025 at 6:51 a.m., with LVN 1, LVN 1 stated there were no signatures on 1/14/2025 for retiring nurses for 7 a.m. - 3 p.m. shift and 3 p.m. - 11 p.m. shift. LVN 1 stated they are supposed to sign after they counted

the narcotic medication. LVN 1 stated she does not know why it was not signed. LVN 1 stated they sign after

the end of their shift and after counting the medications.

During an interview on 1/16/2025 at 2:12 p.m., with RN 2, RN 2 stated the incoming and outgoing licensed nurses would count the narcotics and both licensed nurses would sign the Floor Narcotic Release form accepting the actual number on their shift for all residents that are receiving narcotic medications. RN 2 stated when the licensed nurses do not sign the Floor Narcotic Release form on their shift, it means the licensed nurse did not do the counting. RN 2 stated once the counting is done, they would sign right after

they counted the narcotic medications.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 70 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0755 During a review of the facility's P&P titled, Controlled Substances, last reviewed on 4/18/2024, the P&P indicated controlled substance inventory is monitored and reconciled to identify loss or potential diversion in Level of Harm - Minimal harm or a manner that minimizes the time between loss/diversion and detection/follow-up. The P&P indicated nursing potential for actual harm staff count controlled medication inventory at the end of each shift, using theses records to reconcile the inventory count. Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 71 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0760 Ensure that residents are free from significant medication errors.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43988 potential for actual harm Based on interview and record review the facility failed to ensure residents were free of any significant Residents Affected - Some medication errors to seven (7) out of 7 sampled residents (Residents 64, 66, 73, 64, 111, 213, 96, 73, and 220) investigated under insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) and anticoagulant (blood thinner - that stops the blood from forming blood clots or making them bigger) use by:

1. Failing to rotate (a method to ensure repeated injections are not administered in the same area) the insulin administration sites for Residents 64 and 66.

2. Failing to rotate subcutaneous (beneath the skin) insulin and heparin administration sites for Residents 111, 213, 96, 73, and 220.

These deficient practices had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as excessive bruising, lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up

in the skin).

Cross-reference

F-F658

Findings:

1.a. During a review of Resident 64's Admission Record, the Admission Record indicated the facility originally admitted the resident on 1/22/2021, and readmitted the resident on 12/26/2023, with diagnoses including type 2 diabetes mellitus (DM 2 - a chronic disease that occurs when the body does not produce enough insulin or does not use it properly) without complications, gastrostomy (a surgical opening fitted with

a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and anemia (a condition where the body does not have enough healthy red blood cells).

During a review of Resident 64's Minimum Data Set (MDS, a resident assessment tool), dated 11/2/2024,

the MDS indicated the resident had severely impaired cognition (having the ability to think, learn, and remember clearly). The MDS indicated Resident 64 required substantial/maximal assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 64 had a diagnosis of DM 2 and received insulin.

During a re view of Resident 64's History and Physical (H&P) dated 12/27/2024, the H&P indicated the resident did not have the capacity to make decisions.

During a review of Resident 64's Order Summary Report, the Order Summary Report indicated the following physician's orders dated 12/26/2023:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 72 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0760 - Insulin NPH (a long-acting insulin) subcutaneous suspension 100 unit per milliliter (unit/ml - a unit of measurement). Inject 20 units subcutaneously two times a day for DM 2. Rotate Injection Sites. Give with Level of Harm - Minimal harm or meals. potential for actual harm - Insulin regular human solution (a short-acting insulin) 100 unit/ml. Inject subcutaneously before meals and Residents Affected - Some at bedtime for DM 2. Give 12 units if blood sugar (BS) is more than (>) 350 and notify physician (MD). Inject as per sliding scale (increasing administration of the pre?meal insulin dose based on the blood sugar level

before the meal): if 70 - 149 = 0, if BS less than (<)70 give orange juice via gastrostomy tube if responsive and notify MD.; 150 - 199 = 1; 200 - 249 = 3; 250 - 299 = 5; 300 - 349 = 7; 350+ = 8. Give 12 units if BS is >350 and notify MD.

During a concurrent interview and record review, on 1/16/2025, at 2:30 p.m., with Licensed Vocational Nurse (LVN) 9, Resident 64's Order Summary Report, dated 12/26/2023, Resident 64's Medication Administration

Record (MAR - a daily documentation records used by a licensed nurse to document medications and treatments given to a resident), and Resident 64's Location of Administration Report, dated between 11/2024 to 1/2025, was reviewed and LVN 9 verified Resident 64 had a physician's order for NPH and regular insulin and were administered as follows:

- Insulin regular human solution 100 unit/ml:

12/22/24 5:19 p.m. subcutaneously Abdomen - right upper quadrant (RUQ)

12/23/24 5:18 p.m. subcutaneously Abdomen - RUQ

12/27/24 8:27 a.m. subcutaneously Arm - left

12/29/24 3:58 p.m. subcutaneously Arm - left

1/06/25 4:12 p.m. subcutaneously Abdomen -RUQ

1/07/25 5:10 p.m. subcutaneously Abdomen - RUQ

- Insulin NPH suspension 100 unit/ml:

11/26/24 7:56 a.m. subcutaneously Abdomen - left upper quadrant (LUQ)

11/26/24 8:55 p.m. subcutaneously Abdomen - LUQ

12/21/24 5:58 a.m. subcutaneously Abdomen - right lower quadrant (RLQ)

12/21/24 8:53 p.m. subcutaneously Abdomen - RLQ

12/27/24 8:29 a.m. subcutaneously Abdomen -LUQ

12/27/24 7:53 p.m. subcutaneously Abdomen - LUQ

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 73 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0760 LVN 9 stated insulin administration sites should be rotated per standards of practice, manufacturer's guidelines, and according to physician's orders. LVN 9 verified Resident 64's MAR indicated the insulin Level of Harm - Minimal harm or administration sites were not rotated and that there was a physician's order to rotate injection sites. LVN 9 potential for actual harm stated the insulin administration sites should have been rotated as ordered by the physician to prevent pain, redness, irritation, lipodystrophy, and denting of the resident's skin. LVN 9 stated not rotating insulin Residents Affected - Some administration sites is considered a medication error due to not following physician's order, manufacturer's recommendation, and standards of practice.

During an interview, on 1/17/2025, at 3:38 p.m., with the Director of Nursing (DON), the DON stated the administration sites of insulin should be rotated to prevent complications such as bruising, and lipodystrophy.

The DON stated not rotating insulin administration sites is considered a medication error due to not following physician's order, manufacturer's recommendation, and standards of practice.

During a review of the facility's recent policy and procedure (P&P) titled, Medication Errors and Adverse Consequences, last reviewed on 4/18/2024, the P&P indicated a medication error is defines as the preparation or administration of drugs and biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services.

During a review of the facility's P&P titled, Insulin Administration, last reviewed on 4/18/2024, the P&P indicated to provide guidelines for the safe administration of insulin to residents with diabetes. Select an injection site. The P&P further indicated:

a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of

the thighs and abdomen. Avoid the area approximately 2 inches around the navel.

b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm).

During a review of the facility provided manufacturer's guideline on, Humulin R Regular Insulin Huma Injection, undated, the manufacturer's guideline indicated Humulin R may be administered by subcutaneous injection in the abdominal wall, the thigh, the gluteal region, or in the upper arm. The manufacturer's guideline further indicated injection sites should be rotated within the same region and the following common side effects:

- Skin thickening or pits at the injection site (lipodystrophy). Change (rotated) where to inject the insulin to help prevent lipodystrophy from happening. Do not inject into the exact spot for each injection.

- Injection site reactions (local allergic reaction). Symptoms may include redness, swelling and itching at the injection site.

During a review of the facility provided manufacturer's guideline on Humulin N Pen NPH Human Insulin, undated, the manufacturer's guideline indicated side effects include injection site reactions such as pian, redness, and irritation. The manufacturer's guideline further indicated adverse reactions include lipodystrophy and localized cutaneous amyloidosis.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 74 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0760 1.b. During a review of Resident 66's Admission Record, the Admission Record indicated the facility originally admitted the resident on 9/27/2024, and readmitted the resident on 12/18/2024, with diagnoses Level of Harm - Minimal harm or including DM 2 with foot ulcer, neuromuscular disorder of the bladder (lack bladder control due to a brain, potential for actual harm spinal cord or nerve problem), and pressure ulcer (injuries to the skin and the tissue below the skin that are due to pressure on the skin for a long time) of left buttock. Residents Affected - Some

During a review of Resident 66's Minimum Data Set (MDS, a resident assessment tool) , dated 12/24/2024,

the MDS indicated the resident had severely impaired cognition (having the ability to think, learn, and remember clearly). The MDS indicated Resident 66 required substantial/maximal assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 66 had a diagnosis of DM 2 and received insulin.

During a review of Resident 66's MDS, dated [DATE REDACTED], the MDS indicated the resident had severely impaired cognition (having the ability to think, learn, and remember clearly). The MDS indicated Resident 66 required substantial/maximal assistance from staff with all ADLs. The MDS indicated Resident 66 had a diagnosis of DM 2 and received insulin.

During a review of Resident 66's Order Summary Report, the Order Summary Report indicated the following physician's orders:

- 9/8/2024: Humalog solution (a fast-acting insulin) 100 unit per milliliter (unit/ml - a unit of measurement) (insulin lispro). Inject as per sliding scale (increasing administration of the pre?meal insulin dose based on

the blood sugar level before the meal): if 0 - 150 = 0 units; 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units, subcutaneously before meals and at bedtime for DM 2.

- 12/28/2024: Humalog injection solution 100 unit/ml (insulin lispro). Inject subcutaneously before meals and at bedtime for DM 2 Rotate injection sites. Inject as per sliding scale: if 70 - 149 = 0 units. Notify physician (MD) if blood sugar (BS) is less than 70. Give orange juice if alert, responsive, and able to swallow; 150 - 199 = 2 units; 200 - 249 = 4 units; 250 - 299 = 7 units; 300 - 349 = 10 units; 350+ = 12 units. Give 12 units if BS is greater than 401 and notify MD, subcutaneously before meals and at bedtime.

During a concurrent interview and record review, on 1/16/2025, at 2:45 p.m., with LVN 9, Resident 66's Order Summary Report, dated 9/8/2024 and 12/28/2024, and Resident 66's MAR and Location of Administration Report, dated between 11/2024 to 1/2025, were reviewed and LVN 9 verified Resident 66 had

a physician's order for Humalog insulin and were administered as follows:

11/19/24 9:40 p.m. subcutaneously Abdomen - left lower quadrant (LLQ)

11/20/24 6:30 a.m. subcutaneously Abdomen - LLQ

11/25/24 11:28 a.m. subcutaneously Abdomen -RLQ

11/25/24 10:20 p.m. subcutaneously Abdomen - RLQ

11/27/24 9:33 p.m. subcutaneously Abdomen - LLQ

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 75 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0760 11/28/24 5:20 a.m. subcutaneously Abdomen - LLQ

Level of Harm - Minimal harm or 11/29/24 8:48 p.m. subcutaneously Abdomen - LLQ potential for actual harm 12/02/24 4:42 p.m. subcutaneously Abdomen - LLQ Residents Affected - Some 12/02/24 9:32 p.m. subcutaneously Abdomen - LLQ

12/07/24 2:17 p.m. subcutaneously Abdomen - LLQ

12/07/24 5:47 p.m. subcutaneously Abdomen - LLQ

12/07/24 10:45 p.m. subcutaneously Abdomen - LLQ

12/28/24 11:29 a.m. subcutaneously Abdomen - LLQ

12/29/24 11:36 a.m. subcutaneously Abdomen - LLQ

12/30/24 12:27 p.m. subcutaneously Abdomen - LLQ

12/31/24 11:41 a.m. subcutaneously Abdomen - LLQ

01/03/25 12:20 p.m. subcutaneously Abdomen - LLQ

01/04/25 4:23 a.m. subcutaneously Abdomen - LLQ

01/09/25 12:26 p.m. subcutaneously Abdomen - LLQ

01/10/25 11:14 a.m. subcutaneously Abdomen - LLQ

LVN 9 stated insulin administration sites should be rotated per standards of practice, manufacturer's guidelines, and according to physician's orders. LVN 9 verified Resident 66's MAR indicated the insulin administration sites were not rotated and that there was a physician's order to rotate injection sites. LVN 9 stated the insulin administration sites should have been rotated as ordered by the physician to prevent pain, redness, irritation, lipodystrophy, and denting of the resident's skin. LVN 9 stated not rotating insulin administration sites is considered a medication error due to not following physician's order, manufacturer's recommendation, and standards of practice.

During a review of the facility's recent P&P titled, Medication Errors and Adverse Consequences, last reviewed on 4/18/2024, the P&P indicated a medication error is defines as the preparation or administration of drugs and biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services.

During a review of the facility's recent P&P titled, Insulin Administration, last reviewed on 4/18/2024, the P&P indicated to provide guidelines for the safe administration of insulin to residents with diabetes. Select an injection site.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 76 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0760 a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of

the thighs and abdomen. Avoid the area approximately 2 inches around the navel. Level of Harm - Minimal harm or potential for actual harm b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm).

Residents Affected - Some During a review of the facility provided manufacturer's guideline on insulin Aspart (Humalog - a fast-acting insulin), undated, the manufacturer's guideline indicated to change (rotate) injection site within the chosen area such as stomach or upper arm with each dose and do not inject into the exact same sport for each injection. The manufacturer's guideline further indicated the following side effects:

- Reactions at the injection site such as redness, swelling, and itching.

- Skin thickens or pits at the injection site (lipodystrophy). Change (rotate) the injection site to help prevent lipodystrophy from happening.

44376

2.a. During a review of Resident 111's Admission Record, the Admission Record indicated the facility admitted the resident on 1/18/2023, and readmitted the resident on 12/14/2024, with diagnoses including DM 2 with foot ulcer and DM 2 with diabetic neuropathy (nerve damage caused by diabetes).

During a review of Resident 111's MDS, dated [DATE REDACTED], the MDS indicated the resident had the ability to make self-understood and understand others and had an intact cognition (having the ability to think, learn, and remember clearly). The MDS indicated the resident was on a high-risk drug class hypoglycemic medication (drugs that lower blood sugar levels and are used to treat diabetes).

During a review of Resident 111's Order Summary Report, the Order Summary Report indicated an order of:

12/15/2024 Insulin Aspart Injection Solution 100 unit (a standard measurement of the insulin's biological activity, essentially representing the amount of insulin needed to produce a specific effect on blood sugar levels)/ milliliters (ml, a unit used to measure capacity) (Insulin Aspart). Inject as per sliding scale (the increasing administration of the pre?meal insulin dose based on the blood sugar level before the meal): if 70 - 149 = 0 Units If blood sugar (BS) is less than (<)70 Give orange juice (OJ) if responsive and notify MD.; 150 - 199 = 1 Unit; 200 - 249 = 3 Units; 250 - 299 = 5 Units; 300 - 349 = 7 Units; 350+ = 8 Units If BS is greater than (>)350+ Give 8 Units and notify MD., subcutaneously before meals and at bedtime for Diabetes. Rotate injection sites.

12/15/2024 Lantus (a long-acting insulin) Subcutaneous Solution 100 unit/ml (Insulin Glargine). Inject 10 unit subcutaneously two times a day for type 2 DM. Give with meals.

During a review of Resident 111's Location of Administration Report for Insulin, dated between 12/2024 to 1/2025, the Location of Administration Report for Insulin indicated:

1. Lantus Subcutaneous Solution 100 unit/ml was given subcutaneously on:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 77 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0760 12/17/2024 at 7:49 p.m. on the Abdomen - RLQ

Level of Harm - Minimal harm or 12/18/2024 at 11:13 a.m. on the Abdomen - RLQ potential for actual harm 2. Aspart Injection Solution 100 unit/ml was given subcutaneously on: Residents Affected - Some 1/1/2025 at 8:54 p.m. on the Abdomen - LLQ

1/1/2025 at 10:36 p.m. on the Abdomen - LLQ

1/3/2025 at 11:52 a.m. on the Abdomen - RUQ

1/3/2025 at 4:32 p.m. on the Abdomen - RUQ

1/12/2025 at 5:09 p.m. on the Abdomen - LLQ

1/12/2025 at 9:01 p.m. on the Abdomen - LLQ

During a concurrent interview and record review, on 1/16/2025, at 3:58 p.m., with LVN 5, Resident 111's Order Summary Report, dated 12/15/2024, Resident 111's Location of Administration of Insulin, dated between 12/2024 to 1/2025, MAR, dated between 12/2024 to 1/2025, and Care Plans were reviewed. LVN 5 stated there were multiple instances that insulin administrations were not rotated on the resident. LVN 5 stated the administration sites of insulin should be rotated to prevent bruising, lipodystrophy, and denting of

the resident's skin. LVN 5 stated not rotating insulin administration sites is considered a medication error.

During an interview, on 1/17/2025, at 3:38 p.m., with the DON, the DON stated the administration sites of insulin should be rotated to prevent complications such as deep vein thrombosis (DVT, a blood clot that forms in a deep vein in the body), bruising, and lipodystrophy. The DON stated not rotating insulin administration sites is considered a medication error.

During a review of the facility's recent P&P, titled Medication Errors and Adverse Consequences, last reviewed on 4/18/2024, the P&P indicated a medication error is defines as the preparation or administration of drugs and biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services.

During a review of the facility's recent P&P titled, Insulin Administration, last reviewed on 4/18/2024, the P&P indicated to provide guidelines for the safe administration of insulin to residents with diabetes. Select an injection site.

a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of

the thighs and abdomen. Avoid the area approximately 2 inches around the navel.

b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 78 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0760 2.b. During a review of Resident 213's Admission Record, the Admission Record indicated the facility admitted the resident on 4/16/2024, with diagnoses including DM 2, dementia (a progressive state of decline Level of Harm - Minimal harm or in mental abilities), and atrial fibrillation (a condition where the heart's upper chambers beat irregularly and potential for actual harm often too fast).

Residents Affected - Some During a review of Resident 213's MDS, dated [DATE REDACTED], the MDS indicated the resident usually had the ability to make self-understood and understand others and had severe cognitive impairment (a condition that makes it difficult for a person to think, learn, remember, and make decisions). The MDS indicated the resident was on a high-risk drug class hypoglycemic medication (drugs that lower blood sugar levels and are used to treat diabetes).

During a review of Resident 213's Order Summary Report, dated 4/16/2024, the Order Summary Report indicated an order for:

- Humulin R Injection Solution 100 unit/ml (Insulin Regular [Human]). Inject as per sliding scale: if 70 - 149 = 0 units Notify MD if BS is <70. Give OJ if responsive.; 150 - 199 = 1 unit; 200 - 249 = 2 units; 250 - 299 = 3 units; 300 - 349 = 4 units; 350+ = 5 units Give 5 units if BS is >350. Notify MD., subcutaneously before meals and at bedtime for Diabetes. Rotate injection sites.

- Lantus Subcutaneous Solution 100 unit/ml (Insulin Glargine). Inject 10 unit subcutaneously every 12 hours for Diabetes. Rotate injection sites.

During a review of Resident 213's Location of Administration Report for Insulin, dated between 11/2024 to 1/2025, the Location of Administration Report for Insulin indicated:

1. Lantus subcutaneous solution 100 unit/ml was administered on:

11/7/2024 at 8:58 a.m. on the Abdomen - LLQ

11/7/2024 at 9:23 p.m. on the Abdomen - LLQ

2. Humulin R Injection Solution 100 unit/ml was administered on:

11/5/2024 at 9:37 p.m. on the Arm - right

11/6/2024 at 5:10 p.m. on the Arm - right

11/12/2024 at 9:15 p.m. on the Abdomen - LUQ

11/15/2024 at 9:37 p.m. on the Abdomen - LUQ

11/20/2024 at 6:55 p.m. on the Abdomen - LLQ

11/20/2024 at 8:20 p.m. on the Abdomen - LLQ

11/28/2024 at 4:14 p.m. on the Arm - right

11/28/2024 at 12:14 a.m. on the Arm - right

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 79 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0760 During a concurrent interview and record review, on 1/16/2025, at 3:58 p.m., with LVN 5, Resident 213's Order Summary Report, dated 4/16/2024, Resident 213's Location of Administration of Insulin, dated Level of Harm - Minimal harm or between 11/2024 to 1/2025, Resident 213's MAR, dated between 11/2024 to 1/2025, and Care Plans were potential for actual harm reviewed. LVN 5 stated there were multiple instances that insulin administrations were not rotated on the resident. LVN 5 stated the administration sites of insulin should be rotated to prevent bruising, lipodystrophy, Residents Affected - Some and denting of the resident's skin. LVN 5 stated not rotating insulin administration sites is considered a medication error.

During an interview, on 1/17/2025, at 3:38 p.m., with the DON, the DON stated the administration sites of insulin should be rotated to prevent complications such as DVT, bruising, and lipodystrophy. The DON stated not rotating insulin administration sites is considered a medication error.

During a review of the facility's recent P&P titled, Medication Errors and Adverse Consequences, last reviewed on 4/18/2024, the P&P indicated a medication error is defines as the preparation or administration of drugs and biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services.

During a review of the facility's recent P&P, titled Insulin Administration, last reviewed on 4/18/2024, the P&P indicated to provide guidelines for the safe administration of insulin to residents with diabetes. Select an injection site.

a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of

the thighs and abdomen. Avoid the area approximately 2 inches around the navel.

b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm).

During a review of the facility-provided Highlights of Prescribing Information on the use of Lantus (insulin glargine) injection, for subcutaneous use, with initial U.S. approval in 2000, the highlights of prescribing information indicated to rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis.

During a review of the facility-provided Information for the Physician on the use of Humulin R, Regular Insulin Human Injection, USP (rDNA origin) 100 units per ml (U-100), issued March 2011, the information for the Physician indicated Humulin R U-100 may be administered by subcutaneous injection in the abdominal wall,

the thigh, the gluteal region or in the upper arm. Injection sites should be rotated within the same region.

2.c. During a review of Resident 96's Admission Record, the Admission Record indicated the facility admitted

the resident on 8/28/2019, and readmitted the resident on 11/7/2019, with diagnoses including DM 2 with diabetic neuropathy, and DM 2 with diabetic chronic kidney disease (a kidney disease that develops in people with diabetes).

During a review of Resident 96's MDS, dated [DATE REDACTED], the MDS indicated the resident usually had the ability to make self-understood and understand others and had severe cognitive impairment. The MDS indicated

the resident was on a high-risk drug class hypoglycemic medication.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 80 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0760 During a review of Resident 96's Order Summary Report, the Order Summary Report indicated an order for:

Level of Harm - Minimal harm or - 1/26/2023 Humulin R Injection Solution 100 unit/ml (Insulin Regular [Human]). Inject as per sliding scale: if potential for actual harm 70-140= 0 units. Notify MD if BS is <70. Give OJ if responsive; 141-200= 4 units; 201-250= 6 units; 251-300= 8 units; 301-350= 10 units; 351-400=12 units; 401+= 14 units. Give 14 units if BS>400. Notify MD, Residents Affected - Some subcutaneously before meals and at bedtime for Diabetes. Rotate injection sites.

- 4/11/2024 Humulin N Subcutaneous Suspension 100 unit/ml (Insulin NPH (Human) (Isophane)). Inject 30 unit subcutaneously two times a day for Diabetes. Hold for BS <100. Rotate injection sites.

- 5/10/2024 Lantus Subcutaneous Solution 100 unit/ml (Insulin Glargine). Inject 5 unit subcutaneously at bedtime for Diabetes. Hold for BS <100. Rotate injection sites.

During a review of Resident 96's Location of Administration Report for Insulin for 12/2024, the Location of Administration Report for Insulin indicated-

1. Lantus Subcutaneous Solution 100 unit/ml was administered on:

12/17/2024 at 9:18 p.m. on the Arm - left

12/18/2024 at 9:05 p.m. on the Arm - left

2. Humulin N Subcutaneous Suspension 100 unit/ml was administered on:

12/08/2024 at 4:14 p.m. on the Abdomen - LLQ

12/09/2024 at 4:05 p.m. on the Abdomen - LLQ

12/23/2024 at 5:02 p.m. on the Abdomen - LUQ

12/24/2024 at 6:32 a.m. on the Abdomen - LUQ

12/25/2024 at 6:30 a.m. on the Abdomen - LUQ

3. Humulin R Injection Solution 100 unit/ml was administered on:

12/2/2024 at 4:30 p.m. on the Arm - right

12/3/2024 at 6:32 a.m. on the Arm - right

12/4/2024 at 10:48 p.m. on the Arm - left

12/6/2024 at 11:41 a.m. on the Arm - left

12/21/2024 at 9:33 p.m. on the Abdomen - LUQ

12/22/2024 at 6:30 a.m. on the Abdomen - LUQ

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 81 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0760 During a concurrent interview and record review, on 1/16/2025, at 3:58 p.m., with LVN 5, Resident 96's Order Summary Report, dated 1/26/2023, 4/11/2024, and 5/10/2024, Resident 96's Location of Level of Harm - Minimal harm or Administration of Insulin, dated 12/2024, MAR, dated 12/2024, and Care Plans were reviewed. LVN 5 stated potential for actual harm there were multiple instances that insulin administrations were not rotated on the resident. LVN 5 stated the administration sites of insulin should be rotated to prevent bruising, lipodystrophy, and denting of the Residents Affected - Some resident's skin. LVN 5 stated not rotating insulin administration sites is considered a medication error.

During an interview, on 1/17/2025, at 3:38 p.m., with the DON, the DON stated the administration sites of insulin should be rotated to prevent complications such as DVT, bruising, and lipodystrophy. The DON stated not rotating insulin administration sites is considered a medication error.

During a review of the facility's recent P&P titled, Medication Errors and Adverse Consequences, last reviewed on 4/18/2024, the P&P indicated a medication error is defines as the preparation or administration of drugs and biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services.

During a review of the facility's recent P&P titled, Insulin Administration, last reviewed on 4/18/2024, the P&P indicated to provide guidelines for the safe administration of insulin to residents with diabetes. Select an injection site.

a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of

the thighs and abdomen. Avoid the area approximately 2 inches around the navel.

b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm).

During a review of the facility-provided Information for the Patient 10 ml Vial (1000 Units per vial) Humulin N NPH Human Insulin (rDNA Origin) Isophane Suspension 100 Units per ml (U-100), copyright 1997, the information for patient indicated to avoid tissue damage, choose a site for each injection that is at least 1/2 inch from the previous injection site. The usual sites of injection are abdomen, thighs, and arms.

During a review of the facility-provided Highlights of Prescribing Information on the use of Lantus (insulin glargine) injection, for subcutaneous use, with initial U.S. approval in 2000, the highlights of prescribing information indicated to rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis.

During a review of the facility-provided Information for the Physician on the use of Humulin R, Regular Insulin Human Injection, USP (rDNA origin) 100 units per ml (U-100), issued March 2011, the information for the Physician indicated Humulin R U-100 may be administered by subcutaneous injection in the abdominal wall,

the thigh, the gluteal region or in the upper arm. Injection sites should be rotated within the same region.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 82 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0760 2.d. During a review of Resident 73's Admission Record, the Admission Record indicated the facility admitted

the resident on 10/2/2024, with diagnoses including DM 2 with diabetic polyneuropathy (a complication of Level of Harm - Minimal harm or diabetes that damages nerves in the hands, feet, legs, and arms), anemia, and displaced intertrochanteric potential for actual harm fracture (a break in the bone where the broken bone has shifted or separated) of right femur (he thigh bone

on the right side of the body). Residents Affected - Some

During a review of Resident 73's MDS, dated [DATE REDACTED], the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition. The MDS indicated the resident was on a high-risk drug class hypoglycemic medication.

During a review of Resident 73's Order Summary Report, dated 10/2/2024, the Order Summary Report indicated an order for:

- Humulin R Injection Solution 100 unit/ml (Insulin Regular (Human)). Inject as per sliding scale: if 70 - 149 = 0 units Notify MD if BS is <70. Give OJ if responsive.; 150 - 199 = 2 units; 200 - 249 = 4 units; 250 - 299 = 7 units; 300 - 349 = 10 units; 350+ = 12 units Give 12 units if BS is >350. Notify MD., subcutaneously before meals and at bedtime for Diabetes Rotate injection sites.

- Humulin R Injection Solution 100 unit/ml (Insulin Regular (Human)). Inject as per sliding scale: if 70 - 149 = 0 units Notify MD if BS is <70. Give OJ if responsive.; 150 - 199 = 2 units; 200 - 249 = 4 units; 250 - 299 = 7 units; 300 - 349 = 10 units; 350+ = 12 units Give 12 units if BS is >350. Notify MD., subcutaneously before meals and at bedtime for Diabetes Rotate injection sites.

- Heparin Sodium (Porcine) Injection Solution 5000 unit/ml (Heparin Sodium [Porcine]). Inject 1 ml subcutaneously every 12 hours for DVT prophylaxis (reduces the risk of developing deep vein thrombosis through medications, compression stockings, and devices). Rotate injection sites.

During a review of Resident 73's Location of Administration Report for Insulin and Heparin for 11/2024 to 1/2025, the Location of Administration Report for Insulin and Heparin indicated-

1. Heparin Sodium (Porcine) Injection Solution 5000 unit/ml was administered on:

11/19/2024 at 11:03 p.m. on the Abdomen - LLQ

11/20/2024 at 11:03 p.m. on the Abdomen - LLQ

11/22/2024 at 2:23 p.m. on the Abdomen - LUQ

11/22/2024 at 8:44 p.m. on the Abdomen - LUQ

12/19/2024 at 8:22 a.m. on the Abdomen - RUQ

12/19/2024 at 8:28 p.m. on the Abdomen - RUQ

2. Humulin R Injection Solution 100 unit/ml was administered on:

12/1/2024 at 11:26 a.m. on the Arm - right

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 83 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0760 12/2/2024 at 9 p.m. on the Arm - right

Level of Harm - Minimal harm or 12/3/2024 at 4:53 p.m. on the Arm - right potential for actual harm 12/3/2024 at 8:57 p.m. on the Arm - right Residents Affected - Some 12/19/2024 at 9:07 p.m. on the Arm - left

12/22/2024 at 12:29 p.m. on the Arm - left

12/22/2024 at 9:10 p.m. on the Abdomen - LUQ

12/23/2024 at 7:47 a.m. on the Abdomen - LUQ

3. Humulin 70/30 Subcutaneous Suspension (70-30) 100 unit/ml was administered on:

1/6/2025 at 6:07 a.m. on the Abdomen - LLQ

1/6/2025 at 4:53 p.m. on the Abdomen - LLQ

During a concurrent interview and record review, on 1/16/2025, at 3:58 p.m., with LVN 5, Resident 73's Order Summary Report, dated 10/2/2024, Resident 73's Location of Administration of Insulin, dated between 11/2024 to 1/2025, Resident 73's MAR, dated between 11/2024 to 1/2025, and Care Plans were reviewed. LVN 5 stated there were multiple i

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 84 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm 38552 Residents Affected - Some Based on observation, interview, and record review, the facility failed to:

1. Remove Resident 271's discontinued insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) lispro (fast-acting type of insulin) from the medication cart in one of three inspected medication carts (Station 1 Cart B).

2. Dispose Resident 10's hydrocodone-acetaminophen (medication used to relieve severe pain) when the bubble pack (packaging that have a preformed plastic pocket or shell where a product sits securely in place) slot #17 was found with a non-intact seal and covered with tape in one of three inspected medication carts (Station 1 Cart B).

3. Dispose Resident 37's hydrocodone-acetaminophen when the bubble pack slot #15 was found with a non-intact seal and covered with tape in one of three inspected medication carts (Station 1 Cart B).

4. Maintain residents' medication bubble packs in an orderly manner when Resident 37's Jardiance scheduled during the 11 p.m. to 7 a.m. shift was observed in the 7 a.m. to 3 p.m. shift's medication drawer in one of three inspected medication carts (Station 1 Cart B).

5. Discard Resident 43's insulin glargine with no open date and with printed date of 5/23/2024 observed in one of three sampled medication carts (Station 3 Cart B).

The deficient practices of failing to store and label medications per the manufacturers' requirements and remove expired medications from the medication carts may cause the medications to become ineffective or toxic due to improper storage which can possibly lead to health complications resulting in hospitalization or death.

6. Maintain safe and proper temperatures for all medications stored in the medication refrigerator when it was observed out of range at 32 degrees Fahrenheit (F-a unit of measurement) during an observation on 1/17/2025 in one of three medication storage rooms (Medication Storage 1).

7. Ensure the medication refrigerator temperature log (a record-keeping tool used to monitor the storage temperature of medications) was checked and completed when there were no temperatures recorded on 1/15/2025, 1/16/2025, and 1/17/2025.

These deficient practices had the potential to result in degradation or alteration of the medications, rendering them ineffective or even potentially harmful.

Findings:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 85 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0761 1. During a concurrent observation and interview on 1/16/2025 at 6:50 a.m., inspected Station 1 Cart B with Licensed Vocational Nurse 1 (LVN 1). LVN 1 stated Resident 271's insulin lispro 100 unit/ml, dated Level of Harm - Minimal harm or 12/6/2024, filled 12/6/2024. LVN 1 stated Resident 271's insulin was good for 30 days and should have been potential for actual harm removed from the medication cart on 1/15/2025.

Residents Affected - Some During an interview with the Director of Nursing (DON) on 1/17/2025 at 4:25 p.m., the DON stated when residents are transferred or discharged , the licensed nurse is expected to remove the medication and place

it on the medication bin inside the medication storage room. The DON stated after three (3) days when the resident is discharged home with a physician order, the medications will be release, to the resident. The DON stated if the discontinued and/or expired medications are not removed from the medication cart, there is a potential to cause confusion to some nurses and could give it to another resident.

2 & 3. During a concurrent observation and interview on 1/16/2025 at 6:53 a.m., inspected Station 1 Cart B with LVN 1. LVN 1 stated Resident 10's hydrocodone-acetaminophen 5-325 mg tablet, bubble pack slot #17 had a non-intact seal and was covered with tape. LVN 1 stated for narcotics when the tablets are popped accidentally or not given, the licensed nurse should put it in a plastic pill cover and staple it date and time and hand it over to the DON for disposal. LVN 1 stated Resident 10's hydrocodone-acetaminophen should not have been taped. LVN 1 stated Resident 37's hydrocodone-acetaminophen 10-325 mg tablet, bubble pack slot #15 had a non-intact seal and was covered with tape. LVN 1 stated she never checked the back of

the bubble packs, so she never noticed there was a tape and the seal non-intact.

During an interview on 1/17/2025 at 4:23 p.m., with the DON, the DON stated controlled medications with non-intact seal is a medication error. The DON stated the practice is ensure the seal is not broken and if it is,

the licensed nurses are expected to waste the medication.

4. During a concurrent observation and interview on 1/16/2025 at 10:20 a.m., inspected Station 1 Cart B, with LVN 15. LVN 15 stated she completed medication administration for Resident 37. Requested to see the bubble packs scheduled during the morning medications. LVN 15 stated Jardiance bubble pack was in her drawer, but she did not administer it because it is scheduled for 6:30 a.m. and not during her shift, 7 a.m. to 3 p.m. shift. LVN 15 stated she did not put it there and it should be placed in the 11 p.m. to 7 a.m. drawer.

During an interview on 1/16/2025 at 2:20 p.m.,with Registered Nurse 2 (RN 2 ), RN 2 stated licensed nurses can check in their medication cart in the other drawers depending on the reason what medications they are looking for. RN 2 stated medications inside the medication carts should be organized.

During an interview on 1/17/2025 at 7:01 a.m., with RN 1, RN 1 stated he placed the Jardiance back in the wrong drawer on 1/16/2025 that was why it was in the morning shift drawer.

5. During a concurrent observation and interview on 1/16/2025 at 7:56 a.m., inspected Station 3 Cart B with LVN 16. LVN 16 stated Resident 43's insulin glargine does not have an open date, so she is going to throw it away. LVN 16 stated there should be a date on it. LVN 16 stated there is a printed date 5/23/2024 but she does not know how long it has been in the cart so she would dispose it.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 86 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0761 During an interview on 1/17/2025 at 4:28 p.m., the DON stated Resident 43's insulin glargine should have been removed from the medication cart. The DON stated this is to make sure the potency of medications Level of Harm - Minimal harm or administered to the residents are effective and the manufacturer's guidelines are followed. potential for actual harm 6. During a concurrent observation and interview on 1/17/2025 at 8:17 a.m., inside Station 1 Medication Residents Affected - Some Room (Med Storage 1), the Infection Preventionist (IP) stated the medication refrigerator temperature reading was at 32 F.

7. During a concurrent interview and record review of the facility's Temperature Log, on 1/17/2025 at 8:25 a. m., with the IP, the IP stated temperature log indicated for 1/2025 and refrigerator temperature daily 36 to 46 F daily. The IP stated there were no temperatures and initials recorded on the following dates and shifts:

- 1/15/2025, 3 p.m. to 11 p.m. and 11 p.m. to 7 a.m.

- 1/16/2025 all three shifts

- 1/17/2025, 7 a.m. to 3 p.m.

The IP stated when the licensed nurses checked the medication room, they should initial that they checked

the temperatures and document on the temperature log.

During an interview on 1/17/2025 at 4:29 p.m., with the DON, the DON stated the medication refrigerator temperature is between 36 to 46 F. The DON stated this is done to ensure and maintain the potency and effectiveness of refrigerated medications.

During a review of the facility's policy and procedure (P&P) titled, Administering Medications, last reviewed

on 4/18/2024, the P&P indicated the expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container.

During a review of the facility's P&P titled, Storage of Medications, last reviewed on 4/18/2024, the P&P indicated the nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. The P&P indicated discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

During a review of the facility's P&P titled, Discarding and Destroying Medications, last reviewed on 4/18/2024, the P&P indicated schedule II, III, and IV (non-hazardous) controlled substances are disposed of

in accordance with state regulations and federal guidelines regarding disposition of non-hazardous controlled medications.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 87 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0761 During a review of the facility's P&P titled, Controlled Substances, last reviewed on 4/18/2024, the P&P indicated controlled substance inventory is monitored and reconciled to identify loss or potential diversion in Level of Harm - Minimal harm or a manner that minimizes the time between loss/diversion and detection/follow-up. The P&P indicated nursing potential for actual harm staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count. The P&P indicated unless otherwise instructed by the director of nursing services, when a Residents Affected - Some resident refuses a non-unit dose medication (or it is not given), or a resident receives partial tablets or single dose ampules (or it is not given) the medication is destroyed and may not be returned to the container.

During a review of the facility's P&P titled, Medication Labeling and Storage, last reviewed on 4/18/2024, the P&P indicated medications stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. The P&P indicated each resident's medications are assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents.

During a review of the facility's P&P titled, Insulin Administration, last reviewed on 4/18/2024, the P&P indicated to check expirations date and follow manufacturer recommendations for expiration after opening.

During a review of the facility's P&P titled, Medication Storage in the Facility, last reviewed on 4/18/2024, the P&P indicated medications requiring refrigeration temperatures between 36F to 46F are kept in a refrigerator with a thermometer to allow temperature monitoring. The P&P indicated medication storage conditions are monitored on a regular basis and corrective action taken if problems are identified.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 88 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0802 Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47441

Residents Affected - Some Based on observation, interview and record review, the facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills when staff:

a. Unable to verbalize the process of three (3) compartment sink dishwashing and quaternary ammonium compound (QUAT, a chemical that disinfect) sanitizer concentration testing for the red buckets.

b. Unable to verbalize which type of dishwashing machine they were using and the process of testing the chlorine solution of the dishwashing machine.

These failures had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 271 of 279 medically compromised residents who received food and ice from the kitchen.

Findings:

a. During a concurrent demonstration and interview on 1/15/2024 at 2:44 p.m. with Dietary Aide 1 (DA 1) and Dietary Supervisor (DS), DA 1 stated they used Quat sanitizer in the three-compartment sink to sanitize the dishes. DA 1 stated the concentration of the Quat sanitizer should be at 150-400 parts per million (ppm, strength of chemical concentration) however, the poster indicated 200 ppm is the acceptable concentration. DA 1 dipped the test strip for 17 seconds while agitating it. DA 1 stated the color of the test strips should match the color chart and it was 400 ppm. DA 1 stated, he dipped the test strip in the testing solution for one (1) to two (2) minutes. DA 1 stated he also test the first compartment sink. DA 1 stated the first compartment sink is for soaking the dishes with soap or detergent. DA 1 pulled a test strip and tested the first compartment sink while agitating the strip and stated the concentration was 200 ppm.

During an interview on 1/15/2025 at 3:00 p.m. with the DS, the DS stated they are not supposed to test the first compartment sink with the test strip as it was for soap. The DS stated, DA 1 should not be agitating the test strips during testing, the temperature of the testing solution was not temped, and the test strip was dipped too long in the sanitizer testing solution. The DS stated dipping the test strip too long while agitating it could affect the reading of the solution concentration. The DS stated the sanitizer reading would not be accurate affecting the cleanliness of the dishes leading to unsanitized dishes. The DS stated unsanitized dishes could lead to food borne illnesses to residents. The DS stated it was always important to follow manufacturer's guidelines.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 89 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0802 During a review of the facility's policies and procedures (P&P) titled, Three Compartment Procedure for Manual Dishwashing, dated 4/18/2024, the P&P indicated, Procedure: Three compartment sink washing Level of Harm - Minimal harm or procedures are to be initiated when the dishwasher is inoperable, the dishmachine registers low water potential for actual harm temperature, the machine detergent or sanitizer is not available or other emergencies. Immediately begin using disposable dishes. The first compartment is for washing. Fill the first compartment with detergent per Residents Affected - Some manufacturer's instructions and hot water (110-120 F). Record temperature log. Replace water when it becomes cloudy or dirty, the suds are gone, or when temperature falls below 110 F.

During a review of the test strips manufacturer's guidelines titled Hydrion Quat Test Paper undated, the guidelines indicated Hydrion sanitizer test papers have been trusted worldwide for nearly [AGE] years to test

the concentration of quaternary ammonium-based sanitizer solutions. QT 40 is for 4-chain quats, 0-500ppm.

During a review of the test strips manufacturer's guidelines titled Hydrion QT-40 Instructions Lot 213024 undated, the guidelines indicated, Immerse for 10 seconds. Compare when wet.

1. Dip paper in Quat solution. Not foal surface for 10 seconds. Do not shake. Compare colors at once.

2. Testing solution should be between 65-75 F.

3. Testing solution should have a neutral pH.

4. Follow manufacturer's dilution instructions carefully.

During a review of the facility's job description titled Job Description: Dietary Aide dated and signed by DA 1,

on 11/30/2024 the document indicated Essential duties included: to leave the kitchen in a clean and sanitary manner and be of assistance when called upon by the cook or dietary supervisor.

During a review of the facility's competency checklist titled Job Description and Performance Standards, dated 11/29/2023, the checklist indicated, DA 1 rarely meets standards when assisting in the proper care, use and cleaning of kitchen equipment and there was no action indicated. The checklist further indicated, DA 1 is usually meeting standards in performing all duties assigned in an effective, timely and professional manner but there was no action indicated to train DA 1 to always meet these standards.

b. During an interview on 1/16/2025 at 3:12 p.m. with Dietary Aide 3 (DA 3) in the dishmachine area, DA 3 stated he has been working as a dishwasher for a month, but nobody told him that he needed to check the temperature of the dishmachine and log it, and nobody trained him.

During an interview on 1/16/2025 at 3:14 p.m. with Dietary Aide 4 (DA 4), DA 4 stated they used a high temperature dishmachine and the acceptable temperatures are as follows:

- Wash 130-140 F

- Rinse 130 F

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 90 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0802 - Final Rinse 130-140 F.

Level of Harm - Minimal harm or During a concurrent observation and interview on 1/16/2025 at 3:22 p.m. of the dishwashing process with DA potential for actual harm 4, DA 4 stated the wash gauge was reading 130 F and the rinse temperature was reading 130 F. DA 4 demonstrated the testing of chlorine by pulling a test strip and agitated the strips while dipping it in the Residents Affected - Some solution and blotted it dry with a paper towel. DA 4 compared the test strip in the color chart and stated it was 25ppm and it was not an acceptable range. DA 4 stated the dishes would not be disinfected with this chlorine concentration at 25ppm.

During an interview on 1/16/2025 at 3:29 p.m. with the DS, the DS stated they used a low temperature dishmachine and the minimum temperature should be at 120 F and the maximum acceptable temperature is at 150 F. The DS stated the acceptable chlorine concentration is 150-200ppm. The DS stated the concentration of the chlorine was at 50ppm and it was not acceptable. The DS stated the poster on the wall indicated wash temperature should be at 140-160 F and final rinse was at 180-190 F. The DS stated he needed to call the dishmachine vendor to clarify if they used a high temperature dishmachine or low temperature dishmachine. The DS stated it was important to know what kind of dishmachine they were using to ensure dishes were properly cleaned and sanitized to prevent cross-contamination.

During an interview on 1/16/2025 at 3:29 p.m. with the DS, the DS stated their vendor said they are using low temperature dishmachine and the poster needed to be taken down and updated. The DS stated he will update the poster in the dishmachine area to prevent confusion.

During a review of the facility's P&P titled Dishwashing dated 4/18/2024, the P&P indicated, All dishes will be properly sanitized through the dishwasher. (8) A temperature log (and chlorine log for low temperature machines) will be kept and maintained by dishwashers to assure that the dishmachine is working correctly.

This log will be completed each meal prior to any dishwashing. Low temperature dishmachine: If you do not have the manufacturer's recommendations, use the machine range of 120-140 F. The chlorine should read 50-100ppm on dish surface in final rinse. The proper chlorine level is crucial in sanitizing dishes. If you do not achieve the proper temperature or chlorine level, resort to manual method of dishwashing.

During a review of the facility's job description titled Job Description: Dietary Aide dated and signed by DA 3,

on 10/10/2024 the document indicated Essential duties included:

- Check and record chlorine concentration and water temperature of dishwashing machine at the beginning of shift.

- Observe the water temperature of dishwasher during dishwashing cycles.

- Operate dishwasher.

During a review of the facility's competency checklist titled Job Description and Performance Standards, dated 11/16/2021, the checklist indicated DA 3 did not meet standards for the following job task:

- Assist in the proper care, use and cleaning of kitchen equipment

- Perform all duties assigned in an effective, timely and professional manner.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 91 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0802 The checklist further indicated no actions were done for DA 3 to reach needed competencies to work in the kitchen. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's job description titled Job Description: Dietary Aide dated and signed by DA 4

on 11/17/2021, the document indicated Essential duties included: Residents Affected - Some - Check and record chlorine concentration and water temperature of dishwashing machine at the beginning of shift.

- Observe the water temperature of dishwasher during dishwashing cycles.

- Operate dishwasher.

During a review of the facility's competency checklist titled Job Description and Performance Standards, dated 11/16/2021, the checklist indicated, DA 4 rarely meets standards for the following task:

- Assist in the proper care, use and cleaning of kitchen equipment

- Perform all duties assigned in an effective, timely and professional manner.

The checklist further indicated no actions were done for DA 4 to reach needed competencies to work in the kitchen.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 92 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0803 Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47441

Residents Affected - Some Based on observation, interview, and record review the facility failed to follow the menu and did not meet nutritional needs of 108 of 109 residents on soft mechanical diet (diet consisting of soft, and chopped foods), seven of 46 residents on fortified diet (addition of food to increase calories and proteins in the diet), and three of 14 residents on large portions (doubling portion size of foods to increase calories and protein in the diet) diet when:

1. Residents on soft mechanical diet did not receive toasted garlic bread without hard crust.

2. Residents on fortified diet did not receive additional cheese on their pasta.

3. Residents on large portion diets did not receive eight (8) ounces ([oz], a unit of measurement) of milk as indicated on the menu spreadsheet (a sheet that contains each diet and what food and portions each diet would get).

These failures had the potential to result in difficulty in swallowing, chewing, decreased in food and nutrient intake resulting to unintended weight loss and choking (when food gets stuck in your airway, blocking the flow of air to your lungs).

Cross reference

F-F689

Findings:

During a review of Resident 179's Admission Record, the Admission Record indicated the facility admitted

the resident on 8/28/2023 with diagnoses that included diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (HTN-high blood pressure), and acquired absence of left toes.

During a review of Resident 179's Minimum Data Set (MDS - resident assessment tool) dated 12/4/2024, the MDS indicated the resident was able to understand others and was able to make himself understood. The MDS further indicated the resident required partial/moderate assistance from staff for bathing and dressing, required supervision for toileting and personal hygiene, and required setup or clean up assistance for eating and oral hygiene.

During a review of Resident 179's History and Physical (H&P), dated 12/3/2024, the H&P indicated the resident had fluctuating capacity to understand and make decisions.

During a review of Resident 179's Skin Rash Weekly Monitoring tool, dated 12/6/2024, the Skin Rash Weekly tool indicated the resident had a rash throughout the body.

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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 1 of 126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0554 During a concurrent observation and interview, on 1/14/2025, at 9:34 a.m., inside Resident 179's room, Resident 179 sat in bed and the top of resident's bedside rolling table contained seven clear plastic Level of Harm - Minimal harm or medication cups containing ointment. Resident 179 stated the medications were left by the nurse for him to potential for actual harm apply because he has a rash throughout his body. Resident 179's bilateral lower extremities, torso, and bilateral upper extremities had raised red pustules (small blisters or pimples on the skin containing pus) in Residents Affected - Few various stages of healing. Resident 179 stated the nurse sometimes leaves the ointments for him to apply himself.

During an interview, on 1/16/2025, at 11:28 a.m., with Licensed Vocational Nurse (LVN) 4, LVN 4 stated Resident 179 had a body rash and the treatment nurses provide care for it.

During an interview, on 1/16/2025, at 11:52 a.m., with the Wound Coordinator (WC), the WC stated Resident 179 has been seen by the dermatologist (a doctor who specializes in diagnosing and treating skin conditions) and has been previously treated for a rash that comes and goes and now the rash has returned.

During an interview, on 1/16/2025, at 12:06 a.m., with Certified Nursing Assistant (CNA) 2, CNA 2 stated she worked on 1/14/2025 and cared for Resident 179. CNA 2 stated she did not see any medication cups with ointment left at the resident's bedside. CNA 2 stated maybe the resident hid the cups from her. CNA 2 stated Resident 179 had tubes of ointment sent by his family that he currently kept in his room in his nightstand. CNA 2 stated she did not know if the medication observed by the surveyor in the seven medication cups was left by the nurse or if it was the resident's own ointments.

During a concurrent observation and interview, on 1/16/2025, at 1:44 p.m., with Treatment Nurse (TN) 1, TN 1 stated Resident 179 had a body rash and she and the evening nurses provide topical treatments for the resident. TN 1 stated the process for providing topical medication treatments is to take the medication to the resident and apply the medication. TN 1 stated Resident 179 was not care planned for medication self-administration, so she does not leave his medications for him to self-apply. TN 1 stated she did not know if the seven medications cups observed by the surveyor was medication left by nursing staff or if it was the resident's own medication that he placed in the cups. TN 1 stated Resident 179 had various tubes of ointments and creams in his room provided by his family. TN 1 entered Resident 179's room and stated there was a tube of hydrocortisone cream (medication used to treat skin conditions that cause swelling, redness, itching, and rashes) on Resident 179's bedside table. Resident 179 applied hydrocortisone cream to his left arm in the presence of TN 1. TN 1 exited Resident 179's room. TN 1 did not remove Resident 179's tube of hydrocortisone cream from the resident's room.

During a concurrent observation and interview, on 1/16/2025, at 3:14 p.m., with Resident 179, the resident stated he had three tubes of creams that he applies himself that were provided by his family. Observed two tubes of hydrocortisone cream and a tube labeled Barmicil Compuesto (medication used to treat skin conditions that involve inflammation, infection, and itching). Resident 179 stated the facility staff knows that

he applies the creams by himself and that he stores them in his room.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0554 During a concurrent interview and record review, on 1/16/2025, at 3:32 p.m., with the WC, the WC reviewed Resident 179's care plans, physician orders, and assessments. The WC stated it was a resident's right to Level of Harm - Minimal harm or self-administer medications but there was a process to follow and the physician must be aware of all potential for actual harm medications the resident is using. The WC stated Resident 79 did not have a physician's order for hydrocortisone cream or Barmicil Compuesto and the resident should not be applying those medications. Residents Affected - Few The WC stated Resident 179 was not assessed for the safe self-administration of any kind of medication whether it was provided by the staff or the resident's family. The WC stated if TN 1 and CNA 2 knew Resident 179 wanted to self-administer topical medications, staff should have notified the licensed nurse to ensure the physician was aware and agreed with the treatment and a self-administration assessment was completed. The WC stated if it was determined that the resident was safe for self-administration, then the resident should be supervised during administration of the topical medications, the administration should be documented in the Medication Administration Record, and medications should be kept in a locked and safe environment. The WC stated this process was not followed when CNA 2 and TN 1 allowed Resident 179 to self-administer topical medications unsupervised and to store medications at bedside. The WC stated if the resident was self-administering these medications, it 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.

During a concurrent interview and record review, on 1/17/2025, at 12:10 p.m., with the Director of Nursing (DON), the DON reviewed the facility's policy and procedures regarding self-administration of medication.

The DON stated medications should never be left at a resident's bedside, even if they are care planned for safe self-administration. The DON stated he was just made aware that Resident 179 was self-administering medications with staff knowledge. The DON stated Resident 179 was interviewed and the resident stated the medications were sent by his family member from another country. The DON stated CNA 2 and TN 1 should have notified the DON of the resident's desire to self-administer medication, but they did not. The DON stated 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 DON stated the facility policy and procedure was not followed when CNA 2 and TN 1 allowed Resident 179 to self-administer medications and store the medication at the bedside.

During a review of the facility's policy and procedure (P&P) titled, Resident Rights, last reviewed 4/18/2024,

the P&P indicated federal and state laws guarantee certain basic rights to all residents of the facility. The rights include the resident's right to self-administer medications, if the interdisciplinary care planning team determines it is safe.

During a review of the facility's P&P titled, Self-Administration of Medications, last reviewed 4/18/2024, the P&P indicated residents have the right to self-administer medications if the interdisciplinary team (IDT - a group of health care professionals with various areas of expertise who work together toward the goals of their residents) has determined that it is clinically appropriate and safe for the resident to do so. As part of

the evaluation comprehensive assessment the IDT assess each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. The IDT considers the following factors when determining whether self-administration of medications is safe and appropriate for the resident:

a. The medication is appropriate for self-administration.

b. The resident is able to read and understand medication labels;

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0554 c. The resident can follow directions and tell time to know when to take the medication.

Level of Harm - Minimal harm or d. The resident comprehends the medication's purpose, proper dosage, timing, signs of side effects and potential for actual harm when to report these to the staff;

Residents Affected - Few e. The resident has the physical capacity to open medication bottles, remove medications from a container and to ingest and swallow (or otherwise administer) the medication; and

f. The resident is able to safely and securely store the medication.

If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan. The decision that a resident can safely self-administer medications is re assessed periodically based on changes in the resident's medical and/or decision-making status. If the team determines that a resident cannot safely self-administer medications, the nursing staff administer the resident's medications. The IDT evaluates options which allow residents to safely participate in the medication administration process if they wish to do so. Residents who are identified as being able to self-administer medications are asked whether they wish to do so. For self-administering residents, the nursing staff determines who is responsible (the resident or the nursing staff) for documenting that medications are taken. Self-administered medications are stored in a safe and secure place which is not accessible by other residents. Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0558 Reasonably accommodate the needs and preferences of each resident.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44376 potential for actual harm Based on observation, interview, and record review the facility failed to provide reasonable accommodation Residents Affected - Some of resident needs and preferences by failing to provide a call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) to five of nine sampled residents (Resident 249, 159, 48, 49, and 129) reviewed under the Environment task.

This deficient practice had the potential to result in the delay of care and services and possible injury to residents when they are unable to summon health care workers.

Findings:

a. During a review of Resident 249's Admission Record, the Admission Record indicated the facility admitted

the resident on 11/3/2024, with diagnoses including pathological fracture (a broken bone caused by diseases, rather than an injury) of the right ankle, other symptoms and signs involving the musculoskeletal system (the body's system of bones, muscle, tendons, ligaments, and cartilage that gives the body structure, movement, and stability), and muscle weakness.

During a review of Resident 249's Minimum Data Set (MDS - a resident assessment tool), dated 11/13/2024,

the MDS indicated the resident had the ability to make self-understood and understand others, with intact cognition (a person's mental abilities like thinking, remembering, reasoning, and understanding, are fully functioning and not significantly impaired). The MDS indicated the resident was dependent to requiring partial assistance on mobility and activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily).

During a review of Resident 249's Fall Risk Observation/Assessment, dated 11/3/2024, the Fall Risk

Observation/Assessment indicated the resident was high risk for falls.

During a review of Resident 249's Care Plan (CP) titled, Falls: Resident is at risk for falls with or without injury related to altered balance while standing and/or walking ., initiated on 11/2/2024, the CP indicated an intervention to keep call light within reach.

During a concurrent observation and interview, on 1/14/2025, at 9:59 a.m., with the Assistant Director of Staff Development (ADSD), inside Resident 249's room, observed Resident 249's call light at the left side of the bed near the trashcan. The ADSD stated the resident will not be able to reach the call light and can fall while reaching for it. The ADSD stated the staff should ensure the call light is within reach to prevent accidents to

the resident.

During an interview, on 1/17/2025, at 3:38 p.m., with the Director of Nursing (DON), the DON stated the staff should always check the placement of the call light during their rounds to ensure the call lights are within reach. The DON stated the resident will not be able to ask for help or communicate their needs if the call light was unreachable. The DON stated the resident can fall while reaching for the call light.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0558 During a review of the facility's recent policy and procedure (P&P) titled, Answering the Call Light, last reviewed on 4/18/2024, the P&P indicated the purpose of this procedure is to respond to the resident's Level of Harm - Minimal harm or requests and needs. When the resident is in bed or confined to a chair be sure the call light is within easy potential for actual harm reach of the resident.

Residents Affected - Some b. During a review of Resident 159's Admission Record, the Admission Record indicated the facility admitted

the resident on 11/23/2024, with diagnoses of collapsed vertebra (one of the bones that make up the spinal column), muscle weakness, and other symptoms and signs involving the musculoskeletal system.

During a review of Resident 159's MDS, dated [DATE REDACTED], the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition. The MDS indicated the resident required substantial to partial assistance on mobility and ADLs.

During a review of Resident 159's Fall Risk Observation/Assessment, dated 11/23/2024, the Fall Risk

Observation/Assessment indicated the resident was high risk for falls.

During a review of Resident 159's CP titled, Falls: Resident is at risk for falls with or without injury, last revised on 11/24/2024, the CP indicated an intervention to keep call light within reach.

During a concurrent observation and interview, on 1/14/2025, at 9:59 a.m., with the ADSD, inside Resident 159's room, observed the call light at the right side of the bed near the trashcan. The ADSD stated the resident will not be able to reach the call light and can fall while reaching for them. The ADSD stated the staff should ensure the call light is within reach to prevent accidents to the resident.

During an interview, on 1/17/2025, at 3:38 p.m., with the DON, the DON stated the staff should always check

the placement of the call light during their rounds to ensure the call lights are within reach. The DON stated

the resident will not be able to ask for help or communicate their needs if the call light was unreachable. The DON stated the resident can fall while reaching for the call light.

During a review of the facility's recent P&P titled, Answering the Call Light, last reviewed on 4/18/2024, the P&P indicated the purpose of this procedure is to respond to the resident's requests and needs. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

38552

c. During a review of Resident 48's Admission Record, the Admission Record indicated the facility originally admitted the resident on 7/8/2024 and readmitted on [DATE REDACTED] with diagnoses including type 2 diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing) with foot ulcer (a small open sore or wound generally found in the stomach or on the skin), pneumonia (an infection/inflammation in the lungs), and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs).

During a review of Resident 48's History and Physical (H&P), dated 7/10/2024, the H&P indicated the resident has the capacity to understand and make decisions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0558 During a review of Resident 48's MDS, dated [DATE REDACTED], the MDS indicated the resident was able to usually make self understood and was able to usually understand others. The MDS indicated the resident required Level of Harm - Minimal harm or partial/moderate assistance from staff with ADLs including toileting hygiene, personal hygiene, shower/bathe potential for actual harm self, upper and lower body dressing, and putting on/taking off footwear. The MDS indicated the resident required assistance from staff with mobility including sit to lying, lying to sitting on side of bed, sit to stand, Residents Affected - Some chair/bed-to-chair transfer, toilet transfer, and tub/shower transfer.

During a review of Resident 48's Care Plan focus on at risk for falls, initiated 7/9/2024, the Care Plan indicated the resident with goals of minimizing risk for falls. The care plan indicated interventions of keeping call light within reach and to anticipate and meet the needs of the resident.

During a review of Resident 48's Nursing-Fall Risk Observation/Assessment, dated 10/14/2024, the Nursing-Fall Risk Observation/Assessment indicated the resident was at moderate risk for falls.

During a concurrent observation and interview, on 1/15/2025, at 8:50 a.m., at Resident 48's bedside, the call light was hanging on the right side of the resident's bed out of reach. Resident 48 stated she does not know where her call light is. Resident 48 stated she uses her call light to call for staff for assistance, but when she does no one comes.

During a concurrent observation and interview, on 1/15/2025, at 8:52 a.m., at Resident 48's bedside, Certified Nursing Assistant (CNA) 1 stated the resident's call light was hanging on the right side of her bed. CNA 1 stated it should be within reach because the resident uses it to ask for assistance when they need something such to be changed or request for blankets.

During an interview, on 1/17/2025, at 4:09 p.m., the DON stated call light are used for communication between resident and health team if resident has needs. The DON stated if a call light is not within reach, the ability to address the needs of the resident is affected, the resident's safety is at risk, and residents could fall if not within reach.

During a review of the facility's recent P&P titled, Answering the Call Light, last reviewed on 4/18/2024, the P&P indicated the purpose of this procedure is to respond to the resident's requests and needs. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

44244

d. During a review of Resident 49's Admission Record, the Admission Record indicated the facility admitted

the resident on 3/18/2016 and readmitted the resident on 12/3/2022 with diagnoses that included congestive heart failure (CHF - a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), dementia (a progressive state of decline in mental abilities), bipolar disorder, psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), anxiety disorder (a mental health condition that may result in restlessness, irritability, feelings of nervousness, panic, and fear), and acquired absence of left and right legs below the knee.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0558 During a review of Resident 49's MDS, dated [DATE REDACTED], the MDS indicated the resident was usually able to understand others and usually was able to make himself understood. The MDS further indicated the resident Level of Harm - Minimal harm or required substantial/maximal assistance from staff for bathing, dressing, toileting, and personal hygiene. potential for actual harm

During a review of Resident 49's H&P, dated 2/16/2024, the H&P indicated the resident did not have the Residents Affected - Some capacity to make decisions.

During a review of Resident 49's CP titled, Falls: Resident had an incident of fall ., initiated on 11/14/2024,

the CP indicated the resident slid from the bed trying to reach for items on the floor. The CP indicated an intervention to keep call light within reach and to provide safety devices as ordered.

During a review of Resident 49's CP titled, (Resident 49) has potential for further falls ., initiated 9/26/2020 and last reviewed 1/14/2025, the CP indicated to apply the bed sensor alarm while in bed for fall management and to place the call light within reach.

During an observation, on 1/14/2025, at 10:39 a.m., Resident 49 laid in bed, awake. Resident 49 did not respond to the surveyor. A metal call light plate on the wall behind Resident 49's bed had two call light cord adapter pieces plugged in with no call light cords attached.

During a concurrent interview and record review, on 1/14/2025, at 10:57 a.m., with Restorative Nursing Aid (RNA) 1, RNA 1 entered Resident 49's room and stated the resident did not have a call light. RNA 1 exited Resident 49's room and stated the resident did not have a call light because he breaks the call lights.

During an observation, on 1/14/2025, at 12:57 p.m., Resident 49 laid in bed. Resident 49 did not have a call light.

During an observation, on 1/16/2025, at 11 a.m., Resident 49 laid in bed. Resident 49 did not have a call light.

During a concurrent observation and interview, on 1/16/2025, at 11:07 a.m., with Licensed Vocational Nurse (LVN) 4, LVN 4 stated call lights are a communication method between the resident and staff to ensure the needs of the resident are met and to attend to the resident in case of an emergency. LVN 4 stated all residents should have a call light and Resident 49 usually had a call light. LVN 4 stated Resident 49 had a history of breaking call lights, and they replace them as soon as possible. LVN 4 stated she was not made aware Resident 49 did not have a call light. LVN 4 entered Resident 49's room and stated the resident did not have a call light. LVN 4 stated she administered the resident's medications earlier that day and did not notice the resident did not have a call light. LVN 4 stated she assessed the resident but missed identifying

the resident's missing call light. LVN 4 stated when residents are not provided a call light, the resident's safety is compromised because there may be delay in responding to the resident. LVN 4 stated if staff were aware Resident 49 did not have a call light, they should have notified the maintenance department to fix it.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0558 During a concurrent interview and record review, on 1/16/2025, at 11:16 a.m., with Maintenance Staff 2 (MS 2), MS 2 reviewed the Station 4 Maintenance Log and stated he was not aware of Resident 49's call light Level of Harm - Minimal harm or and it was not reported to the maintenance department that Resident 49 did not have and needed a call light. potential for actual harm

During an interview, on 1/16/2025, at 12:06 p.m., with CNA 2, CNA 2 stated she regularly cares for Resident Residents Affected - Some 49 and the resident had not had a call light for months. CNA 2 stated all residents should have a call light in case they need anything. CNA 2 stated Resident 49 had a history of pulling the call light out of the wall. CNA 2 stated she did not know who removed Resident 49's call light but she had reported it to the charge nurses because it concerned her that the resident may not get assistance. CNA 2 stated she did not remember which nurse she reported it to, but all the nurses knew the resident did not have a call light.

During an interview, on 1/16/2025, at 2:10 p.m., with RNA 1, RNA 1 stated he did not notify anyone on 1/14/2025 that Resident 49 did not have a call light because he believed the maintenance department knew

the resident did not have a call light. RNA 1 stated he believed Resident 49 had not had a call light for no longer that a week.

During a concurrent interview and record review, on 1/17/2025, at 12:10 p.m., with the DON, the DON reviewed the facility policy and procedure regarding call lights. The DON stated he was made aware that Resident 49 was not provided a call light. The DON stated there was a communication disconnect between

the staff regarding Resident 49's call light. The DON stated every resident requires a call light, no matter what their clinical condition is. The DON stated had he known the resident was not provided a call light, he would have taken action to ensure a call light was provided. The DON stated the importance of the call light is for a resident's dignity and safety. The DON stated if a resident is breaking the call light, then there should be an interdisciplinary meeting to ensure the resident has a way to communicate with staff, but there was no meeting. The DON stated when a resident is not provided a call light, it can potentially result in the resident not having a way to communicate with the care team in the event of emergency. The DON stated the facility policy regarding call lights was not followed when Resident 49 was not provided a call light or way to communicate with staff.

During a review of the facility P&P titled, Answering the Call Light, last reviewed 4/18/2024, the P&P indicated the purpose of the procedure is to respond to the resident's requests and needs. Be sure the call light is plugged in at all times. When the resident is in bed be sure the call light is within easy reach of the resident. Report all defective call lights to the nurse supervisor promptly.

During a review of the facility's P&P titled, Resident Rights, the P&P indicated federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to communication with and access to people and services, both inside and outside of the facility.

43988

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0558 e. During a review of Resident 129's Admission Record, the Admission Record indicated the facility originally admitted the resident on 8/3/2021 and readmitted the resident on 8/16/2021 with diagnoses Level of Harm - Minimal harm or including dysphagia (difficulty swallowing), unspecified intellectual disabilities (a lifelong condition that limits a potential for actual harm person's mental functioning and skills), and difficulty in walking.

Residents Affected - Some During a review of Resident 129's H&P, dated 9/5/2024, the H&P indicated the resident did not have the capacity to understand and make decisions.

During a review of Resident 129's MDS, dated [DATE REDACTED], the MDS indicated the resident had severely impaired cognition. The MDS indicated Resident 129 required total assistance from staff with lower body dressing, partial/moderate assistance with bathing, toileting hygiene, upper body dressing, toilet transfer, and shower transfer, and substantial/maximal assistance with all other ADLs.

During a review of Resident 129's Fall Risk Assessments, dated 5/27/2024, 8/24/2024, and 11/23/2024, the Fall Risk Assessments indicated the resident was a high risk for falls.

During a review of Resident 129's CP on potential for injury or falls due to unsteady gait or balance and poor safety awareness, initiated 8/4/2021 and last revised on 8/25/2023, the CP indicated the following interventions to prevent falls:

- Call light placed within reach.

- Instruct use of call light whenever in need of assistance. Instruct use of safety.

During a concurrent observation and interview, on 1/14/2025, at 10:38 a.m., inside Resident 129's room, with LVN 12, Resident 129's call light coiled and hung on the wall plug outside of Resident 129's reach. LVN 12 stated staff should place all call lights within reach prior to leaving the room. LVN 12 stated the call light should have not been coiled and hung on the wall plug. LVN 12 stated the call light should have been placed within Resident 129's reach so the resident would be able to call for assistance when needed. LVN 12 stated if the call light was not within reach, Resident 129 may try to get out of bed unassisted and fall which may lead to injury.

During an interview, on 1/17/2025, at 3:38 p.m., with the DON, the DON stated the staff should always check

the placement of the call light during their rounds to ensure the call lights were within reach. The DON stated

the resident will not be able to ask for assistance or communicate their needs if the call light was not within reach. The DON stated Resident 129 may try to get out of bed and fall if the call light was not within reach and is unable to call for assistance.

During a review of the facility's recent P&P titled, Answering the Call Light, last reviewed on 4/18/2024, the P&P indicated the purpose of this procedure is to respond to the resident's requests and needs. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0584 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. Level of Harm - Minimal harm or potential for actual harm 44376

Residents Affected - Few Based on observation, interview, and record review, the facility failed to provide a comfortable and homelike environment to one of two sampled residents (Resident 109) investigated under physical environment by failing to ensure the hot water temperature in the bathroom sink was within acceptable levels per the facility's policy and procedure.

This deficient practice violated the resident's rights to a safe, clean, sanitary, and homelike environment.

Findings:

During a review of Resident 109's Admission Record, the Admission Record indicated the facility admitted

the resident on 7/17/2024, with diagnoses including muscle weakness, depression (a mental health condition that involves persistent feelings of sadness, loss of interest, and difficulty with daily life), and history of falling.

During a review of Resident 109's Minimum Data Set (MDS - a resident assessment tool), dated 10/23/2024,

the MDS indicated the Resident 109 had the ability to make self-understood and understand others and had mild cognitive impairment (a condition that causes memory or thinking difficulties that are more severe than what's expected for a person's age). The MDS indicated Resident 109 required substantial to maximal assistance on showering and bathing.

During a review of Resident 109's Care Plan (CP) titled Resident requires 24-hour care and will remain in facility long term under custodial care, initiated on 8/25/2024, the CP indicated an intervention to help create

a home like environment.

During a concurrent observation and interview, on 1/14/2025, at 8:41 a.m., with Resident 109, inside the resident's room, Resident 109 stated the water in their bathroom sink was cold and it takes time to warm up.

The hot water faucet in the sink ran for five minutes and turned lukewarm.

During a concurrent observation and interview, on 1/17/2025, at 8:55 a.m., with Maintenance Staff 1 (MS 1), inside Resident 109's room, MS 1 ran the hot water at the sink faucet for 5 minutes and measured the temperature of the water with a thermometer. MS 1 stated the temperature of the water was 85 to 86 degrees Fahrenheit (F, a temperature scale where water freezes at 32 degrees and boils at 212 degrees). MS 1 stated the hot water should be in between 105 to 120 degrees F to promote a comfortable temperature of water for residents to wash their face and body with.

During an interview, on 1/17/2025, at 3:38 p.m., with the Director of Nursing (DON), the DON stated the hot water in the sink faucet should be within 105 to 120 degrees F to promote comfort when residents are washing their faces or having a bath.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0584 During a review of the facility's recent policy and procedure (P&P) titled, Water Temperatures, Safety of, last reviewed on 4/18/2024, the P&P indicated tap water in the facility shall be kept within a temperature range to Level of Harm - Minimal harm or prevent scalding of residents. Water heaters that service resident rooms, bathrooms, common areas, and potential for actual harm tub/shower areas shall be set to temperatures of no more than 105 degrees to 120 degrees F (45.9 degrees C), or maximum allowable temperature per state regulation. Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44376 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure residents were treated with Residents Affected - Some respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for 10 of 10 sampled residents (Residents 264, 109, 96, 481, 165, 82, 193, 129, 160, 39) investigated during review of physical restraints care area by failing to ensure:

1. Resident 264 had a physician's order, an informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered), a restraint assessment, and a care plan for restraint wedge pillow (a triangular pillow that raises the top half of your body, usually made of foam) tucked under the sheet.

2. Residents 109, 96, 193, 82, and 165 had restraint assessments and informed consents (the act of agreeing to allow something to happen, or to do something, with a full understanding of all risks and available alternatives) obtained from the residents and/or their representatives on the use of bed placed against the wall.

3. Residents 481 and 129 had a physician's order, an informed consent, a restraint assessment, and a care plan on the use of restraint bed placed against the wall.

4. Resident 160's bedside safety mattress was not placed on its side preventing the resident from getting out of bed freely.

5. Side rails (SR, adjustable rigid bars attached to the bed that may be positioned in various locations on the bed; upper or lower, either or both sides) were not placed in the raised (up) position on bilateral lower sides (area including the legs) without assessing for the need, assessing for safety, and obtaining informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) prior to use for Resident 39.

These deficient practices had the potential to result in the restriction of residents' freedom of movement, a decline in physical functioning, psychosocial harm, physical harm from entrapment (a state in which a person is trapped by the bed rail in a position that they cannot move from), and death of residents.

Findings:

1. During a review of Resident 264's Admission Record, the Admission Record indicated the facility admitted

the resident on 12/16/2024, with diagnoses including muscle weakness and altered mental status.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0604 During a review of Resident 264's Minimum Data Set (MDS, a resident assessment tool), dated 12/22/2024,

the MDS indicated the resident had the ability to make self-understood and understand others and had mild Level of Harm - Minimal harm or cognitive impairment (a condition that causes memory or thinking difficulties that are more severe than potential for actual harm normal aging). The MDS indicated the resident required substantial assistance on mobility and activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) and had a Residents Affected - Some history of fall.

During a review of Resident 264's Fall Risk Observation/Assessment, dated 12/23/2024, the Fall Risk

Observation/Assessment indicated the resident was a low risk for fall.

During a concurrent observation and interview on 1/14/2025, at 11:43 a.m., with Certified Nursing Assistant 4 (CNA 4), inside Resident 264's room, observed Resident 264 had a wedge pillow tucked under the sheet at

the right side of the bed. CNA 4 stated placing a wedge pillow under the sheet was a form of restraint as the resident will not be able to remove them easily. CNA 4 stated they were placing the wedge pillow on the right side of the resident's bed to prevent the resident from getting out of the right side of the bed to prevent a fall.

During a concurrent interview and record review on 1/16/2025, at 3:43 p.m., with Licensed Vocational Nurse 5 (LVN 5), LVN 5 stated placing a wedge pillow under the sheet is a form of a restraint. Reviewed Resident 264's Order Summary Report, Informed Consent, Restraint Assessment, and Care Plans with LVN 5. LVN 5 stated there was no physician's order, informed consent, restraint assessment, and a care plan on the use of wedge pillow tucked under the sheet on the resident's medical chart. LVN 5 stated it was important to have a physician's order, informed consent, restraint assessment, and a care plan on the use of wedge pillow tucked under the sheet to ensure its safe use.

During an interview on 1/17/2025, at 3:31 p.m., with the Director of Nursing (DON), the DON stated the staff should obtain a physician's order, secure an informed consent from the resident or resident representative, perform a restraint assessment, and develop and implement a care plan on the use of wedge pillow tucked under the sheet to ensure its safe use.

During a review of the facility's recent policy and procedure (P&P) titled Use of Restraints, last reviewed 4/18/2024, the P&P indicated physical restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). The order shall include the following:

a. The specific reason for the restraint (as it relates to the resident's medical symptom);

b. How the restraint will be used to benefit the resident's medical symptom; and

c. The type of restraint, and period of time for the use of the restraint.

Care plans shall also include the measurable takes to systematically reduce or eliminate the need for restraint use.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0604 2. During a review of Resident 109's Admission Record, the Admission Record indicated the facility admitted

the resident on 7/17/2024, with diagnoses including muscle weakness, history of falling, depression (a Level of Harm - Minimal harm or mental health condition that involves a persistent feeling of sadness and a loss of interest in activities). potential for actual harm

During a review of Resident 109's MDS, dated [DATE REDACTED], the MDS indicated the resident had the ability to Residents Affected - Some make self-understood and understand others and had mild cognitive impairment. The MDS indicated the resident required substantial assistance on mobility and activities of daily living (ADLs).

During a review of Resident 109's Fall Risk Observation/Assessment, dated 7/18/2024, the Fall Risk

Observation/Assessment indicated the resident was high risk for falls.

During a concurrent observation and interview on 1/15/2025, at 4:54 p.m., with the Assistant Director of Staff Development (ADSD), observed Resident 109's bed was placed against the wall at the left side of the bed.

The ADSD stated placing the bed against the wall is a form of physical restraint.

During a concurrent interview and record review on 1/15/2025, at 5:14 p.m., with LVN 5, reviewed Resident 109's Order Summary Report, Informed Consent, Restraint Assessment, and Care Plans. LVN 5 stated there was no informed consent and restraint assessment on the use of bed placed against the wall on the resident. LVN 5 stated it was important to have a physician's order, informed consent, restraint assessment, and a care plan on the use of bed against the wall to ensure its safe use.

During an interview on 1/17/2025, at 3:31 p.m., with the DON, the DON stated the staff should obtain a physician's order, secure an informed consent from the resident or resident representative, perform a restraint assessment, and develop and implement a care plan on the use of bed placed against the wall to ensure its safe use.

During a review of the facility's recent policy and procedure (P&P) titled Use of Restraints, last reviewed 4/18/2024, the P&P indicated physical restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). The order shall include the following:

a. The specific reason for the restraint (as it relates to the resident's medical symptom);

b. How the restraint will be used to benefit the resident's medical symptom; and

c. The type of restraint, and period of time for the use of the restraint.

Care plans shall also include the measurable takes to systematically reduce or eliminate the need for restraint use.

3. During a review of Resident 96's Admission Record, the Admission Record indicated the facility admitted

the resident on 8/28/2019, and readmitted the resident on 11/7/2019, with diagnoses including muscle weakness, acquired absence of left leg below knee (a condition where the left leg has been surgically removed below the knee), and age-related osteoporosis (a bone disease that causes bones to become weak and more likely to break).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0604 During a review of Resident 96's MDS, dated [DATE REDACTED], the MDS indicated the resident usually had the ability to make self-understood and understand others and had severe cognitive impairment (a condition that Level of Harm - Minimal harm or makes it difficult for a person to think, learn, remember, and make decisions). The MDS indicated the potential for actual harm resident was dependent to requiring substantial assistance on mobility and activities of daily living (ADLs).

Residents Affected - Some During a review of Resident 96's Fall Risk Observation/Assessment, dated 12/7/2024, the Fall Risk

Observation/Assessment indicated the resident was high risk for falls.

During a concurrent observation and interview on 1/15/2025, at 4:54 p.m., with the ADSD, observed Resident 96's bed was placed against the wall at the left side of the bed. The ADSD stated placing the bed against the wall is a form of physical restraint.

During a concurrent interview and record review on 1/15/2025, at 5:14 p.m., with LVN 5, reviewed Resident 96's Order Summary Report, Informed Consent, Restraint Assessment, and Care Plans. LVN 5 stated there was no informed consent and restraint assessment on the use of bed placed against the wall on the resident. LVN 5 stated 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.

During an interview on 1/17/2025, at 3:31 p.m., with the DON, the DON stated the staff should obtain a physician's order, secure an informed consent from the resident or resident representative, perform a restraint assessment, and develop and implement a care plan on the use of bed placed against the wall to ensure its safe use.

During a review of the facility's recent policy and procedure (P&P) titled Use of Restraints, last reviewed 4/18/2024, the P&P indicated physical restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). The order shall include the following:

a. The specific reason for the restraint (as it relates to the resident's medical symptom);

b. How the restraint will be used to benefit the resident's medical symptom; and

c. The type of restraint, and period of time for the use of the restraint.

Care plans shall also include the measurable takes to systematically reduce or eliminate the need for restraint use.

4. During a review of Resident 481's Admission Record, the Admission Record indicated the facility admitted

the resident on 7/20/2024, and readmitted the resident on 1/13/2025, with diagnoses including repeated falls, difficulty walking, hemiplegia (paralysis that affects only one side of the body.), and hemiparesis (a condition that causes weakness or an inability to move on one side of the body).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0604 During a review of Resident 481's MDS, dated [DATE REDACTED], the MDS indicated the resident usually had the ability to make self-understood and understand others and had intact cognition (having the ability to think, learn, Level of Harm - Minimal harm or and remember clearly). The MDS indicated the resident required supervision on mobility and activities of potential for actual harm daily living (ADLs).

Residents Affected - Some During a review of Resident 481's Fall Risk Observation/Assessment, dated 7/22/2024, the Fall Risk

Observation/Assessment indicated the resident was a moderate risk for falls.

During a concurrent interview and record review on 1/15/2025, at 5:14 p.m., with LVN 5, reviewed Resident 481's Order Summary Report, Informed Consent, Restraint Assessment, and Care Plans. LVN 5 stated there was no physician's order, informed consent, restraint assessment, and care plan on the use of bed placed against the wall on the resident. LVN 5 stated 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.

During an interview on 1/17/2025, at 3:31 p.m., with the DON, the DON stated the staff should obtain a physician's order, secure an informed consent from the resident or resident representative, perform a restraint assessment, and develop and implement a care plan on the use of bed placed against the wall to ensure its safe use.

During a review of the facility's recent policy and procedure (P&P) titled Use of Restraints, last reviewed 4/18/2024, the P&P indicated physical restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). The order shall include the following:

a. The specific reason for the restraint (as it relates to the resident's medical symptom);

b. How the restraint will be used to benefit the resident's medical symptom; and

c. The type of restraint, and period of time for the use of the restraint.

Care plans shall also include the measurable takes to systematically reduce or eliminate the need for restraint use.

43988

5. During a review of Resident 193's Admission Record, the Admission Record indicated the facility originally admitted the resident on 11/7/2023, and readmitted the resident in the facility on 7/28/2024, with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body) following cerebrovascular disease (stroke, loss of blow to a part of the brain) affecting right dominant side, type 2 diabetes mellitus (a chronic disease that occurs when

the body does not produce enough insulin or does not use it properly) with foot ulcer, and generalized weakness.

During a review of Resident 193's History and Physical (H&P) dated 7/28/2024, the H&P indicated Resident 193 had fluctuating capacity to understand and make decisions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0604 During a review of Resident 193's MDS dated [DATE REDACTED], the MDS indicated the resident had severely impaired cognition (having the ability to think, learn, and remember clearly). The MDS indicated Resident 193 required Level of Harm - Minimal harm or supervision or touching assistance with eating and oral hygiene; partial/moderate assistance with mobility, potential for actual harm upper body dressing, and personal hygiene; total assistance with lower body dressing, tub and toilet transfers; substantial/maximal assistance with all other activities of daily living (ADLs - basic tasks that must Residents Affected - Some be accomplished every day for an individual to thrive).

During a review of Resident 193's Order Summary Report, the Order Summary Report indicated a physician's order dated 10/29/2024 that resident and family wanted to place the bed against the wall for comfort.

During a review of Resident 193's Fall Risk Assessments dated 7/28/2024, 8/15/2024, and 10/21/2024, the Fall Risk Assessments indicated Resident 193 was a high risk for falls.

During a concurrent observation and interview on 1/14/2025, at 11:31 a.m., inside Resident 193's room with Treatment Nurse 1 (TN 1), observed Resident 193's bed was placed against the wall on the right side. TN 1 verified the bed was placed against the wall and that it was a family preference.

During a concurrent interview and record review on 1/14/2025 at 11:45 a.m. inside Resident 193's room with Licensed Vocational Nurse 12(LVN 12), LVN 12 verified Resident 193's bed was placed against the wall on

the right side as he was a high risk for fall, and it can be considered a form of restraint as it was preventing

the resident's movement from the other side of the bed.

During a concurrent interview and record review on 1/16/2025, at 5:30 p.m. with Licensed Vocational Nurse 10 (LVN 10), reviewed Resident 193's physician's orders, informed consent, restraint assessment, fall risk assessment, and care plan with LVN 10. LVN 10 verified there was no restraint assessment, and informed consent on the use of bed against the wall in Resident 193's medical record. LVN 10 stated it was important to have a a restraint assessment and care plan on the use of bed placed against the wall to ensure appropriateness of the use of restraint and the staff aware of the resident plan of care.

During an interview on 1/17/2025, at 3:31 p.m., with the DON, the DON stated the staff prior to use of any type of restraints, there should be a physician's order, obtain informed consent from the resident or resident representative, complete a restraint assessment, and develop and implement a care plan. The DON stated

the restraint assessment should have been completed and informed consent should have been obtained from Resident 193 and/or representative so the resident and/or representative would be aware of the risks and benefits of having a bed placed against the wall.

During a review of the facility's recent policy and procedure (P&P) titled Use of Restraints, last reviewed 4/18/2024, the P&P indicated physical restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). The order shall include the following:

a. The specific reason for the restraint (as it relates to the resident's medical symptom);

b. How the restraint will be used to benefit the resident's medical symptom; and

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0604 c. The type of restraint, and period of time for the use of the restraint.

Level of Harm - Minimal harm or Care plans shall also include the measurable takes to systematically reduce or eliminate the need for potential for actual harm restraint use.

Residents Affected - Some 6. During a review of Resident 82's Admission Record, the Admission Record indicated the facility originally admitted the resident on 6/25/20218 and readmitted the resident in the facility on 6/21/2019 with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body) following intracerebral hemorrhage (a sudden bleeding into

the tissues of the brain) affecting right dominant side, and generalized muscle weakness.

During a review of Resident 82's H&P dated 3/22/2024, the (H&P) indicated the resident had the capacity to understand and make decisions.

During a review of Resident 82's MDS dated [DATE REDACTED], the MDS indicated the resident had moderately impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 82 required partial/moderate assistance with eating; total assistance from staff with lower body dressing, personal hygiene, and shower transfers; substantial/maximal assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).

During a review of Resident 82's fall risk assessments dated 7/3/2024, 10/3/2024, and 1/3/2025, the fall risk assessments indicated the resident was a high risk for falls.

During a concurrent observation and interview on 1/5/2025 at 8:00 a.m. inside Resident 82's room, observed Resident 82 lying in bed eating breakfast and the bed remained placed against the wall. Resident 82 stated his bed had always been against the wall on the left side. Resident 82 stated his weak side is on the right side and with the bed against the wall on the left side, Resident 82 verified he would be unable to get out of bed from the left side.

During a concurrent observation and interview on 1/16/2025 at 5:20 p.m. inside Resident 82's room with Licensed Vocational Nurse 9 (LVN 9), LVN 9 verified Resident 82's bed was placed against the wall on the left side and the resident has weakness and paralysis on the right side of the body. LVN 9 stated the bed against the wall on the left side can be considered a restraint as it was restricting Resident 82 to be able to get out of bed on the left side.

During a concurrent interview and record review on 1/16/2025, at 5:30 p.m. with Licensed Vocational Nurse 10 (LVN 10), reviewed Resident 82's physician's orders, informed consent, restraint assessment, fall risk assessment, and care plan with LVN 10. LVN 10 verified there was no restraint assessment, and informed consent on the use of bed against the wall in Resident 82's medical record. LVN 10 stated it was important to have a restraint assessment and care plan on the use of bed placed against the wall to ensure appropriateness of the use of restraint and for the staff to be aware of the resident's plan of care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0604 During an interview on 1/17/2025, at 3:31 p.m., with the DON, the DON stated the staff prior to use of any type of restraints, there should be a physician's order, obtain informed consent from the resident or resident Level of Harm - Minimal harm or representative, complete a restraint assessment, and develop and implement a care plan. The DON stated potential for actual harm the restraint assessment should have been completed and informed consent should have been obtained from Resident 82 and/or representative so the resident and/or representative would be aware of the risks Residents Affected - Some and benefits of having a bed placed against the wall.

During a review of the facility's recent policy and procedure (P&P) titled Use of Restraints, last reviewed 4/18/2024, the P&P indicated physical restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). The order shall include the following:

a. The specific reason for the restraint (as it relates to the resident's medical symptom);

b. How the restraint will be used to benefit the resident's medical symptom; and

c. The type of restraint, and period of time for the use of the restraint.

Care plans shall also include the measurable takes to systematically reduce or eliminate the need for restraint use.

7. During a review of Resident 129's Admission Record, the Admission Record indicated the facility originally admitted the resident on 8/3/2021 and readmitted the resident on 8/16/2021 with diagnoses including dysphagia (difficulty swallowing), unspecified intellectual disabilities (a lifelong condition that limits a person's mental functioning and skills), and difficulty in walking.

During a review of Resident 129's History and Physical (H&P) dated 9/5/2024, the (H&P) indicated the resident did not have the capacity to understand and make decisions.

During a review of Resident 129's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 11/24/2024, the MDS indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 129 required total assistance from staff with lower body dressing, partial/moderate assistance with bathing, toileting hygiene, upper body dressing, toilet transfer, and shower transfer, and substantial/maximal assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).

During a review of Resident 129's fall risk assessments dated 5/27/2024, 8/24/2024, and 11/23/2024, the fall risk assessments indicated the resident was a high risk for falls.

During a concurrent observation and interview on 1/14/2025 at 10:38 a.m. inside Resident 129's room with Licensed Vocational Nurse 12 (LVN 12), observed Resident 129's bed was placed against the wall on the right side as he was a high risk for fall, and it can be considered a form of restraint as it was preventing the resident's movement from the other side of the bed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0604 During a concurrent interview and record review on 1/16/2025, at 5:30 p.m. with Licensed Vocational Nurse 10 (LVN 10), reviewed Resident 129's physician's orders, informed consent, restraint assessment, fall risk Level of Harm - Minimal harm or assessment, and care plan with LVN 10. LVN 10 verified there was no physician's order, restraint potential for actual harm assessment, informed consent, and care plan on the use of bed against the wall in Resident 129's medical record. LVN 10 stated it was important to have a physician's order, informed consent, restraint assessment, Residents Affected - Some and care plan on the use of bed placed against the wall to ensure appropriateness of the use of restraint and for the staff to be aware of the resident's plan of care.

During an interview on 1/17/2025, at 3:31 p.m., with the Director of Nursing (DON), the DON stated the staff prior to use of any type of restraints, there should be a physician's order, obtain informed consent from the resident or resident representative, complete a restraint assessment, and develop and implement a care plan. The DON stated the restraint assessment should have been completed and informed consent should have been obtained from Resident 193 and/or representative so the resident and/or representative would be aware of the risks and benefits of having a bed placed against the wall.

During a review of the facility's recent policy and procedure (P&P) titled Use of Restraints, last reviewed 4/18/2024, the P&P indicated physical restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). The order shall include the following:

a. The specific reason for the restraint (as it relates to the resident's medical symptom);

b. How the restraint will be used to benefit the resident's medical symptom; and

c. The type of restraint, and period of time for the use of the restraint.

Care plans shall also include the measurable takes to systematically reduce or eliminate the need for restraint use.

8. During a review of Resident 165's Admission Record, the Admission Record indicated the facility originally admitted the resident on 6/18/2023 and readmitted the resident in the facility on 9/17/2024 with diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (persistent and excessive worry that interferes with daily activities), chronic osteomyelitis (a bone infection caused by injuries and blood circulation disorders) of the left ankle and foot.

During a review of Resident 165's H&P dated 12/19/2024, the (H&P) indicated the resident had the capacity to understand and make decisions.

During a review of Resident 165's MDS dated [DATE REDACTED], the MDS indicated the resident had an intact cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 165 required set up assistance with eating; supervision with oral hygiene and mobiity; substantial/maximal assistance with lower body dressing; partial/moderate assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0604 During a review of Resident 165's fall risk assessments dated 9/17/2024, 9/30/2024, 12/4/2024, and 12/31/2024, the fall risk assessments indicated the resident was a high risk for falls. Level of Harm - Minimal harm or potential for actual harm During a concurrent observation and interview on 1/14/2025 at 10:11 a.m. inside Resident 165's room with Licensed Vocational Nurse 12 (LVN 12), observed Resident 165's bed was placed against the wall on the left Residents Affected - Some side and verified he was a high risk for fall, and it can be considered a form of restraint as it was preventing

the resident's movement from the other side of the bed.

During a concurrent interview and record review on 1/16/2025, at 5:30 p.m. with Licensed Vocational Nurse 10 (LVN 10), reviewed Resident 165's physician's orders, informed consent, restraint assessment, fall risk assessment, and care plan with LVN 10. LVN 10 verified there was no restraint assessment, and care plan

on the use of bed against the wall in Resident 165's medical record. LVN 10 stated it was important to have

a restraint assessment, and care plan on the use of bed placed against the wall to ensure appropriateness of

the use of restraint and for the staff to be aware of the resident's plan of care.

During an interview on 1/17/2025, at 3:31 p.m., with the DON, the DON stated the staff prior to use of any type of restraints, there should be a physician's order, obtain informed consent from the resident or resident representative, complete a restraint assessment, and develop and implement a care plan. The DON stated

the restraint assessment should have been completed and informed consent should have been obtained from Resident 165 and/or representative so the resident and/or representative would be aware of the risks and benefits of having a bed placed against the wall.

During a review of the facility's recent policy and procedure (P&P) titled Use of Restraints, last reviewed 4/18/2024, the P&P indicated physical restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). The order shall include the following:

a. The specific reason for the restraint (as it relates to the resident's medical symptom);

b. How the restraint will be used to benefit the resident's medical symptom; and

c. The type of restraint, and period of time for the use of the restraint.

Care plans shall also include the measurable takes to systematically reduce or eliminate the need for restraint use.

9. During a review of Resident 160's Admission Record, the Admission Record indicated the facility originally admitted the resident on 6/27/2023 and readmitted the resident in the facility on 8/3/2023 with diagnoses including nontraumatic intracranial hemorrhage (a sudden bleeding into the tissues of the brain), seizures (a sudden uncontrolled electrical disturbance on the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), and abnormalities of gait and mobility.

During a review of Resident 160's H&P dated 8/10/2[TRUNCATED]

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities

Level of Harm - Potential for 43988 minimal harm Based on interview and record review, the facility failed to accurately code on one (1) of two (2) sampled Residents Affected - Some residents (Resident 164) Preadmission Screening and Resident Review (PASARR - a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) when the PASARR prior to admission did not indicate Resident 103 had schizophrenia (a mental illness that is characterized by disturbances in thought).

This deficient practice had the potential to result in the resident's medical and nursing care needs not being met.

Findings:

During a review of Resident 164's Admission Record, the Admission Record indicated the facility originally admitted the resident on 6/27/2024 and readmitted the resident on 9/1/2024, with diagnoses including schizophrenia, abnormalities of gait and mobility, and anxiety disorder (a mental health condition that causes excessive and persistent feelings of fear, dread, and worry).

During a review of Resident 164's Minimum Data Set (MDS - a resident assessment tool), dated 12/19/2024,

the MDS indicated Resident 164 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 164 required set up or cleanup assistance with eating and oral hygiene; supervision or touching assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).

During a review of Resident 164's History and Physical (H&P), dated 9/1/2024, the H&P indicated Resident 164 had fluctuating capacity to understand and make decisions.

During a review of Resident 164's PASARR, date started 8/11/2024, the PASARR indicated that the resident did not have a diagnosed mental disorder.

During a concurrent interview and record review, on 1/15/2025, at 12:53 p.m., with the Director of Admissions (DA), Resident 164's PASARR Level 1 Screening form (a preliminary assessment that determines if someone might have a mental illness or intellectual disability before being admitted to a nursing facility), dated 8/11/2024, and Resident 164's Admission Record were reviewed. The DA verified she completed Resident 164's PASARR Level 1 Screening and the screening did not indicate the resident had a mental disorder. The DA stated the Admission Record indicated Resident 164 had a diagnosis of schizophrenia upon original admission on 6/27/2024. The DA stated the PASARR Level 1 Screening was not completed accurately prior to admission to the facility. The DA stated prior to admission, the facility requests

the general acute care hospital (GACH) to complete the PASARR Level 1 Screening and uploaded in the electronic health record. The DA stated she will complete the PASARR Level 1 Screening upon admission if

the GACH did not complete prior to transferring the resident to the facility. The DA stated she should have checked Resident 164's Admission Record and should have coded the PASARR Level 1 Screening accurately to reflect the resident's current medical condition such as diagnoses of behavioral issues, mental illness, or mood disorder to ensure Resident 164 received the proper care and services the resident needed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0645 During an interview, on 1/17/2025, at 5:30 p.m., with the Director of Nursing (DON), the DON stated the PASARR Level 1 Screening is completed in the GACH prior to admission to the facility when they submit Level of Harm - Potential for inquiry for bed availability in the facility. The DON stated the DA is responsible to make sure the GACH minimal harm completed the Level 1 Screening prior to admission. The DON stated if not completed, then the DA will complete the Level 1 Screening. The DON stated the PASARR Level 1 Screening should be completed Residents Affected - Some accurately to ensure resident placement in the facility is appropriate to receive the proper services the resident needs. The DON stated Resident 164's PASARR Level 1 Screening should have been completed accurately to reflect Resident 164's diagnosis of schizophrenia to ensure proper placement and avoid delay

in the delivery of necessary care and services Resident 164 needs.

During a review of the facility's policy and procedure (P&P) titled, PASARR, last reviewed 4/18/2024, the P&P indicated:

- Before a [resident] can be transferred from a hospital, they must undergo a PASARR Level 1 Screening.

This initial screening is to identify individuals who may have mental illness, intellectual disability, or related conditions. The goal is to determine whether they require further evaluation to assess the need for specialized services.

- If the Level 1 screen indicates that the individual may meet the criteria for a mental disorder, intellectual disability, or related disorders, he or she is referred to the Stated PASARR representative for the Level II (evaluation and determination) screening process.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44376

Residents Affected - Some Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for three of 10 sampled residents (Resident 249, 109, and 481) during initial sampling of residents by failing to develop and implement a care plan on:

1. Resident 249's use of Trazadone (a drug used to treat depression [a mental health condition that involves

a persistent feeling of sadness and a loss of interest in activities]) and Buspirone (a medication that treats anxiety).

2. Resident 109's use of Zoloft (also known as sertraline, medication that can help treat depression and other mental health conditions).

3. Resident 481's use of indwelling urinary catheter (a hollow tube inserted into the bladder to drain or collect urine).

4. Resident 481's use of restraint (the use of a manual hold to restrict freedom of movement of all or part of a person's body, or to restrict normal access to the person's body) bed placed against the wall.

These deficient practices had the potential for residents to not receive necessary care and treatment.

Findings:

1. During a review of Resident 249's Admission Record, the Admission Record indicated the facility admitted

the resident on 11/3/2024, with diagnoses including anxiety disorder (a mental health condition that involves excessive and persistent feelings of fear, worry, and dread), major depressive disorder (a serious mental illness that causes a persistent low mood and loss of interest in activities), and psychosis (a mental health condition that causes a person to lose touch with reality).

During a review of Resident 249's Minimum Data Set (MDS - a resident assessment tool), dated 11/13/2024,

the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition (having the ability to think, learn, and remember clearly). The MDS further indicated the resident was on a high-risk drug class antianxiety (something that reduces or prevents anxiety) and antidepressant (a type of medicine used to treat clinical depression) medications.

During a review of Resident 249's Order Summary Report, dated 11/3/2024, the Order Summary Report indicated an order for:

Trazadone HCl Oral Tablet (Trazadone HCl). Give 200 milligrams (mg - a unit of measurement of mass in

the metric system equal to a thousandth of a gram) by mouth at bedtime for depression monitor behavior (m/b) inability to sleep at night. Risks and benefits explained. Physician obtained informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0656 Buspirone HCl Oral Tablet 15 mg (Buspirone HCl). Give 15 mg by mouth three times a day for anxiety m/b overly concern about health risks and benefits explained. Physician obtained informed consent. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review, on 1/16/2025, at 3:51 p.m., with Licensed Vocational Nurse (LVN) 5, Resident 249's Order Summary Report, dated 11/3/2024, and Resident 249's Care Plans were Residents Affected - Some reviewed. LVN 5 stated there was no care plan developed and implemented on the use of Trazadone and Buspirone. LVN 5 stated it was important to have care plan on the use of psychotropic medications (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) Trazadone and Buspirone to ensure safe use of the medication. LVN 5 stated care plans sets the goal of therapy and the interventions to meet the needs of the resident.

During an interview, on 1/17/2025, at 3:38 p.m., with the Director of Nursing (DON), the DON stated the staff should have developed and implemented a care plan on the use of Trazadone and Buspirone to ensure the medications were appropriately used. The DON stated the care plan serves as a communication tool to the healthcare team and the family members. The DON stated the care plan standardizes the care that is being provided to the resident.

During a review of the facility's recent policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, last reviewed on 4/18/2024, the P&P indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS).

2. During a review of Resident 109's Admission Record, the Admission Record indicated the facility admitted

the resident on 7/17/2024, with a diagnosis of depression.

During a review of Resident 109's MDS, dated [DATE REDACTED], the MDS indicated the resident had the ability to make self-understood and understand others and had mild cognitive impairment (a condition that causes memory or thinking difficulties that are more severe than normal aging). The MDS also indicated the resident was on a high-risk drug class antidepressant (a type of medicine used to treat clinical depression) medication.

During a review of Resident 109's Order Summary Report, dated 7/17/2024, the Order Summary Report indicated an order for Zoloft oral tablet 25 mg, give 25 mg by mouth one time a day for depression m/b verbalization of sadness.

During a concurrent interview and record review, on 1/16/2025, at 5:03 p.m., with LVN 5, Resident 109's Order Summary Report, dated 7/17/2024, and Resident 109's Care Plans were reviewed. LVN 5 stated there was no care plan developed and implemented on the use of Zoloft. LVN 5 stated it was important to have care plan on the use of psychotropic medications Zoloft to ensure safe use of the medication. LVN 5 stated care plans sets the goal of therapy and the interventions to meet the needs of the resident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0656 During an interview, on 1/17/2025, at 3:38 p.m., with the DON, the DON stated the staff should have developed and implemented a care plan on the use of Zoloft to ensure the medications were appropriately Level of Harm - Minimal harm or used. The DON stated the care plan serves as a communication tool to the healthcare team and the family potential for actual harm members. The DON stated the care plan standardizes the care that is being provided to the resident.

Residents Affected - Some During a review of the facility's recent P&P titled, Care Plans, Comprehensive Person-Centered, last reviewed on 4/18/2024, the P&P indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS).

3. During a review of Resident 481's Admission Record, the Admission Record indicated the facility admitted

the resident on 7/20/2024, and readmitted the resident on 1/13/2025, with diagnoses including repeated falls, benign prostatic hyperplasia (a noncancerous condition that causes the prostate gland to enlarge), and urinary tract infection (UTI - an infection in the bladder/urinary tract).

During a review of Resident 481's MDS, dated [DATE REDACTED], the MDS indicated the resident usually had the ability to make self-understood and understand others and had intact cognition. The MDS indicated the resident requires supervision on mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily) and had an indwelling urinary catheter.

During a review of Resident 481's Order Summary Report, dated 7/22/2024, the Order Summary Report indicated an order of indwelling catheter size 16 French (FR - a unit of measurement for catheters)/10 cubic centimeter (cc, a unit of volume in the metric system that measures the amount of space a three-dimensional object occupies). Diagnosis (Dx): Benign prostatic hyperplasia with lower urinary tract symptoms.

During a concurrent observation and interview, on 1/15/2024, at 4:59 p.m., with the Assistant Director of Staff Development (ADSD), the left side of Resident 481's bed was against the wall. The ADSD stated placing the bed against the wall was a form of physical restraint.

During a concurrent interview and record review, on 1/15/2025, at 6:05 p.m., with LVN 5, Resident 481's Care Plans were reviewed. LVN 5 stated there was no care plan on placing Resident 481's bed against the wall as a form of restraint. LVN 5 stated it was important to have care plan on the use of restraint bed placed against the wall to ensure safe use of the restraint. LVN 5 stated care plans sets the goal of therapy and the interventions to meet the needs of the resident.

During a concurrent interview and record review, on 1/17/2025, at 10:49 a.m., with LVN 5, Resident 481's Order Summary Report, dated 7/22/2024, and Resident 481's Care Plans were reviewed. LVN 5 stated there was no care plan on the use of urinary catheter on the resident's medical record. LVN 5 stated it was important to have care plan on the use of urinary catheter to ensure its safe use. LVN 5 stated care plans sets the goal of therapy and the interventions to meet the needs of the resident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0656 During an interview, on 1/17/2025, at 3:38 p.m., with the DON, the DON stated the staff should have developed and implemented a care plan on the use of restraint bed placed against the wall and indwelling Level of Harm - Minimal harm or urinary catheter to ensure safe and appropriate use of the device. The DON stated the care plan serves as a potential for actual harm communication tool to the healthcare team and the family members. The DON stated the care plan standardizes the care that is being provided to the resident. Residents Affected - Some

During a review of the facility's recent P&P titled, Care Plans, Comprehensive Person-Centered, last reviewed on 4/18/2024, the P&P indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0658 Ensure services provided by the nursing facility meet professional standards of quality.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43988 potential for actual harm Based on interview and record review, the facility's licensed nursing staff failed to provide care in accordance Residents Affected - Some with professional standards to seven (7) out of 7 sampled residents (Residents 64, 66, 73, 64, 111, 213, 96, 73, and 220) investigated under insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) and anticoagulant (blood thinner - that stops the blood from forming blood clots or making them bigger) use by:

1. Failing to rotate (a method to ensure repeated injections are not administered in the same area) the insulin administration sites for Residents 64 and 66.

2. Failing to rotate subcutaneous (beneath the skin) insulin and heparin administration sites for Residents 111, 213, 96, 73, and 220.

These deficient practices had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin and heparin such as excessive bruising, lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin).

Cross-reference

F-F760

Findings:

1.a. During a review of Resident 64's Admission Record, the Admission Record indicated the facility originally admitted the resident on 1/22/2021, and readmitted the resident on 12/26/2023, with diagnoses including type 2 diabetes mellitus (DM 2 - a chronic disease that occurs when the body does not produce enough insulin or does not use it properly) without complications, gastrostomy (a surgical opening fitted with

a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and anemia (a condition where the body does not have enough healthy red blood cells).

During a review of Resident 64's Minimum Data Set (MDS - a resident assessment tool), dated 11/2/2024,

the MDS indicated the resident had severely impaired cognition (having the ability to think, learn, and remember clearly). The MDS indicated Resident 64 required substantial/maximal assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 64 had a diagnosis of DM 2 and received insulin.

During a review of Resident 64's History and Physical (H&P), dated 12/27/2024, the H&P indicated the resident did not have the capacity to make decisions.

During a review of Resident 64's Order Summary Report, the Order Summary Report indicated the following physician's orders dated 12/26/2023:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0658 - Insulin NPH (a long-acting insulin) subcutaneous suspension 100 unit per milliliter (unit/ml - a unit of measurement). Inject 20 units subcutaneously two times a day for DM 2. Rotate Injection Sites. Give with Level of Harm - Minimal harm or meals. potential for actual harm - Insulin regular human solution (a short-acting insulin) 100 unit/ml. Inject subcutaneously before meals and Residents Affected - Some at bedtime for DM 2. Give 12 units if blood sugar (BS) is more than (>) 350 and notify physician (MD). Inject as per sliding scale (increasing administration of the pre?meal insulin dose based on the blood sugar level

before the meal): if 70 - 149 = 0, if BS less than (<)70 give orange juice via gastrostomy tube if responsive and notify MD.; 150 - 199 = 1; 200 - 249 = 3; 250 - 299 = 5; 300 - 349 = 7; 350+ = 8. Give 12 units if BS is >350 and notify MD.

During a concurrent interview and record review, on 1/16/2025, at 2:30 p.m., with Licensed Vocational Nurse (LVN) 9, Resident 64's Order Summary Report, dated 12/26/2023, Resident 64's Medication Administration

Record (MAR - a daily documentation records used by a licensed nurse to document medications and treatments given to a resident), and Resident 64's Location of Administration Report, dated between 11/2024 to 1/2025, was reviewed and LVN 9 verified Resident 64 had a physician's order for NPH and regular insulin and were administered as follows:

- Insulin regular human solution 100 unit/ml:

12/22/24 5::19 p.m. subcutaneously Abdomen - right upper quadrant (RUQ)

12/23/24 5:18 p.m. subcutaneously Abdomen - RUQ

12/27/24 8:27 a.m. subcutaneously Arm - left

12/29/24 3:58 p.m. subcutaneously Arm - left

1/06/25 4:12 p.m. subcutaneously Abdomen -RUQ

1/07/25 5:10 p.m. subcutaneously Abdomen - RUQ

- Insulin NPH suspension 100 unit/ml:

11/26/24 7:56 a.m. subcutaneously Abdomen - left upper quadrant (LUQ)

11/26/24 8:55 p.m. subcutaneously Abdomen - LUQ

12/21/24 5:58 a.m. subcutaneously Abdomen - right lower quadrant (RLQ)

12/21/24 8:53 p.m. subcutaneously Abdomen - RLQ

12/27/24 8:29 a.m. subcutaneously Abdomen -LUQ

12/27/24 7:53 p.m. subcutaneously Abdomen - LUQ

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0658 LVN 9 stated insulin administration sites should be rotated per standards of practice, manufacturer's guidelines, and according to physician's orders. LVN 9 verified Resident 64's MAR indicated the insulin Level of Harm - Minimal harm or administration sites were not rotated and that there was a physician's order to rotate injection sites. LVN 9 potential for actual harm stated the insulin administration sites should have been rotated as ordered by the physician to prevent pain, redness, irritation, lipodystrophy, and denting of the resident's skin. Residents Affected - Some

During an interview, on 1/17/2025, at 3:38 p.m., with the Director of Nursing (DON), the DON stated the administration sites of insulin should be rotated to prevent complications such as bruising, and lipodystrophy.

During a review of the facility's policy and procedure (P&P) titled, Insulin Administration, last reviewed on 4/18/2024, the P&P indicated to provide guidelines for the safe administration of insulin to residents with diabetes. Select an injection site. The P&P further indicated:

a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of

the thighs and abdomen. Avoid the area approximately 2 inches around the navel.

b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm).

During a review of the facility provided manufacturer's guideline on, Humulin R Regular Insulin Huma Injection, undated, the manufacturer's guideline indicated Humulin R may be administered by subcutaneous injection in the abdominal wall, the thigh, the gluteal region, or in the upper arm. The manufacturer's guideline further indicated injection sites should be rotated within the same region and the following common side effects:

- Skin thickening or pits at the injection site (lipodystrophy). Change (rotated) where to inject the insulin to help prevent lipodystrophy from happening. Do not inject into the exact spot for each injection.

- Injection site reactions (local allergic reaction). Symptoms may include redness, swelling and itching at the injection site.

During a review of the facility provided manufacturer's guideline on Humulin N Pen NPH Human Insulin, undated, the manufacturer's guideline indicated side effects include injection site reactions such as pian, redness, and irritation. The manufacturer's guideline further indicated adverse reactions include lipodystrophy and localized cutaneous amyloidosis.

1.b. During a review of Resident 66's Admission Record, the Admission Record indicated the facility originally admitted the resident on 9/27/2024, and readmitted the resident on 12/18/2024, with diagnoses including DM 2 with foot ulcer, neuromuscular disorder of the bladder (lack bladder control due to a brain, spinal cord or nerve problem), and pressure ulcer (injuries to the skin and the tissue below the skin that are due to pressure on the skin for a long time) of left buttock.

During a review of Resident 66's MDS, dated [DATE REDACTED], the MDS indicated the resident had severely impaired cognition (having the ability to think, learn, and remember clearly). The MDS indicated Resident 66 required substantial/maximal assistance from staff with all ADLs. The MDS indicated Resident 66 had a diagnosis of DM 2 and received insulin.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0658 During a review of Resident 66's Order Summary Report, the Order Summary Report indicated the following physician's orders: Level of Harm - Minimal harm or potential for actual harm - 9/8/2024: Humalog solution (a fast-acting insulin) 100 unit per milliliter (unit/ml - a unit of measurement) (insulin lispro). Inject as per sliding scale (increasing administration of the pre?meal insulin dose based on Residents Affected - Some the blood sugar level before the meal): if 0 - 150 = 0 units; 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units, subcutaneously before meals and at bedtime for DM 2.

- 12/28/2024: Humalog injection solution 100 unit/ml (insulin lispro). Inject subcutaneously before meals and at bedtime for DM 2 Rotate injection sites. Inject as per sliding scale: if 70 - 149 = 0 units. Notify physician (MD) if blood sugar (BS) is less than 70. Give orange juice if alert, responsive, and able to swallow; 150 - 199 = 2 units; 200 - 249 = 4 units; 250 - 299 = 7 units; 300 - 349 = 10 units; 350+ = 12 units. Give 12 units if BS is greater than 401 and notify MD, subcutaneously before meals and at bedtime.

During a concurrent interview and record review, on 1/16/2025, at 2:45 p.m., with LVN 9, Resident 66's Order Summary Report, dated 9/8/2024 and 12/28/2024, and Resident 66's MAR and Location of Administration Report, dated between 11/2024 to 1/2025, were reviewed and LVN 9 verified Resident 66 had

a physician's order for Humalog insulin and were administered as follows:

11/19/24 9:40 p.m. subcutaneously Abdomen - left lower quadrant (LLQ)

11/20/24 6:30 a.m. subcutaneously Abdomen - LLQ

11/25/24 11:28 a.m. subcutaneously Abdomen -RLQ

11/25/24 10:20 p.m. subcutaneously Abdomen - RLQ

11/27/24 9:33 p.m. subcutaneously Abdomen - LLQ

11/28/24 5:20 a.m. subcutaneously Abdomen - LLQ

11/29/24 8:48 p.m. subcutaneously Abdomen - LLQ

12/02/24 4:42 p.m. subcutaneously Abdomen - LLQ

12/02/24 9:32 p.m. subcutaneously Abdomen - LLQ

12/07/24 2:17 p.m. subcutaneously Abdomen - LLQ

12/07/24 5:47 p.m. subcutaneously Abdomen - LLQ

12/07/24 10:45 p.m. subcutaneously Abdomen - LLQ

12/28/24 11:29 a.m. subcutaneously Abdomen - LLQ

12/29/24 11:36 a.m. subcutaneously Abdomen - LLQ

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0658 12/30/24 12:27 p.m. subcutaneously Abdomen - LLQ

Level of Harm - Minimal harm or 12/31/24 11:41 a.m. subcutaneously Abdomen - LLQ potential for actual harm 01/03/25 12:20 p.m. subcutaneously Abdomen - LLQ Residents Affected - Some 01/04/25 4:23 a.m. subcutaneously Abdomen - LLQ

01/09/25 12:26 p.m. subcutaneously Abdomen - LLQ

01/10/25 11:14 a.m. subcutaneously Abdomen - LLQ

LVN 9 stated insulin administration sites should be rotated per standards of practice, manufacturer's guidelines, and according to physician's orders. LVN 9 verified Resident 66's MAR indicated the insulin administration sites were not rotated and that there was a physician's order to rotate injection sites. LVN 9 stated the insulin administration sites should have been rotated as ordered by the physician to prevent pain, redness, irritation, lipodystrophy, and denting of the resident's skin.

During an interview on 1/17/2025, at 3:38 p.m., with the DON, the DON stated the administration sites of insulin should be rotated to prevent complications such as bruising, and lipodystrophy.

During a review of the facility's P&P titled, Insulin Administration, last reviewed on 4/18/2024, the P&P indicated to provide guidelines for the safe administration of insulin to residents with diabetes. Select an injection site. The P&P further indicated:

a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of

the thighs and abdomen. Avoid the area approximately two inches around the navel.

b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm).

During a review of the facility provided manufacturer's guideline on insulin Aspart (Humalog), undated, the manufacturer's guideline indicated to change (rotate) injection site within the chosen area such as stomach or upper arm with each dose and do not inject into the exact same sport for each injection. The manufacturer's guideline further indicated the following side effects:

- Reactions at the injection site such as redness, swelling, and itching.

- Skin thickens or pits at the injection site (lipodystrophy). Change (rotate) the injection site to help prevent lipodystrophy from happening.

44376

2.a. During a review of Resident 111's Admission Record, the Admission Record indicated the facility admitted the resident on 1/18/2023, and readmitted the resident on 12/14/2024, with diagnoses including DM 2 with foot ulcer and DM 2 with diabetic neuropathy (nerve damage caused by diabetes).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0658 During a review of Resident 111's MDS, dated [DATE REDACTED], the MDS indicated the resident had the ability to make self-understood and understand others and had an intact cognition (having the ability to think, learn, Level of Harm - Minimal harm or and remember clearly). The MDS indicated the resident was on a high-risk drug class hypoglycemic potential for actual harm medication (drugs that lower blood sugar levels and are used to treat diabetes).

Residents Affected - Some During a review of Resident 111's Order Summary Report, the Order Summary Report indicated an order of:

12/15/2024 Insulin Aspart Injection Solution 100 unit (a standard measurement of the insulin's biological activity, essentially representing the amount of insulin needed to produce a specific effect on blood sugar levels)/ milliliters (ml, a unit used to measure capacity) (Insulin Aspart). Inject as per sliding scale (the increasing administration of the pre?meal insulin dose based on the blood sugar level before the meal): if 70 - 149 = 0 Units If blood sugar (BS) is less than (<)70 Give orange juice (OJ) if responsive and notify MD.; 150 - 199 = 1 Unit; 200 - 249 = 3 Units; 250 - 299 = 5 Units; 300 - 349 = 7 Units; 350+ = 8 Units If BS is greater than (>)350+ Give 8 Units and notify MD., subcutaneously before meals and at bedtime for Diabetes. Rotate injection sites.

12/15/2024 Lantus (a long-acting insulin) Subcutaneous Solution 100 unit/ml (Insulin Glargine). Inject 10 unit subcutaneously two times a day for type 2 DM. Give with meals.

During a review of Resident 111's Location of Administration Report for Insulin, dated between 12/2024 to 1/2025, the Location of Administration Report for Insulin indicated:

1. Lantus Subcutaneous Solution 100 unit/ml was given subcutaneously on:

12/17/2024 at 7:49 p.m. on the Abdomen - RLQ

12/18/2024 at 11:13 a.m. on the Abdomen - RLQ

2. Aspart Injection Solution 100 unit/ml was given subcutaneously on:

1/1/2025 at 8:54 p.m. on the Abdomen - LLQ

1/1/2025 at 10:36 p.m. on the Abdomen - LLQ

1/3/2025 at 11:52 a.m. on the Abdomen - RUQ

1/3/2025 at 4:32 p.m. on the Abdomen - RUQ

1/12/2025 at 5:09 p.m. on the Abdomen - LLQ

1/12/2025 at 9:01 p.m. on the Abdomen - LLQ

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0658 During a concurrent interview and record review, on 1/16/2025, at 3:58 p.m., with LVN 5, Resident 111's Order Summary Report, dated 12/15/2024, Resident 111's Location of Administration of Insulin, dated Level of Harm - Minimal harm or between 12/2024 to 1/2025, MAR, dated between 12/2024 to 1/2025, and Care Plans were reviewed. LVN 5 potential for actual harm stated there were multiple instances that insulin administrations were not rotated on the resident. LVN 5 stated the administration sites of insulin should be rotated to prevent bruising, lipodystrophy, and denting of Residents Affected - Some the resident's skin.

During an interview, on 1/17/2025, at 3:38 p.m., with the DON, the DON stated the administration sites of insulin should be rotated to prevent complications such as deep vein thrombosis (DVT, a blood clot that forms in a deep vein in the body), bruising, and lipodystrophy.

During a review of the facility's recent P&P titled, Insulin Administration, last reviewed on 4/18/2024, the P&P indicated to provide guidelines for the safe administration of insulin to residents with diabetes. Select an injection site.

a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of

the thighs and abdomen. Avoid the area approximately 2 inches around the navel.

b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm).

During a review of the facility-provided Highlights of Prescribing Information on the use of Lantus (insulin glargine) injection, for subcutaneous use, with initial U.S. approval in 2000, the highlights of prescribing information indicated to rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis.

2.b. During a review of Resident 213's Admission Record, the Admission Record indicated the facility admitted the resident on 4/16/2024, with diagnoses including DM 2, dementia (a progressive state of decline

in mental abilities), and atrial fibrillation (a condition where the heart's upper chambers beat irregularly and often too fast).

During a review of Resident 213's MDS, dated [DATE REDACTED], the MDS indicated the resident usually had the ability to make self-understood and understand others and had severe cognitive impairment (a condition that makes it difficult for a person to think, learn, remember, and make decisions). The MDS indicated the resident was on a high-risk drug class hypoglycemic medication (drugs that lower blood sugar levels and are used to treat diabetes).

During a review of Resident 213's Order Summary Report, dated 4/16/2024, the Order Summary Report indicated an order for:

- Humulin R Injection Solution 100 unit/ml (Insulin Regular [Human]). Inject as per sliding scale: if 70 - 149 = 0 units Notify MD if BS is <70. Give OJ if responsive.; 150 - 199 = 1 unit; 200 - 249 = 2 units; 250 - 299 = 3 units; 300 - 349 = 4 units; 350+ = 5 units Give 5 units if BS is >350. Notify MD., subcutaneously before meals and at bedtime for Diabetes. Rotate injection sites.

- Lantus Subcutaneous Solution 100 unit/ml (Insulin Glargine). Inject 10 unit subcutaneously every 12 hours for Diabetes. Rotate injection sites.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0658 During a review of Resident 213's Location of Administration Report for Insulin, dated between 11/2024 to 1/2025, the Location of Administration Report for Insulin indicated: Level of Harm - Minimal harm or potential for actual harm 1. Lantus subcutaneous solution 100 unit/ml was administered on:

Residents Affected - Some 11/7/2024 at 8:58 a.m. on the Abdomen - LLQ

11/7/2024 at 9:23 p.m. on the Abdomen - LLQ

2. Humulin R Injection Solution 100 unit/ml was administered on:

11/5/2024 at 9:37 p.m. on the Arm - right

11/6/2024 at 5:10 p.m. on the Arm - right

11/12/2024 at 9:15 p.m. on the Abdomen - LUQ

11/15/2024 at 9:37 p.m. on the Abdomen - LUQ

11/20/2024 at 6:55 p.m. on the Abdomen - LLQ

11/20/2024 at 8:20 p.m. on the Abdomen - LLQ

11/28/2024 at 4:14 p.m. on the Arm - right

11/28/2024 at 12:14 a.m. on the Arm - right

During a concurrent interview and record review, on 1/16/2025, at 3:58 p.m., with LVN 5, Resident 213's Order Summary Report, dated 4/16/2024, Resident 213's Location of Administration of Insulin, dated between 11/2024 to 1/2025, Resident 213's MAR, dated between 11/2024 too 1/2025, and Care Plans were reviewed. LVN 5 stated there were multiple instances that insulin administrations were not rotated on the resident. LVN 5 stated the administration sites of insulin should be rotated to prevent bruising, lipodystrophy, and denting of the resident's skin.

During an interview, on 1/17/2025, at 3:38 p.m., with the DON, the DON stated the administration sites of insulin should be rotated to prevent complications such as DVT, bruising, and lipodystrophy.

During a review of the facility's recent P&P titled, Insulin Administration, last reviewed on 4/18/2024, the P&P indicated to provide guidelines for the safe administration of insulin to residents with diabetes. Select an injection site.

a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of

the thighs and abdomen. Avoid the area approximately 2 inches around the navel.

b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0658 During a review of the facility-provided Highlights of Prescribing Information on the use of Lantus (insulin glargine) injection, for subcutaneous use, with initial U.S. approval in 2000, the highlights of prescribing Level of Harm - Minimal harm or information indicated to rotate injection sites to reduce risk of lipodystrophy and localized cutaneous potential for actual harm amyloidosis.

Residents Affected - Some During a review of the facility-provided Information for the Physician on the use of Humulin R, Regular Insulin Human Injection, USP (rDNA origin) 100 units per ml (U-100), issued March 2011, the information for the Physician indicated Humulin R U-100 may be administered by subcutaneous injection in the abdominal wall,

the thigh, the gluteal region or in the upper arm. Injection sites should be rotated within the same region.

2.c. During a review of Resident 96's Admission Record, the Admission Record indicated the facility admitted

the resident on 8/28/2019, and readmitted the resident on 11/7/2019, with diagnoses including DM 2 with diabetic neuropathy, and DM 2 with diabetic chronic kidney disease (a kidney disease that develops in people with diabetes).

During a review of Resident 96's MDS, dated [DATE REDACTED], the MDS indicated the resident usually had the ability to make self-understood and understand others and had severe cognitive impairment. The MDS indicated

the resident was on a high-risk drug class hypoglycemic medication.

During a review of Resident 96's Order Summary Report, the Order Summary Report indicated an order for:

- 1/26/2023 Humulin R Injection Solution 100 unit/ml (Insulin Regular [Human]). Inject as per sliding scale: if 70-140= 0 units. Notify MD if BS is <70. Give OJ if responsive; 141-200= 4 units; 201-250= 6 units; 251-300= 8 units; 301-350= 10 units; 351-400=12 units; 401+= 14 units. Give 14 units if BS>400. Notify MD, subcutaneously before meals and at bedtime for Diabetes. Rotate injection sites.

- 4/11/2024 Humulin N Subcutaneous Suspension 100 unit/ml (Insulin NPH (Human) (Isophane)). Inject 30 unit subcutaneously two times a day for Diabetes. Hold for BS <100. Rotate injection sites.

- 5/10/2024 Lantus Subcutaneous Solution 100 unit/ml (Insulin Glargine). Inject 5 unit subcutaneously at bedtime for Diabetes. Hold for BS <100. Rotate injection sites.

During a review of Resident 96's Location of Administration Report for Insulin for 12/2024, the Location of Administration Report for Insulin indicated-

1. Lantus Subcutaneous Solution 100 unit/ml was administered on:

12/17/2024 at 9:18 p.m. on the Arm - left

12/18/2024 at 9:05 p.m. on the Arm - left

2. Humulin N Subcutaneous Suspension 100 unit/ml was administered on:

12/08/2024 at 4:14 p.m. on the Abdomen - LLQ

12/09/2024 at 4:05 p.m. on the Abdomen - LLQ

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0658 12/23/2024 at 5:02 p.m. on the Abdomen - LUQ

Level of Harm - Minimal harm or 12/24/2024 at 6:32 a.m. on the Abdomen - LUQ potential for actual harm 12/25/2024 at 6:30 a.m. on the Abdomen - LUQ Residents Affected - Some 3. Humulin R Injection Solution 100 unit/ml was administered on:

12/2/2024 at 4:30 p.m. on the Arm - right

12/3/2024 at 6:32 a.m. on the Arm - right

12/4/2024 at 10:48 p.m. on the Arm - left

12/6/2024 at 11:41 a.m. on the Arm - left

12/21/2024 at 9:33 p.m. on the Abdomen - LUQ

12/22/2024 at 6:30 a.m. on the Abdomen - LUQ

During a concurrent interview and record review, on 1/16/2025, at 3:58 p.m., with LVN 5, Resident 96's Order Summary Report, dated 1/26/2023, 4/11/2024, and 5/10/2024, Resident 96's Location of Administration of Insulin, dated 12/2024, MAR, dated 12/2024, and Care Plans were reviewed. LVN 5 stated there were multiple instances that insulin administrations were not rotated on the resident. LVN 5 stated the administration sites of insulin should be rotated to prevent bruising, lipodystrophy, and denting of the resident's skin.

During an interview, on 1/17/2025, at 3:38 p.m., with the DON, the DON stated the administration sites of insulin should be rotated to prevent complications such as DVT, bruising, and lipodystrophy.

During a review of the facility's recent P&P titled, Insulin Administration, last reviewed on 4/18/2024, the P&P indicated to provide guidelines for the safe administration of insulin to residents with diabetes. Select an injection site.

a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of

the thighs and abdomen. Avoid the area approximately 2 inches around the navel.

b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm).

During a review of the facility-provided Information for the Patient 10 ml Vial (1000 Units per vial) Humulin N NPH Human Insulin (rDNA Origin) Isophane Suspension 100 Units per ml (U-100), copyright 1997, the information for patient indicated to avoid tissue damage, choose a site for each injection that is at least 1/2 inch from the previous injection site. The usual sites of injection are abdomen, thighs, and arms.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0658 During a review of the facility-provided Highlights of Prescribing Information on the use of Lantus (insulin glargine) injection, for subcutaneous use, with initial U.S. approval in 2000, the highlights of prescribing Level of Harm - Minimal harm or information indicated to rotate injection sites to reduce risk of lipodystrophy and localized cutaneous potential for actual harm amyloidosis.

Residents Affected - Some During a review of the facility-provided Information for the Physician on the use of Humulin R, Regular Insulin Human Injection, USP (rDNA origin) 100 units per ml (U-100), issued March 2011, the information for the Physician indicated Humulin R U-100 may be administered by subcutaneous injection in the abdominal wall,

the thigh, the gluteal region or in the upper arm. Injection sites should be rotated within the same region.

2.d. During a review of Resident 73's Admission Record, the Admission Record indicated the facility admitted

the resident on 10/2/2024, with diagnoses including DM 2 with diabetic polyneuropathy (a complication of diabetes that damages nerves in the hands, feet, legs, and arms), anemia, and displaced intertrochanteric fracture (a break in the bone where the broken bone has shifted or separated) of right femur (he thigh bone

on the right side of the body).

During a review of Resident 73's MDS, dated [DATE REDACTED], the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition. The MDS indicated the resident was on a high-risk drug class hypoglycemic medication.

During a review of Resident 73's Order Summary Report, dated 10/2/2024, the Order Summary Report indicated an order for:

- Humulin R Injection Solution 100 unit/ml (Insulin Regular (Human)). Inject as per sliding scale: if 70 - 149 = 0 units Notify MD if BS is <70. Give OJ if responsive.; 150 - 199 = 2 units; 200 - 249 = 4 units; 250 - 299 = 7 units; 300 - 349 = 10 units; 350+ = 12 units Give 12 units if BS is >350. Notify MD., subcutaneously before meals and at bedtime for Diabetes Rotate injection sites.

- Humulin R Injection Solution 100 unit/ml (Insulin Regular (Human)). Inject as per sliding scale: if 70 - 149 = 0 units Notify MD if BS is <70. Give OJ if responsive.; 150 - 199 = 2 units; 200 - 249 = 4 units; 250 - 299 = 7 units; 300 - 349 = 10 units; 350+ = 12 units Give 12 units if BS is >350. Notify MD., subcutaneously before meals and at bedtime for Diabetes Rotate injection sites.

- Heparin Sodium (Porcine) Injection Solution 5000 unit/ml (Heparin Sodium [Porcine]). Inject 1 ml subcutaneously every 12 hours for DVT prophylaxis (reduces the risk of developing deep vein thrombosis through medications, compression stockings, and devices). Rotate injection sites.

During a review of Resident 73's Location of Administration Report for Insulin and Heparin for 11/2024 to 1/2025, the Location of Administration Report for Insulin and Heparin indicated-

1. Heparin Sodium (Porcine) Injection Solution 5000 unit/ml was administered on:

11/19/2024 at 11:03 p.m. on the Abdomen - LLQ

11/20/2024 at 11:03 p.m. on the Abdomen - LLQ

11/22/2024 at 2:23 p.m. on the Abdomen - LUQ

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0658 11/22/2024 at 8:44 p.m. on the Abdomen - LUQ

Level of Harm - Minimal harm or 12/19/2024 at 8:22 a.m. on the Abdomen - RUQ potential for actual harm 12/19/2024 at 8:28 p.m. on the Abdomen - RUQ Residents Affected - Some 2. Humulin R Injection Solution 100 unit/ml was administered on:

12/1/2024 at 11:26 a.m. on the Arm - right

12/2/2024 at 9 p.m. on the Arm - right

12/3/2024 at 4:53 p.m. on the Arm - right

12/3/2024 at 8:57 p.m. on the Arm - right

12/19/2024 at 9:07 p.m. on the Arm - left

12/22/2024 at 12:29 p.m. on the Arm - left

12/22/2024 at 9:10 p.m. on the Abdomen - LUQ

12/23/2024 at 7:47 a.m. on the Abdomen - LUQ

3. Humulin 70/30 Subcutaneous Suspension (70-30) 100 unit/ml was administered on:

1/6/2025 at 6:07 a.m. on the Abdomen - LLQ

1/6/2025 at 4:53 p.m. on the Abdomen - LLQ

During a concurrent interview and record review, on 1/16/2025, at 3:58 p.m., with LVN 5, Resident 73's Order Summary Report, dated 10/2/2024, Resident 73's Location of Administration of Insulin, dated between 11/2024 to 1/2025, Resident 73's MAR, dated between 11/2024 to 1/2025, and Care Plans were reviewed. LVN 5 stated there were multiple instances that insulin and heparin administrations were not rotated on the resident. LVN 5 stated the administration sites of insulin and heparin should be rotated to prevent bruising, lipodystrophy, and denting of the resident's skin.

During an interview on 1/17/2025, at 3:38 p.m., with the DON, the DON stated the administration sites of insulin and heparin should be rotated to prevent complications such as DVT, bruising, and lipodystrophy.

During a review of the facility's recent P&P titled, Insulin Administration, last reviewed on 4/18/2024, the P&P indicated to provide guidelines for the safe administration of insulin to residents with diabetes. Select an injection site.

a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of

the thighs and abdomen. Avoid the area approximately 2 inches around the navel.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0658 b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm).

Level of Harm - Minimal harm or During a review of the facility-provided Manufacturer's Specification on the use of Heparin Sodium Injection, potential for actual harm USP, undated, the manufacturer's specification indicated a different side should be used for each injection to prevent the development of massive hematoma. Residents Affected - Some

During a review of the facility-provided Information for the Physician on the use of Humulin R, Regular Insulin Human Injection, USP (rDNA origin) 100 units per ml (U-100), issued March 2011, the information for the Physician indicated Humulin R U-100 may be administered by subcutaneous injection in the abdominal wall,

the thigh, the gluteal region or in the upper arm. Injection sites should be rotated within the same region.

During a review of the facility-provided Highlights of Prescribing Information on the use of Humulin 70/30 (insulin isophane human and insulin human) injectable suspension, for subcutaneous use, with initial U.S. approval in 1989, the highlights of prescribing information indicated to rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis.

2.e. During a review of Resident 220's Admission Record, the Admission Record indicated the facility admitted the resident on 4/28/2024, with diagnoses including DM 2 with diabetic neuropathy and dysphagia (swallowing difficulties).

During a review of Resident 220's MDS, dated [DATE REDACTED], the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition. The MDS indicated the resident was

on a high-risk drug class hypoglycemic medication.

During a review of Resident 220's Order Summary Report, the Order Summary Report indicated an order for:

- 4/29/2024 Humulin 70/30 Subcutaneous Suspension (70-30) 100 unit/ml (Insulin NPH Isophane & Reg (Human)). Inject 30 unit subcutaneously two times a day for Diabetes Give before meals. Rotate injection sites.

- 4/30/2024 Novolog Injection Solution 100 unit/ml (Insulin Aspart). Inject as per sliding scale: if 200 - 250 = 2 units Notify MD if BS is <70. Give OJ if responsive.; 251 - 300

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Level of Harm - Minimal harm or 38552 potential for actual harm Based on observation, interview, and record review, the facility failed to provide treatment and services to Residents Affected - Few maintain or improve a resident's ability to carry out activities of daily living (ADL - activities such as bathing, dressing, grooming, oral care, mobility, elimination, dining, and communication) for one of one sampled resident (Resident 115) when Resident 115 was not provided nail trimming and cleaning to his fingernails.

This deficient practice had the potential in Resident 115 having dirty fingernails, which could lead to scratching himself and cause skin tears or bleeding.

Findings:

During a review of Resident 115's Admission Record, the Admission Record indicated the facility originally admitted the resident on 2/1/2022 and readmitted the resident on 1/4/2025 with diagnoses including coronavirus disease (COVID-19 - a highly contagious respiratory illness capable of producing severe symptoms), chronic pulmonary edema (a long-term condition that occurs when fluid builds up in the lungs), and other cirrhosis of the liver (chronic disease that occurs when healthy liver tissue is replaced by scar tissue).

During a review of Resident 115's Minimum Data Set (MDS-a resident assessment tool) dated 1/10/2025,

the MDS indicated the resident was able to make self understood and was able to understand others. The MDS indicated the resident required assistance with ADLs including toileting hygiene, putting on/taking off footwear, and upper and lower body dressing.

During a review of Resident 115's care plan addresing resident's assistance with ADLs, revised 11/11/2023,

the care plan indicated the resident required one person extensive assistance with bathing/showers and personal hygiene.

During an observation on 1/15/2025 at 8:58 a.m., at Resident 115's bedside, resident's fingernails were noted with black substance underneath his long fingernails.

During a concurrent observation and interview on 1/17/2025 at 7:50 a.m., at Resident 115's bedside, with Certified Nursing Assistant 9 (CNA 9), CNA 9 stated she was the assigned CNA for Resident 115. CNA 9 stated Resident 115's fingernails were long and had dirt underneath his fingernails and needs trimming. CNA 9 stated any CNAs can trim the resident's nails as the task is part of the resident's morning care or as needed. CNA 9 stated if the fingernails are not trimmed, Resident 115 can accidentally scratch himself and can cause an infection. CNA 9 stated she will trim and clean the resident's nails.

During an interview on 1/17/2025 at 4:11 p.m., with the Director of Nursing (DON), the DON stated the resident's fingernails are checked daily when CNAs are doing their daily care and Resident 115's nails should have been checked. The DON stated it is not acceptable that residents have long and dirty fingernails because for infection control and for the wellness of the resident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0676 During a review of the facility's recent policy and procedure (P&P) titled Fingernails/Toenails, Care of, last reviewed on 4/18/2024, the P&P indicated the purpose of this procedure is to clean the nail bed, to keep Level of Harm - Minimal harm or nails trimmed, and to prevent infections. The P&P indicated nail care includes daily cleaning and regular potential for actual harm trimming and trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin. Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Level of Harm - Minimal harm or 43988 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure residents received care Residents Affected - Few consistent with professional standards of practice to prevent pressure injury (the breakdown of skin integrity due to pressure) for one (1) out of two (2) sampled residents (Resident 66) investigated under pressure injury when Resident 66's low air loss mattress (LALM - a mattress that helps prevent and treat pressure wounds by circulating air and relieving pressure on the body) was not turned on and was set according to resident's Body Mass Index (BMI - a tool used to estimate the amount of body fat by using the height and weight measurements).

This deficient practice had the potential for the resident's pressure injury to worsen.

Findings:

During a review of Resident 66's Admission Record, the Admission Record indicated the facility originally admitted the resident on 9/27/2024, and readmitted the resident on 12/18/2024, with diagnoses including type 2 diabetes mellitus (a chronic disease that occurs when the body does not produce enough insulin or does not use it properly) with foot ulcer, neuromuscular disorder of the bladder (lack bladder control due to a brain, spinal cord or nerve problem), and pressure ulcer (injuries to the skin and the tissue below the skin that are due to pressure on the skin for a long time) of left buttock.

During a review of Resident 66's Minimum Data Set (MDS - a resident assessment tool), dated 12/24/2024,

the MDS indicated the resident had severely impaired cognition (having the ability to think, learn, and remember clearly). The MDS indicated Resident 66 required substantial/maximal assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 66 had 1 Stage 2 (a partial thickness wound that exposes a layer of tissue that is moist and red or pink in color) and 1 Stage three (3) [a deep wound that affect the top 2 layers of skin as well as fatty tissue] pressure ulcers that were present on admission.

During a review of Resident 66's Order Summary Report, the Order Summary Report indicated the following physician's order:

- 1/3/2025: Air Pressure redistribution mattress for prevention. Monitor settings and function every shift. Set according to current BMI. BMI: 12-20 setting 1; BMI: 21-35 setting 2; BMI: 36-50 setting 3; BMI: 51-70 setting 4; BMI: 71-100 setting 5. Every day shift for wound management.

During a review of Resident 66's care plan (CP) on risk for skin breakdown and/or slow wound healing due to decreased mobility, incontinence of bowel and G-tube feeding, initiated on 11/21/2024 and last revised on 1/2/2025, the CP indicated interventions including air pressure redistribution mattress for prevention, set according to current BMI, and monitor setting and functioning to help heal the ulcers without complications.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0686 During a review of Resident 66's Braden Scale for Predicting Pressure Sore Risk form (tool used to assess risk for pressure injury), dated 12/25/2024 and 1/3/2025, the Braden Scale for Predicting Pressure Sore Risk Level of Harm - Minimal harm or form indicated the resident was a moderate risk for developing pressure injury. potential for actual harm

During a review of Resident 66's Weights and Vitals Summary, dated 1/13/2025, the Weights and Vitals Residents Affected - Few Summary indicated the resident's current height, weight, and BMI were as follows:

- Weight: 212.4 pounds (lbs. - a unit of measurement)

- Height: 72 inches

- BMI: 28.7

During an observation, on 1/14/2025, at 9:50 a.m., inside Resident 66's room, Resident 66 appeared sunk in

the bed and the LALM machine's power button indicator light was a light shade of orange.

During a concurrent observation and interview, on 1/14/2025, at 9:57 a.m., inside Resident 66's room, with Treatment Nurse (TN) 1, TN 1 verified Resident 66 appeared sunk in the bed, the LALM machine was turned off and was unable to determine how long the machine had been turned off. When TN 1 pressed the On/Off button, green lights illuminated in the panel and setting was at number 3. TN 1 verified the label on the machine was pointing at number 2 setting. TN 1 stated licensed nurses, especially the treatment nurse assigned to resident, ensures proper functioning of the mattress and machine and that the setting was correct according to resident's BMI every day shift. TN 1 stated Resident 66's LALM machine should have been turned on at all times, and setting should be at number 2 as indicated in the label. TN 1 stated if the machine was turned off and the setting was not correct, it placed the resident at risk for worsening of pressure ulcer.

During an interview, on 1/17/2025, at 5:15 p.m., with the Director of Nursing (DON), the DON stated the nurses should always makes sure the LALM was always turned on and setting should be correct according to resident's weight and BMI. The DON stated Resident 66's LALM should not have been turned off unless

the resident was not in bed and should have been at the correct setting as indicated in the label on the machine and according to Resident 66's BMI as it placed the resident at risk for worsening of pressure ulcers.

During a review of the facility's policy and procedure (P&P) titled, Beds, Special - Low Air Loss Therapy, last reviewed 4/18/2024, the P&P indicated:

- Utilize low air loss therapy under the direction of the physician's order.

- Always leave unit turned on when in use.

- Pressure adjustments may be made by staff in accordance with resident condition and need.

During a review of the facility provided manufacturer's guideline on LALM 1, undated, the manufacturer's guideline indicated the following:

- Indication:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0686 LALM 1 models are intended for the prevention and treatment of pressure ulcers. Powered modes are intended for active wound treatment and may be indicated for use as a preventive tool against further Level of Harm - Minimal harm or complications associated with immobility. potential for actual harm - On/Off: Residents Affected - Few Plug power cord into wall outlet. On/Off indicator light will illuminate in amber,

indicating that the unit is drawing current but not yet powered up.

Press On/Off switch button to On. Indicator light will change to green, along with

additional lights on control panel, indicating the unit is powered up. Unit will resume

the settings it was in when last powered down.

- Comfort Level:

In powered mode, elevating the head of bed (HOB) may require adjusting comfort level to ensure appropriate support, especially if elevated beyond 30 degrees. With HOB elevated this way, caregivers may find the following BMI setting suggestions helpful in determining an ideal comfort setting: BMI: 12-20 setting 1; BMI: 21-35 setting 2; BMI: 36-50 setting 3; BMI: 51-70 setting 4; BMI: 71-100 setting 5.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44376

Residents Affected - Few Based on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards for eight of 12 sampled residents (Residents 213, 220, 471, 482, 159, 193, 58, 19) investigated under accidents by failing to ensure:

1. Resident 213's fall mat (a cushioned mat that reduces the risk of injury from a fall) did not have a furniture or equipment on top of them.

This deficient practice increases the risk of injury when the resident slips, trips, and falls by hitting the hard surface of the equipment or furniture that is on top of the fall mat.

2. Resident 220's Fluocinonide External Ointment (is used to treat the itching, redness, dryness, crusting, scaling, inflammation, and discomfort of various skin conditions) were not left at the bedside.

3. Resident 471's metronidazole (an antibiotic), valacyclovir (an antiviral drug that has been used to manage and treat various herpes infections), glipizide (stimulates the release of insulin from the pancreas, directing your body to store blood sugar), and cefpodoxime (used to treat bacterial infections in many different parts of

the body) was not left at the bedside.

4. Resident 482's sucralfate (used to treat and prevent duodenal ulcers and other conditions as determined by your doctor), Telmisartan (controls blood pressure ), metoprolol (a medication that lowers your blood pressure and heart rate), multivitamins (MVI), and baclofen (treats muscle spasms) was not left at the bedside.

These deficient practice increases the risks of harm to the resident from omitting the dose, double dosing, and mixing the medications that could cause adverse (unfavorable) or even fatal effects on the resident.

5. Resident 159's call light had no frayed wires on them and Resident 129's call light did not have black and white wires exposed.

The deficient practice had a potential for accidents such as electrocution on residents.

6. Resident 193's bedside safety mattress was in place as ordered by the physician.

7. There was no furniture or equipment on top of Residents 58's and 19's floor mats for a long period of time.

These deficient practices placed the residents at risk for increased chances of incurring injury such as falls with fracture (a break or crack in a bone) and even death.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0689 8. Seven medication cups containing ointments, two tubes labeled hydrocortisone cream (a topical medication used to treat skin conditions), and one tube labeled Barmicil Compuesto (a topical medication Level of Harm - Minimal harm or used to treat skin conditions) were not left unattended at resident bedside accessible and readily available potential for actual harm for self-administration for one of three sampled residents (Resident 179) reviewed under the General-Skin Conditions care area. Residents Affected - Few

These deficient practices had the potential to result in resident self-administration of medication potentially resulting in resident overdose and illness.

9. Residents were provided and monitored for a bed pad alarm (bed sensor alarm, a pad with sensors that will alarm when a resident stands up unassisted to help prevent falls by alerting staff)per physician's orders for one of one sampled residents (Resident 49) reviewed under the dementia care area.

This deficient practice had the potential to result in resident falls resulting in injuries like fractures (broken bones) and lacerations.

Cross reference

F-F803

Findings:

1. During a review of the facility's cook's spreadsheet (a sheet that contains each diet and what food and portions each diet would get) titled, Winter Menus, dated 1/14/2025, the spreadsheet indicated residents on regular diet would include the following foods in the tray:

a. Italian Lasagna 3x3 1/3 inches = 1 square

b. Seasoned broccoli 1/2 cup ([c], household measurement)

c. Parsley garnish- yes

d. Garlic bread- yes

e. Peanut butter cup pudding #12 scoop (1/3 c)

f. Milk 4 ounces (oz - unit of measurement)

During an observation on 1/14/2025 at 12:05 p.m. of residents' tray

on fortified diet, there were seven residents (Resident 104, Resident 96, Resident 213, Resident 145, Resident 135, Resident 129, and Resident 84) on fortified diet who did not get extra cheese on their trays.

During a review of Resident 135's Admission Record, the Admission Record indicated the facility admitted Resident 135 on 11/30/2021 with diagnoses including atrial fibrillation (irregular heart rhythm), essential hypertension (HTN, high blood pressure) and anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page107of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0808 During a review of Resident 135's Minimum Data Set (MDS- a resident assessment tool), dated 12/8/2024,

the MDS indicated Resident 135 usually made self understood and can understand others. The MDS further Level of Harm - Minimal harm or indicated Resident 135 required set up and clean up assistance with eating. The MDS further indicated potential for actual harm Resident 35 had mechanically altered diet (food texture that is intended to be safe and easy to swallow) while a resident of the facility and within the last seven days. Residents Affected - Some

During a review of Resident 135's Order Summary Report, dated 7/18/2024, the Order Summary Report indicated a physician's order for

fortified, no added salt (NAS, no salt packet on the trays), regular texture, thin liquid consistency diet.

During a review of Resident 135's care plan titled, [Resident 135] has nutritional problems and potential for nutritional problems related to therapeutic diet, last revised on 7/10/2023, the Care Plan indicated interventions including monitoring, recording, and reporting to MD significant weight loss and gain, provide and serve diet of regular, NAS, fortified, and health shakes with meal.

During a review of Resident's 135's Nutritional Risk Assessment, dated 12/10/2024, the Nutritional Risk Assessment indicated Resident 135 had inadequate food intake and the Registered Dietitian recommended to continue with fortified diet for weight gain goals.

During a trayline observation on 1/14/2025 at 12:05 a.m., of Resident 135's tray, observed Resident 135 did not get additional cheese on the tray.

During a review of Resident 213's Admission Record, the Admission Record indicated the facility admitted Resident 213 on 4/16/2024 with diagnoses including atrial fibrillation, type 2 diabetes (a chronic condition that affects the way the body processes blood sugar) and anxiety disorder.

During a review of Resident 213's MDS, dated [DATE REDACTED], the MDS indicated Resident 213 usually made self understood and can understand others. The MDS further indicated Resident 213 required assistance with supervision or touching assistance with eating.

During a review of Resident 213's Order Summary Report, dated 7/9/2024, the Order Summary Report indicated a physician's order for

fortified, mechanical soft texture, thin liquid consistency diet.

During a review of Resident 213's care plan titled, [Resident 213] was at risk for malnutrition (lack of nutrition

in the body) due to dementia, diabetes and fracture, last revised on 4/16/2023, the care plan indicated interventions including encourage adequate nutrition and hydration and intake monitoring.

During a review of Resident's 213's Nutritional Risk Assessment, dated 10/13/2024, the Nutritional Risk Assessment indicated Resident 213 had weight loss due to inadequate food intake and the Registered Dietitian recommended to continue with fortified diet for weight maintenance goals.

During a trayline observation on 1/14/2025 at 12:05 a.m., of Resident 213's tray, observed Resident 213 did not get additional cheese on the tray.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page108of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0808 During an interview on 1/14/2025 at 12:07 p.m. with Dietary Aide 5 (DA 5), DA 5 stated residents on fortified diets get extra cheese. The DS asked the staff to prepare grated cheese on containers and give the extra Level of Harm - Minimal harm or cheese for the rest of the trays that have not been distributed yet. potential for actual harm

During an observation on 1/14/2025 at 12:21 p.m. of the trayline, observed staff started giving fortified diet Residents Affected - Some trays extra cheese.

During an interview on 1/14/2025 at 1:35 p.m. with the DS, the DS stated there were residents on fortified diets who did not get extra shredded cheese on their meal and the trayline staff missed putting it on the trays. The DS stated fortifying food is adding extra gravy, sauces, butter, and cheese to help residents with weight loss. The DS stated the residents not given the one (1) oz grated cheese were missing nutrition and calories affecting their diets and as a result, these residents would continue to lose weight as a potential outcome.

During a review of the facility's P&P titled, Food Preparation, dated 4/18/2024, the P&P indicated, (1) The facility will use approved recipes, standardized to meet the resident census. This count is to be kept current so that an accurate amount of food is prepared. (2) Recipes are specific as to portion yield, method of preparation, amounts of ingredients, and time and temperature guide.

During a review of the facility' diet manual titled, Fortified Diet, dated 4/18/2024, the diet manual indicated, Description: The fortified diet is designed for residents who cannot consume adequate amounts of calories and/or protein to maintain their weight or nutritional status. Nutritional breakdown: The goal is to increase the calorie density of foods commonly consumed by the resident. The amount of calorie increase should be approximately 300-400 per day. Examples of adding calories include add cheese to soups, pasta or vegetables. Approximate calories of food used for fortifying diet: cheese- 1 Tablespoon = 55 calories.

During a review of the facility's diet manual titled, Fortification of Food: Increasing Calories and/or Protein in

the Diet, dated 4/18/2024, the diet manual indicated, The enrichment of food will be done on an individual basis for residents who cannot consume adequate amounts of calories and/or protein to sustain their weight or nutrition status. The goal is to increase the calorie and/or protein density of foods commonly consumed by

the resident to promote improvement in their nutritional status.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page109of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47441

Residents Affected - Some Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when:

1. Kitchen equipment and areas were not cleaned and sanitized.

a. There was an ice, dirt buildup and dirt debris in the chest freezer. Walk-in freezer roof had ice buildup.

b. Walk-in refrigerator floors had dirt buildup and food debris.

c. Reach-in refrigerator vents had dust buildup and shelves had dirt and food debris.

d. Dry storage room floor had dirt and food debris.

e. Ice machine internal parts had reddish dirt and mineral buildup. The ice machine filter was dirty to touch.

f. Mixer guard, agitator shaft had dried up food and splatters.

g. Residents' refrigerator had dirt buildup.

2. Kitchen equipment and utensils were not smooth, had scratches and cracks.

a. Seven (7) of 7 racks had rust, dirt, chips, and cracks in the walk-in refrigerator.

b. Can opener blade have had chips (a small piece of something removed while opening cans).

c. [NAME] chopping board had brown liquid splatters stored in the clean area.

3. One (1) rack in the walk-in freezer was not six (6) inches from the floor.

4. Food boxes were stored in the floor in the walk-in freezer.

5. Five (5) dented cans were stored with non-dented cans.

6. Pots and pans were stacked wet.

7. Two (2) of 2 cooks had beards sticking out of their mask and hair restraint while serving and preparing food.

8. Staff failed to label a resident's food (fiery chicken vindaloo, cheese, cottage cheese and butter) with the name in the residents' refrigerator and burrito had no received date.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page110of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0812 9. Residents' freezer did not have a thermometer, and staff were not monitoring freezer temperatures.

Level of Harm - Minimal harm or These failures had the potential to result in harmful bacterial growth and cross contamination (transfer of potential for actual harm harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 271 of 279 medically Residents Affected - Some compromised residents who received food and ice from the kitchen.

Findings:

1. a. During an observation on [DATE REDACTED] at 8:42 a.m., observed dirt debris at the bottom shelves of the chest freezer and ice buildup.

During an observation on [DATE REDACTED] at 8:58 a.m., observed an ice buildup on the freezer roof.

During a concurrent observation and interview on [DATE REDACTED] at 9:09 a.m. with the Dietary Supervisor (DS), the DS stated the dirt on the bottom shelves of the chest in freezer was coming from the food boxes and it was not okay because of physical contamination to the food. The DS stated the ice buildup in the chest freezer was not okay as it affects the temperature of the freezer causing poor quality of the food product like freezer burn. The DS stated hot air could be coming inside the freezer and it affects food temperature causing food borne illnesses as a potential outcome to the residents.

b. During an observation on [DATE REDACTED] at 8:46 a.m., observed food debris and dirt buildup on the floor in the Walk-in Refrigerator 1.

During a concurrent observation and interview on [DATE REDACTED] at 9:12 a.m. with the DS, the DS stated there was dirt buildup and food debris on the floor in the Walk-in Refrigerator 1. The DS stated the staff sweep and mop

the floor daily to prevent rodents, mice, and insects but it was not done. The DS stated this could cause cross-contamination to food.

During a review of the facility's policies and procedures (P&P) titled, Refrigerator and Freezer, dated [DATE REDACTED],

the P&P indicated, Maintaining a clean refrigerator and freezer can improve the safety and quality of your foods. (1) Refrigerator and freezer should be on a weekly cleaning schedule. (2) wipe spills immediately (6) Remove all items and clean shelves. Wipe with sanitizer. (7) Sweep freezer floor and mop with a freezer cleaner product obtained from your chemical company.

c. During an observation on [DATE REDACTED] at 9:05 a.m., observed dirt debris on the shelves and dust buildup on the vent in the reach-in refrigerator near the kitchen entrance.

During a concurrent observation and interview on [DATE REDACTED] at 9:16 a.m. of the reach-in refrigerator with the DS, the DS stated the dirt on the shelves and the dust buildup were not okay as it could caused food contamination.

During an interview on [DATE REDACTED] at 9:36 a.m. with the DS, the DS stated the vent in the reach-in refrigerator was dusty to touch. The DS stated they needed to keep the dust and debris away from the vent so it would not contaminate the food.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page111of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0812 d. During an observation on [DATE REDACTED] at 9:39 a.m., of the dry storage area, observed the dry storage area floors had food and dirt debris. Level of Harm - Minimal harm or potential for actual harm During an interview on [DATE REDACTED] at 9:58 a.m., the DS stated the floor had dirt debris, hairnet and food debris and it was not acceptable as it could attract pest resulting to contamination of food. Residents Affected - Some

During a review of the facility's P&P titled, Storage of Food and Supplies, dated [DATE REDACTED], the P&P indicated, Food and supplies will be stored properly and in a safe manner. (1) The storeroom should be well-lighted, well-ventilated, cool, dry, and clean at all times. (4) All shelves and storage racks or platforms should be in accordance with state and federal regulations to facilitate air circulation and promote easy and regular cleaning. All food and food containers are to be stored 6 inches off the floor and on clean surfaces in a manner that protects it from contamination.

e. During an observation on [DATE REDACTED] at 10:00 a.m., of the ice machine, observed the vent of the ice machine had dust and the internal parts had reddish residues coming off when wiped with a paper towel.

During an interview on [DATE REDACTED] at 10:09 a.m., the DS stated the internal part of the ice machine was last cleaned on [DATE REDACTED] per their log. The DS stated the filter was dusty to touch and it would be the maintenance staff's responsibility. The DS stated the internal part of the ice machine had reddish dirt and it was not supposed to be dirty due to infection control as they used their ice for resident's tea and lemonade.

During an interview on [DATE REDACTED] at 10:19 a.m. with the Maintenance Supervisor (MS), the MS stated they empty the ice machine bin and clean it with bleach once a week. The MS stated they were getting a quote from an outside company to clean it and the Administrator (ADM) must approve it. The MS stated there was dust on the vent and the internal part had reddish mineral buildup. The MS stated they needed to maintain

the cleanliness of the ice machine for infection control for the residents.

During a review of the facility's P&P titled, Ice Machine Cleaning Procedures, dated [DATE REDACTED], the P&P indicated, The ice machine needs to be cleaned and sanitized monthly. (3) Clean inside of the ice machine with a sanitizing agent per the manufacturer's instructions.

f. During a concurrent observation and interview on [DATE REDACTED] at 10:30 a.m., of the mixer with [NAME] 1, observed the mixer guard and agitator shaft had dried up food debris and whipped cream splatters. [NAME] 1 stated the mixer was not used this morning, but it needed to be cleaned after every use to prevent bacterial growth. [NAME] 1 stated if there is bacterial growth in the food, the residents could get sick.

During an interview on [DATE REDACTED] at 10:56 a.m. with the DS, the DS stated the mixer must be cleaned after every use and the last time it was used was Sunday as they prepared biscuit, peanut butter cups and cake mix. The DS stated the staff in the pots and pans did not clean it. The DS stated not cleaning the mixer could cause cross-contamination resulting to the residents potentially getting sick.

During a review of the facility's P&P titled, Electrical Food Machines, dated [DATE REDACTED], the P&P indicated, Keep and maintain all food machines in good operating, sanitary condition. This includes mixers, grinders, slices, and toasters. (3) Clean the beater shaft and body of the machine with warm water and detergent following manufacturer's instructions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page112of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0812 g. During a concurrent observation and interview on [DATE REDACTED] at 9:50 a.m., of the Residents' refrigerator with Registered Nurse 2 (RN 2), observed dirt debris on the refrigerator shelves. RN 2 stated dirty refrigerator for Level of Harm - Minimal harm or the residents was not acceptable as bacteria could grow and could contaminate food resulting to food potential for actual harm poisoning to the residents as a potential outcome.

Residents Affected - Some During a review of Food Code 2022, dated [DATE REDACTED], the Food Code 2022 indicated, ,d+[DATE REDACTED].11 (A) Equipment Food Contact Surfaces and utensils shall be cleaned: (1) Except as specified in (B) of this section, before use with a different type of raw animal food such as beef, fish, lamb, pork or poultry; (2) Each time there is a change from working with raw foods to working with ready-to-eat food; (3) Between uses with raw fruits and vegetables and with time/temperature control for safety food. (4) Before using or storing a food temperature measuring device, and (5) At the time during the operation when contamination may have occurred.

During a review of Food Code 2022, dated [DATE REDACTED], the Food Code 2022 indicated,,d+[DATE REDACTED].13 Nonfood-Contact Surfaces. Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues.

During a review of Food Code 2022, dated [DATE REDACTED], the Food Code 2022 indicated, ,d+[DATE REDACTED].12 Cooking and Baking Equipment. (A) The food contact surfaces of cooking and baking equipment shall be cleaned at least every 24 hours. This section does not apply to hot oil cooking and filtering equipment if it is cleaned as specified subparagraph ,d+[DATE REDACTED].11 (D)(6).

During a review of Food Code 2022, dated [DATE REDACTED], the Food Code 2022 indicated, ,d+[DATE REDACTED].11 Miscellaneous Sources of Contamination. Food shall be protected from contamination that may result from a factor or source not specified under Subparts [DATE REDACTED]-306.

2. a. During an observation on [DATE REDACTED] at 8:46 a.m. observed seven (7) of 7 racks were chipped and had amber discoloration in the walk-in refrigerator.

During a concurrent observation and interview on [DATE REDACTED] at 9:22 a.m. with the DS, the DS stated the racks were bad, old, and needed to be replaced. The DS stated the racks were rusty and had chips that could fall to the food causing cross-contamination.

During a review of the facility's P&P titled, Refrigerator and Freezer, dated [DATE REDACTED], the P&P indicated, 9). Periodically inspect shelves and replace if coating is chipped away exposing metal shelves.

b. During an observation on [DATE REDACTED] at 10:38 a.m., of the can opener, observed the can opener blade had chips.

During a concurrent observation and interview on [DATE REDACTED] at 10:59 p.m. with the DS, the DS stated the can opener blade was corroded and chipped. The DS stated the can opener would be hard to clean and it could grow bacteria. The DS stated chipped can opener could cause physical contamination to food and residents could get sick as a potential outcome.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page113of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0812 During a review of the facility's P&P titled, Can Opener and Base, dated [DATE REDACTED], the P&P indicated, Proper sanitation and maintenance of the can opener and base is important to sanitary of food preparation. Metal Level of Harm - Minimal harm or shavings and shredding can result from dull cutting blade and work out cogwheel. (6) Replace blade on can potential for actual harm opener as needed.

Residents Affected - Some c. During an observation on [DATE REDACTED] at 10:41 a.m., of the clean area where chopping boards are stored, observed green and white chopping board had scratches and brown liquid splatters.

During a concurrent observation and interview on [DATE REDACTED] at 10:43 a.m., of the white chopping board with Dietary Aide 2 (DA 2) in the preparation area, DA 2 stated the chopping board had scratches and it was not okay as the dirt could go in between the scratches and bacteria could grow it in. DA 2 stated the area would be hard to clean if its was not smooth and could contaminate the food causing residents to get sick.

During a concurrent observation an interview on [DATE REDACTED] at 11:02 a.m. with the DS, DS stated the chopping board had cut and knife marks making it hard to clean. The DS stated the chopping board could harbor bacteria and could contaminate food resulting to residents getting food borne illnesses.

During an interview on [DATE REDACTED] at 11:06 a.m. with the DS, the DS stated the white chopping board had a dirt spill and we did not know if that was from the raw meat. The DS stated the residents could get sick due to cross-contamination. The DS stated the green chopping board needed replacement as it was scratched, and

the white chopping board had plenty of dents from chopping.

During a review of the facility's P&P titled, Sanitation, dated [DATE REDACTED], the P&P indicated, All equipment shall be maintained as necessary and kept in working order. (9) All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosion, open seam, cracks, and chipped areas. (10) Plastic ware, china and glassware that becomes unsightly, unsanitary, or hazardous because of chips, cracks or loss of glaze shall be discarded. (17) Separate chopping boards are to be used for preparing meats and vegetables. After each use, chopping boards shall be thoroughly cleaned and sanitized.

During a review of Food Code 2022, dated [DATE REDACTED], the Food Code 2022 indicated, ,d+[DATE REDACTED].11 Food-Contact Surfaces. (A) Multiuse Food-contact surfaces shall be (1) Smooth (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections. (3) Free of sharp internal angles, corners, and crevices, (4) Finished to have smooth welds and joints.

3. During an observation on [DATE REDACTED] at 8:58 a.m., observed one rack was not six (6) inches elevated from the floor.

During a concurrent observation and interview on [DATE REDACTED] at 9:32 a.m. with the DS, the DS stated a rack was not 6 inches above the ground and it should be. The DS stated it was important that the racks are elevated 6 inches or more so that they could have access to clean the floor for potential dirt build up and rodents that could cause cross-contamination to food.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page114of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0812 During a review of the facility's P&P titled, Storage of Food and Supplies, dated [DATE REDACTED], the P&P indicated, (4) All shelves and storage racks or platforms should be in accordance with state and federal regulations to Level of Harm - Minimal harm or facilitate air circulation and promote easy and regular cleaning. All food and food containers are to be stored potential for actual harm 6 inches off the floor and on clean surfaces in a manner that protects it from contamination.

Residents Affected - Some A review of Food Code 2022, dated [DATE REDACTED], the Food Code indicated, ,d+[DATE REDACTED].11 Food Storage (A) Except as specified in (B) and (C) of this section, food shall be protected from contamination by storing the food: (3) at least 15 cm (6 inches) above the floor.

4. During an observation on [DATE REDACTED] at 8:58 a.m., observed boxes

of food stored on the floor inside the walk-in freezer.

During an interview on [DATE REDACTED] at 9:33 a.m. with the DS, the DS stated he placed the food boxes on the floor

in the walk-in freezer because if he placed it in the cart, it would block the walkway. The DS stated, he would figure it out as it was not okay to store food on the floor due to physical contamination.

5. During an observation on [DATE REDACTED] at 9:39 a.m., of the dry

storage area rack, observed three (3) dented cans were stored with non-dented cans.

6. During an interview on [DATE REDACTED] at 9:51 a.m. with the DS, the DS stated there were five (5) dented cans stored with non-dented cans. The DS stated they needed to place all the dented cans to a designated area as they need to bring it back to the vendor for credit and it needed to be separated because they could not use them. The DS stated residents could get ill and die from botulism (a rare but serious illness caused by a toxin that attacks the body's nerves from consuming food from dented cans) from consuming food from dented cans as a potential outcome.

During a review of the facility's P&P titled, Storage of Food and Supplies, dated [DATE REDACTED], the P&P indicated, 15). Food in unlabeled rusty, leaking, broken containers or cans with side seam dents, rim dents or swells shall not be retained or used.

During a review of the facility's P&P titled, Food Storage-Dented Cans, dated [DATE REDACTED], the P&P indicated, POLICY: Food in unlabeled, rusty, leaking, broken containers or cans with side seam dents, rim dent or swells shall not be retained or use by the facility. PROCEDURE: All dented cans (defined as side seam or rim dents) and rusty cans are to be separated from remaining stock and placed in a specified labeled area for return to purveyor for refund. All leaking cans are to be disposed immediately.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page115of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0812 During a review of Food Code 2022, dated [DATE REDACTED], the Food Code 2022 indicated, ,d+[DATE REDACTED].11 Safe Unadulterated, and Honestly Presented. Food shall be safe, unadulterated, and, as specified under , Level of Harm - Minimal harm or d+[DATE REDACTED].12, honestly presented. ,d+[DATE REDACTED].11 Compliance with Food Law. A primary line of defense potential for actual harm ensuring that food meets the requirements of S,d+[DATE REDACTED].11 is to obtain food from approved sources, the implications of which are discussed below. However, it is also critical to monitor food products to ensure that, Residents Affected - Some after harvesting, processing, they do not fail victim to conditions that endanger their safety, make them adulterated, or compromise their honest presentation. The regulatory community, industry, and consumers should exercise vigilance in controlling the conditions to which foods are subjected and be alert to signs of abuse. FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated and actionable under the Federal Food, Drug, and Cosmetic Act. Depending on the circumstances, rusted, and pitted or dented cans may also present a serious potential hazard.

7. During an observation on [DATE REDACTED] at 10:41 a.m., of the drying rack, observed the pans were stacked wet.

During an interview on [DATE REDACTED] at 11:04 a.m. with the DS, the DS stated the pots and pans needed to be air dried first before putting it away so there would no moist and mildew that would spread to pots and pans and could go to the food. The DS stated cross-contamination would be the potential outcome for stacking the pots and pans wet.

During an interview on [DATE REDACTED] at 2:44 p.m. with Dietary Aide 1 (DA 1) stated their process of pots and pans washing in the three-compartment sink were as follows:

- Wash

- Rinse

- Sanitize

- Air dry

DA 1 stated air dry was the last process, and he would know if the pots and pans we completely dry if there was no water dripping from the pots and pans. DA 1 stated the if the pans were stacked wet, it could spread germs for the residents.

During a review of the facility's P&P titled, Three Compartment Procedure for Manual Dishwashing, dated [DATE REDACTED], the P&P indicated, Step 6: All items are air-dried, which means no water droplets are present.

During a review of Food Code 2022, dated [DATE REDACTED], the Food Code 2022 indicated, ,d+[DATE REDACTED].11 Equipment and Utensils, air-drying required. After cleaning and sanitizing equipment and utensils: (A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (food-contact surface sanitizing solutions), before contact with food and; (B) May not be cloth dried except that utensils that have been air-dried may be polished with cloths that are maintained clean and dry.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page116of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0812 8. During an observation on [DATE REDACTED] at 12:43 p.m. of the trayline, observed Dietary Aide 5 (DA 5), was at the end of trayline checking the trays with his beard sticking out of his mask. Level of Harm - Minimal harm or potential for actual harm During an observation on [DATE REDACTED] at 12:45 p.m., of the food preparation by [NAME] 2, [NAME] 2 was preparing food at the grill and his beard was not fully covered with a hair restraint. Residents Affected - Some

During a concurrent observation and interview on [DATE REDACTED] at 1:31 p.m. with the DS, the DS stated facial hair should all be covered because hair could go to the food causing cross-contamination. The DS stated they needed to have hair restraints to prevent hair from falling off to the food.

During a review of the facility's P&P titled, Dress Code dated [DATE REDACTED], the P&P indicated, 8. Beards and mustaches (any facial hair) must wear beard restraint.

During a review of Food Code 2022, the Food Code 2022 indicated ,d+[DATE REDACTED] Hair Restraints. ,d+[DATE REDACTED].11 Effectiveness (A) except as provided in (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils, and linens, and unwrapped single-service and single use article.

9. During an observation an interview on [DATE REDACTED] at 9:38 a.m. of

the Resident's refrigerator with RN 2, the following food were not labeled with resident's name:

i. Fiery chicken vindaloo

ii. Cheese

iii. Cottage cheese

iv. Butter

RN 2 stated they would not know which food belong to the residents and other residents could accidentally consume the food and they could get allergic reaction if they are allergic to certain foods. RN 2 stated a burrito for a resident did not have a received date so they would not know if its safe for the resident to consume or if it is expired. RN 2 stated they keep food for only 72 hours hence it was important to label it with received date to prevent potential food poisoning from eating expired food.

During a review of the facility's P&P titled, Food Brought by Family/Visitors, dated [DATE REDACTED], the P&P indicated, (6) Perishable foods must be stored in re-sealable containers such as zip lock or tightly fitting lids

in the refrigerator. Containers will be labeled with the resident's name, the items, and the use by date. (7)

The nursing staff is responsible for discarding perishable foods on or before the use by date.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page117of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0812 During a review of Food Code 2022, dated [DATE REDACTED], the Food Code 2022 indicated, ,d+[DATE REDACTED].17 Commercially processed food, open and hold cold, (B) except specified in (E) - (G) of this section, Level of Harm - Minimal harm or refrigerated, ready-to-eat time/temperature control for food safety food prepared and packed by a food potential for actual harm processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be Residents Affected - Some consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacture's use-by- date if the manufacturer determined the use-by date based on food safety.

10. During an observation and interview on [DATE REDACTED] at 9:50 a.m. of

the Residents' freezer with RN 2, observed that there was no thermometer inside the freezer and the ice cream sneaker and hot packet in it were not completely frozen. RN 2 stated there was no thermometer in the freezer and the freezer should be at 0 degree Fahrenheit ( F, a scale of temperature on which water freezes). RN 2 stated if there was no thermometer in the freezer, they would not know what temperature the freezer was maintaining and if the food was in their proper temperature. RN 2 stated residents could get food poisoning as bacteria grows on food if they are not in their proper temperatures.

During a review of Food Code 2022, dated [DATE REDACTED], the Food Code indicated ,d+[DATE REDACTED].112 Temperature Measuring Devices. (A) In a mechanically refrigerated or hot FOOD storage unit, the sensor of a TEMPERATURE MEASURING DEVICE shall be located to measure the air temperature or a simulated product temperature in the warmest part of a mechanically refrigerated unit and in the coolest part of a hot FOOD storage unit. (B) Except as specified in (C) of this section, cold or hot holding EQUIPMENT used for TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be designed to include and shall be equipped with at least one integral or permanently affixed TEMPERATURE MEASURING DEVICE that is located to allow easy viewing of the device's temperature display.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page118of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0814 Dispose of garbage and refuse properly.

Level of Harm - Minimal harm or 47441 potential for actual harm Based on observation, interview, and record review, the facility failed to dispose garbage and refuse (broad, Residents Affected - Some overarching term that applies to anything that is leftover after it is used) properly when the dumpster (large trash container designed to be emptied into a truck) surroundings had liquid and food juices spills on the ground since Monday, 1/13/2025.

This failure had a potential to result to attracting birds, flies, insects, pest and possibly spread infection to 266 of 274 facility residents.

Findings:

During a concurrent observation and interview on 1/15/2025 at 11:28 a.m. with the Dietary Supervisor (DS),

the dumper surrounding had liquid spills on the ground. The DS stated there were a lot of juices and liquid spills from the trash on the ground and needed to be cleaned everyday as it could attract pests. The DS stated they prevent pests in the facility due to infection control.

During a concurrent observation and interview on 1/15/2025 at 11:36 a.m. with the Maintenance Supervisor (MS) near the dumpster area, the MS stated the trash pickup came late last Monday, and the trash was too full that they had to put the trash on the floor causing a lot of spills on the ground from the trash. The MS stated the dumpster area was not cleaned yesterday and it was important to maintain its cleanliness for it not to attract flies, pests, and mice. The MS stated the pests could go inside the facility and could spread bacteria and diseases to the residents as a potential outcome of the trash area not being cleaned.

During a review of the facility's policies and procedures (P&P) titled, Trash Collection Area, dated 4/18/2024, indicated The trash collection area is a potential feeding ground for vermin and rodents and must be kept clean. (1) The area must be swept and washed down by maintenance with a detergent on a regular basis. If

a commercial rubbish service is used, arrangements must be made for periodic exchange of trash bins.

During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 5-501.113 Covering Receptacles and waste handling units for refuse, recyclables, and returnable shall be kept covered: (A) Inside food establishment if the receptacles and units: (1) Contain food residue and are not in continuous use; or (2) After they are filled; and 174 (B) With tight-fitting lids or doors if kept outside the food establishment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page119of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0814 During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 5-501.116 Cleaning Receptacles. Proper storage and disposal of garbage and refused are necessary to minimize the Level of Harm - Minimal harm or development of odors, prevent such waste from becoming an attractant and harborage of breeding place for potential for actual harm insects and rodents, and prevent the soiling of food preparation and food service areas. Improperly handled garbage creates nuisance conditions, makes housekeeping difficult, and may be possible source of Residents Affected - Some contamination of food, equipment, and utensils. Outside receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents. Proper equipment and supplies must be made available to accomplish thorough and proper cleaning of garbage storage areas and receptacles so that unsanitary conditions can be eliminated.

During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, A review of Food Code 2017, indicated, 5-501.15 Outside receptacles. (A) Receptacles and waste handling units for REFUSE, recyclables, and returnable used with materials containing FOOD residue and used outside the FOOD ESTABLISHMENT shall be designed and constructed to have tight-fitting lids, doors, or covers.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page120of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44376 potential for actual harm Based on observation, interview, and record review, the facility failed to maintain an infection prevention and Residents Affected - Some control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for five of six sampled residents (Residents 73, 47, 129, 72, and 225) by failing to ensure:

1. The oxygen tubing was labeled with the date it was last changed for one of two sampled residents (Resident 73).

2. The urinal bottle (a container for collecting urine that is used by people who are unable to use a bathroom toilet) was labeled with the name and room number of the resident for one of one sampled resident (Resident 47).

3. Failing to ensure Residents 129's and 72's oxygen tubing were labeled with the date they were last changed.

4. Failing to ensure Resident 225's urine bottle was labeled with the resident's room number.

5. Licensed Vocational Nurse 8 (LVN 8) disinfected (cleanse of bacteria that may cause disease) the glucometer (blood glucose meter - device that measures the amount of glucose [sugar] in the blood of someone with diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) prior to placing the used glucometer in Medication Cart 1A for one five sampled residents (Resident 13) observed during the Medication Administration task.

These deficient practices had the potential to spread infections and illnesses among residents.

Findings:

1. During a review of Resident 73's Admission Record, the Admission Record indicated the facility admitted

the resident on 10/2/2024, with diagnoses including displaced intertrochanteric fracture of right femur ( broken hip bone where the broken bone has shifted or separated) and anemia (a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues).

During a review of Resident 73's Minimum Data Set (MDS, a resident assessment tool), dated 1/8/2025, the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition (having the ability to think, learn, and remember clearly).

During a review of Resident 73's Order Summary Report, dated 1/15/2025, the Order Summary Report indicated an order of oxygen at 2 liters per minute (LPM, a metric unit that measures the volume of a liquid or gas that flows in one minute) - 5 LPM via nasal cannula (a medical device that delivers oxygen to a patient through their nose) inhalation if needed (PRN) for shortness of breath (SOB) may use humidifier (a medical device that adds moisture to supplemental oxygen). As needed for shortness of breath monitor oxygen saturation (O2 sats, the percentage of oxygen currently bound to the hemoglobin in your blood) every (q) shift.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page121of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0880 During a concurrent observation and interview on 1/14/2025, at 11:25 a.m., with Certified Nursing Assistant 3 (CNA 3), inside Resident 73's room, observed Resident 73's oxygen tubing without any date of when it was Level of Harm - Minimal harm or last changed. CNA 3 stated the tubing was not dated and stated oxygen tubing should be changed every potential for actual harm week and dated for the staff to know when to change them again.

Residents Affected - Some During an interview on 1/17/2025, at 3:38 p.m., with the Director of Nursing (DON), the DON stated the licensed staff should label the tubing with the date it was last changed to prevent the growth of microorganisms on the tubing that can cause infection to the resident. The DON stated the oxygen tubing should be changed every 7 days and PRN if soiled.

During a review of the facility provided policy and procedure (P&P) titled Oxygen Administration, last reviewed on 4/18/2024, the P&P indicated the purpose of this procedure is to provide guidelines for safe oxygen administration. Replace oxygen supplies/tubings typically every 7-14 days or per manufacturer's guidelines.

2. During a review of Resident 47's Admission Record, the Admission Record indicated the facility admitted

the resident on 4/9/2017, and readmitted the resident on 10/24/2024, with diagnoses including sepsis (a life-threatening condition that occurs when the body has an extreme response to an infection), personal history of other infections and parasitic diseases (an illness caused by organisms called parasites that live in or on another organism, known as the host).

During a review of Resident 47's MDS, dated [DATE REDACTED], the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition. The MDS indicated the resident required substantial assistance on toileting and hygiene.

During an observation and interview on 1/14/2025, at 10:15 a.m., with the Assistant Director of Staff Development (ADSD), observed Resident 47's two urinals hanging at bedside rail of the resident. The ADSD stated the urinal should be labeled with the name and the room number of the resident to prevent switching of urinals with other residents that can cause infection.

During an interview on 1/17/2025, at 3:38 p.m., with the DON, the DON stated the urinal should be labeled with the name and room number of the resident to prevent cross-contamination (the transfer of harmful bacteria or other microorganisms from one object to another) among residents.

During a review of the facility's recent policy and procedure (P&P) titled Policies and Procedures- Infection Prevention and Control, last reviewed on 4/18/2024, the P&P indicated the facility adopted infection prevention and control policies and procedures are intended to help maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections.

43988

3. During a review of Resident 129's Admission Record, the Admission Record indicated the facility originally admitted the resident on 8/3/2021 and readmitted the resident on 8/16/2021 with diagnoses including dysphagia (difficulty swallowing), unspecified intellectual disabilities (a lifelong condition that limits a person's mental functioning and skills), and difficulty in walking.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page122of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0880 During a review of Resident 129's History and Physical (H&P) dated 9/5/2024, the (H&P) indicated the resident did not have the capacity to understand and make decisions. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 129's MDS dated [DATE REDACTED], the MDS indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident Residents Affected - Some 129 required total assistance from staff with lower body dressing, partial/moderate assistance with bathing, toileting hygiene, upper body dressing, toilet transfer, and shower transfer, and substantial/maximal assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for

an individual to thrive).

During a review of Resident 129's Order Summary Report, the Order Summary Report indicated a physician's order dated 10/25/2024 for humidified oxygen at two (2) liter per minute (liters/min - a unit of measurement) to five (5) liters/min via nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) as needed for shortness of breath.

During a concurrent observation and interview on 1/14/2025 at 10:38 a.m. inside Resident 129's room with Licensed Vocational Nurse 12 (LVN 12), observed Resident 129's oxygen nasal cannula tubing was placed

on top of personal belongings at the bedside table and did not indicate the date of when it was last changed. LVN 12 stated oxygen tubing are changed every Sunday and should be labeled with the date. LVN 12 stated

the oxygen tubing should be placed inside a plastic bag when not in use. LVN 12 stated Resident 129's oxygen tubing should have been labeled when it was last changed so staff would be aware when it was last changed. LVN 12 stated the oxygen tubing should have been placed inside the plastic storage bag when not

in use, so it does not get contaminated. LVN 12 stated not indicating the date on the tubing and not placing

in a plastic storage bag placed the resident at risk for acquiring infection due to contaminated tubing.

During an interview on 1/17/2025, at 3:38 p.m., with the DON, the DON stated the licensed staff should label

the tubing with the date it was last changed to prevent the growth of microorganisms on the tubing that can cause infection to the resident. The DON stated the oxygen tubing should be changed every 7 days and as needed if soiled. The DON stated Resident 129 oxygen tubing should have been labeled with the date it was last changed to prevent the resident from acquiring infection due to contaminated tubing.

During a review of the facility provided policy and procedure (P&P) titled Oxygen Administration, last reviewed on 4/18/2024, the P&P indicated a purpose of providing guidelines for safe oxygen administration.

The P&P further indicated to replace oxygen supplies/tubing typically every 7-14 days or per manufacturer's guidelines.

4. During a review of Resident 72's Admission Record, the Admission Record indicated the facility admitted

the resident on 8/23/2018 with diagnoses including chronic respiratory failure with hypoxia (a condition that occurs when the is not enough oxygen in the blood), chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing), and dependence on supplemental oxygen.

During a review of Resident 72's History and Physical (H&P) dated 12/8/2024, the (H&P) indicated the resident had fluctuating capacity to understand and make decisions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page123of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0880 During a review of Resident 72's MDS dated [DATE REDACTED], the MDS indicated the resident had an intact cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 73 Level of Harm - Minimal harm or required set up or clean up assistance with eating; supervision or touching assistance with oral hygiene; potential for actual harm partial/moderate assistance with mobility; substantial/maximal assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). Residents Affected - Some

During a review of Resident 72's Order Summary Report, the Order Summary Report indicated a physician's order dated 1/22/2024:

- Oxygen at 2 - four (4) liters/min via nasal cannula to maintain oxygen saturation (O2 Sat - a measurement of how much oxygen the blood is carrying as a percentage) above 90 percent (% - a unit of measurement) every shift.

During a concurrent observation and interview on 1/14/2025 at 11:41 a.m. inside Resident 72's room with Licensed Vocational Nurse 116 (LVN 16), observed Resident 72's oxygen nasal cannula tubing did not indicate the date of when it was last changed. LVN 16 stated oxygen tubing are changed every week and should be labeled with the date it was last changed. LVN 16 stated Resident 72's oxygen tubing should have been labeled with the date of when it was last changed so staff would be aware when it was last changed and infection control. LVN 16 stated bacteria can grow in the tubing if not changed as scheduled. LVN 16 stated not indicating the date on the tubing placed the resident at risk for acquiring infection due to contaminated tubing.

During an interview on 1/17/2025, at 3:38 p.m., with the DON, the DON stated the licensed staff should label

the tubing with the date it was last changed to prevent the growth of microorganisms on the tubing that can cause infection to the resident. The DON stated the oxygen tubing should be changed every 7 days and as needed if soiled. The DON stated Resident 129 oxygen should have been labeled with the date it was last changed to prevent the resident from acquiring infection due to contaminated tubing.

During a review of the facility provided policy and procedure (P&P) titled Oxygen Administration, last reviewed on 4/18/2024, the P&P indicated a purpose of providing guidelines for safe oxygen administration.

The P&P further indicated to replace oxygen supplies/tubing typically every 7-14 days or per manufacturer's guidelines.

5. During a review of Resident 225's Admission Record, the Admission Record indicated the facility admitted

the resident on 8/23/2018 with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on

the same side of the body) and hemiparesis (weakness on the same side of the body) following cerebral infarction (stroke - loss of blood flow to a part of the body) affecting left dominant side, and chest pain.

During a review of Resident 225's History and Physical (H&P) dated 10/24/2024, the (H&P) indicated the resident had fluctuating capacity to understand and make decisions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page124of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0880 During a review of Resident 225's MDS dated [DATE REDACTED], the MDS indicated the resident had an intact cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident Level of Harm - Minimal harm or 225 required supervision or touching assistance with eating; substantial/maximal assistance with ambulation, potential for actual harm toileting hygiene, bathing, upper body and lower body dressing; partial/moderate assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). Residents Affected - Some The MDS indicated Resident 225 was frequently incontinent of bowel and bladder.

During a concurrent observation and interview on 1/14/2025 at 10:52 a.m., inside Resident 225's room with Licensed Vocational Nurse 13 (LVN 13), LVN 13 verified Resident 225's urine bottle on top of the overbed table and was not labeled with the resident's room number. LVN 13 stated urine bottles are labeled with at least the room number every time the staff changes the urine bottle. LVN 13 stated Resident 225's urine bottle should have been labeled with the room number of the resident to prevent switching with other residents that can cause cross contamination which may lead to infection.

During an interview on 1/17/2025, at 3:38 p.m., with the DON, the DON stated the urinal should be labeled with the name and room number of the resident to prevent cross-contamination (the transfer of harmful bacteria or other microorganisms from one object to another) among residents which may lead the residents to acquire infection.

During a review of the facility's recent policy and procedure (P&P) titled Policies and Procedures- Infection Prevention and Control, last reviewed on 4/18/2024, the P&P indicated the facility adopted infection prevention and control policies and procedures are intended to help maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections.

44244

6. During a review of Resident 13's Admission Record, the Admission Record indicated the facility admitted

the resident on 5/16/2023 with diagnoses that included DM and hypertension (HTN-high blood pressure).

During a review of Resident 13's MDS dated [DATE REDACTED], the MDS indicated the resident was able to understand others and was able to make himself understood. The MDS further indicated the resident required insulin injections (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) while a resident in the facility.

During a review of Resident 13's Order Summary Report, the report indicated an order for insulin regular, inject subcutaneously (under the skin) per sliding scale (dosage of medication is determined by the resident's blood sugar) before meals and at bedtime, dated 9/5/2023.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page125of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0880 During a medication pass observation on 1/15/2025 at 5:15 p.m. with Licensed Vocational Nurse 8 (LVN 8) at Medication Cart 1A, LVN 8 stated he would check Resident 13's blood sugar. Observed LVN 8 remove a Level of Harm - Minimal harm or glucometer from Medication Cart 1A, walked into Resident 13's room, placed the glucometer on Resident potential for actual harm 13's bedside rolling table, used a disposable lancet (sharp needle that's used to prick the skin to draw a small amount of blood) on the resident's finger, placed a test strip in the glucometer, and angled the Residents Affected - Some glucometer at the resident's finger to test the blood. After the test was completed LVN 8 then removed and disposed of the used test strip, walked back to Medication Cart 1A and stated the resident did not require any insulin. LVN 8 stated he had no other residents that required a blood sugar check and then placed the glucometer back in Medication Cart 1A's top left drawer. Observed LVN 8 did not disinfect the glucometer prior to placing it back in the medication cart. LVN 8 then stated he did not clean Resident 13's bedside rolling table prior to placing the glucometer on top of it, and he did not clean the glucometer after testing Resident 13's blood sugar and placing the glucometer back in Medication Cart 1A. LVN 8 stated the facility process is to sanitize and clean the glucometer before putting it back in the medication cart, but he was using

an unfamiliar medication cart and did not have sanitizing wipes on the cart as he usually did. LVN 8 stated it was important to sanitize for infection control purposes.

During an interview on 1/15/2025 at 6:27 p.m. with the Infection Preventionist (IP), the IP stated glucometers are always cleaned between resident use and prior to placing back in the medication cart because there is a potential that the glucometer may be contaminated with bacteria or the resident's blood. The IP stated if the glucometer was not cleaned after resident use and prior to placing it in the medication cart it could result in

the spread of infection between residents by cross contamination (the process by which bacteria, blood born pathogens, or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) The IP stated the glucometer and Medication Cart 1A would be disinfected.

During a concurrent interview and record review on 1/17/2025 at 12:10 p.m., with the DON, the DON reviewed the facility policy and procedures on Infection Control and glucometer use. The DON stated he was made aware that LVN 8 did not disinfect the glucometer after use on a resident and prior to placing the glucometer back in the medication cart. The DON stated LVN 8 was using an unfamiliar medication cart and was very nervous. The DON stated the facility policy was not followed when the glucometer was not cleaned and could have potentially resulted in the cross contamination of blood borne pathogens and bacteria to residents.

During a review of the facility policy and procedure (P&P) titled, Infection Control, last reviewed 4/18/2024,

the P&P indicated the facility adopted infection prevention and control policies and procedures are intended to help maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. All personell are trained on infection prevention and control policies and procedures upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control.

During a review of the facility P&P titled, Obtaining a Fingerstick Glucose Level, last reviewed 4/18/2024, the P&P indicated always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page126of126 056039

F-F808

Findings:

1. During a review of the facility's cook's spreadsheet titled Winter Menus, dated 1/14/2025, the spreadsheet indicated residents on soft mechanical diet would include the following foods in the tray:

- Italian Lasagna 3x3 1/3 inches = 1 square

- Soft seasoned broccoli 1/2 cup ([c], household measurement)

- Parsley flakes garnish- yes

- Soft garlic bread, no hard crusts

- Peanut butter cup pudding #12 scoop (1/3 c)

- Milk 4 oz.

During a review of Resident 35's Admission Record, the Admission Record indicated the facility admitted Resident 35 on 6/9/2021 with diagnoses including dementia (a progressive state of decline in mental abilities), peptic ulcer (open sores on the inner lining of the stomach and upper part of the small intestines) and anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 93 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0803 During a review of Resident 35's Minimum Data Set (MDS - a resident assessment tool), dated 12/18/2024,

the MDS indicated Resident 35 usually made self understood and understand others. The MDS further Level of Harm - Minimal harm or indicated Resident 35 required set up and clean up assistance with eating. The MDS further indicated potential for actual harm Resident 35 had mechanically altered diet (food texture that is intended to be safe and easy to swallow) while being a resident of the facility and within the last seven days. Residents Affected - Some

During a review of Resident 35's Order Summary Report, dated 4/10/2024, the Order Summary Report indicated a physician's order for regular, soft mechanical texture, thin liquid consistency, chopped meat and vegetables.

During a review of Resident 35's Care Plan titled, [Resident 35] has nutritional problems and potential for nutritional problems related to (wanting) meat to be chopped, be mechanically altered diet due to visual loss to both eyes, last revised on 7/10/2023, the care plan indicated interventions including providing and serving diet, monitor intake and record every meal of regular soft chopped texture.

During an observation on 1/14/2025 at 11:59 a.m. of the trayline (an area where foods were assembled on

the trays), Resident 35 got two (2) slices of garlic bread with hard crust on the tray.

During a review of Resident 134's Admission Record, the Admission Record indicated the facility admitted Resident 134 on 8/24/2023 with diagnoses including mild protein-calorie malnutrition (a nutritional status in which reduced ability of nutrients leads to changes in body composition and function), hypothyroidism (a condition where the thyroid gland does not make enough thyroid hormones, leading to symptoms like fatigue, weight again, and feeling cold), and essential hypertension ([HTN], high blood pressure).

During a review of Resident 134's MDS, dated [DATE REDACTED], the MDS indicated Resident 134 did not make self understood and did not understand others. The MDS further indicated Resident 134 required set up and clean up assistance with eating. The MDS further indicated Resident 134 had mechanically altered diet while

a resident of the facility and within the last seven days.

During a review of Resident 134's Order Summary Report, dated 10/9/2023, the Order Summary Report indicated a physician's order for fortified, no added salt (NAS, no salt packet on the tray), mechanical soft with chopped meat texture, and thin liquid consistency diet.

During a review of Resident 134's care plan titled, [Resident 134] was at risk for or potential for nutritional problems related to diet modification and or restrictions with diet of regular diet, mechanical soft with chopped meat texture and thin liquid consistency, last revised on 8/24/2023, the care plan indicated interventions including ensuring dental appliances are in good repair and in place for meals and activities to promote intake.

During an observation on 1/14/2025 at 12:02 p.m. of Resident 134's tray, Resident 134 got two slices of garlic bread with hard crust on the tray.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 94 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0803 During a review of Resident 32's Admission Record, the Admission Record indicated the facility originally admitted Resident 32 on 1/18/2023 and readmitted on [DATE REDACTED] and 12/14/2024 with diagnoses including type Level of Harm - Minimal harm or 2 diabetes (DM, a disorder characterized by difficulty in blood sugar control and poor would healing), mild potential for actual harm protein-calorie malnutrition, and dysphagia, oropharyngeal phase (difficulty swallowing occurring in mouth or

in the throat). Residents Affected - Some

During a review of Resident 32's MDS, dated [DATE REDACTED], the MDS indicated Resident 32 did not make self-understood and did not understand others.

During a review of Resident 32's Order Summary Report, dated 12/14/2024, the Order Summary Report indicated a physician's order for CCHO, NAS diet, mechanical soft texture, thin liquids consistency.

During a review of Resident 32's care plan titled, [Resident 32] was at risk for or potential for nutritional problems related to diet modification and or restrictions with diet of regular diet, mechanical soft with chopped meat texture and thin liquid consistency, last revised on 8/24/2023, the care plan indicated interventions including ensuring dental appliances are in good repair and in place for meals and activities to promote intake.

During an observation on 1/14/2025 at 12:18 p.m. of Resident 32's tray, Resident 32 got two slices of garlic bread with hard crust on the tray.

During a concurrent test tray (a process of tasting, temping, and evaluating the quality of food) observation and interview on 1/14/2025 at 2:22 p.m. with the Dietary Supervisor (DS), the DS stated the soft mechanical test tray had hard bread and crust. The DS stated the garlic bread must be soft with no hard crust as soft mechanical diets are used for residents with swallowing and chewing difficulties. The DS stated residents could potentially choke if the food they ate was not soft.

During a review of the facility's policies and procedures (P&P) titled, Menu Planning, dated 4/18/2024, the P&P indicated, (1) Menu service which provides the seasonal menus with corresponding recipes. (2) Menus and cook's spreadsheets are to be dated and posted in the kitchen and on consumer bulletin board in the entrance of the facility by the FNS director two weeks in advance. (4). The menus are planned to meet nutritional needs of residents in accordance with established national guidelines, physician's diet orders and, to the extent medically possible, in accordance to the most recent recommended dietary allowances of the Food and Nutrition Board of the National Research Council National Academy of Sciences. Menus are planned to consider: (f) texture and color of all foods in meals. Procedures: (1) The facilities' diet manual and diets ordered by the physician should mirror the nutritional care provided by the facility.

During a review of the facility's diet manual titled, Regular Mechanical Soft Diet, dated 4/18/2024, the diet manual indicated, Description: The Mechanical Soft diet is designed for residents who experience chewing or swallowing limitations. The regular diet is modified texture to a soft, chopped or ground consistency as per foods below. Other textures may be included such as a mechanical soft diet with pureed meats if further texture reduction is required.

During a review of the facility's recipe titled, Recipe: Garlic Bread, dated 4/18/2024, the recipe indicated, Mechanical soft: may use soft French bread, no hard crusts, or cut crust off. Keep soft. Can cut off crusts if

they become hard or overdone.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 95 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0803 2. During an observation on 1/14/2025 at 12:05 p.m. of residents' trays on fortified diet, there were seven (7) residents (Resident 104, Resident 96, Resident 213, Resident 145, Resident 135, Resident 129, and Level of Harm - Minimal harm or Resident 84) on fortified diet did not get extra cheese on their trays. potential for actual harm

During an interview on 1/14/2025 at 12:07 p.m. with Dietary Aide 5 (DA 5), DA 5 stated residents on fortified Residents Affected - Some diets get extra cheese. The DS asked the staff to prepare grated cheese on containers and give the extra cheese on the following trays that have not been distributed yet.

During an observation on 1/14/2025 at 12:21 p.m. of the trayline, observed staff started giving fortified diet trays with extra cheese.

During an interview on 1/14/2025 at 1:35 p.m. with the DS, the DS stated there were residents on fortified diets who did not get extra shredded cheese on their meals and the trayline staff missed putting it in the tray.

The DS stated fortifying food is adding extra gravy, sauces, butter, and cheese to help residents with weight loss. The DS stated the residents not given the one (1) oz grated cheeses were missing nutrition and calories affecting their diets and as a result, these residents would continue to lose weight as a potential outcome.

During a review of the facility's P&P titled Food Preparation, dated 4/18/2024, the P&P indicated, (1) The facility will use approved recipes, standardized to meet the resident census. This count is to be kept current so that an accurate amount of food is prepared. (2) Recipes are specific as to portion yield, method of preparation, amounts of ingredients, and time and temperature guide.

During a review of the facility' diet manual titled, Fortified Diet, dated 4/18/2024, the diet manual indicated, Description: The fortified diet is designed for residents who cannot consume adequate amounts of calories and/or protein to maintain their weight or nutritional status. Nutritional breakdown: The goal is to increase the calorie density of foods commonly consumed by the resident. The amount of calorie increase should be approximately 300-400 per day. Examples of adding calories include: add cheese to soups, pasta or vegetables. Approximate calories of food used for fortifying diet: cheese- 1 Tablespoon = 55 calories.

During a review of the facility's diet manual titled, Fortification of Food: Increasing Calories and/or Protein in

the Diet, dated 4/18/2024, the diet manual indicated, The enrichment of food will be done on an individual basis for residents who cannot consume adequate amounts of calories and/or protein to sustain their weight or nutrition status. The goal is to increase the calorie and/or protein density of foods commonly consumed by

the resident to promote improvement in their nutritional status.

3. During a review of the facility's cook's spreadsheet titled Winter

Menus, dated 1/14/2025, the spreadsheet indicated residents on regular diet would include the following foods in the tray:

- Italian Lasagna 3x3 1/3 inches = 1 square

- Seasoned broccoli 1/2 c

- Parsley granish- yes

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 96 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0803 - Garlic bread- yes

Level of Harm - Minimal harm or - Peanut butter cup pudding 1/3 c potential for actual harm - Milk 4 oz. Residents Affected - Some

During a review of the facility's cook's spreadsheet titled, Winter

Menus, dated 1/14/2025, the spreadsheet indicated residents on large portion diet would include the following foods in the tray:

- Italian Lasagna 3x3 1/3 inches = 1 square

- Seasoned broccoli 1/2 c

- Parsley granish- yes

- Garlic bread- yes

- Peanut butter cup pudding 1/3 c

- Milk 8 oz.

During an interview on 1/14/2025 at 12:11 p.m. with DA 5, DA 5 stated large portion diets would get the same food as regular diet and it is only the double portion diets that they double the food.

During an observation on 1/14/2025 at 12:18 p.m., of Resident 32's

menu ticket, the menu ticket indicated, Resident 32 was on mechanical soft, chopped, fortified, large portions, consistent carbohydrate diet (CCHO, a diet to manage blood sugar levels containing the same amount of carbohydrates per meal), thin liquid. Observed Resident 32 did not get 8 oz of milk.

During a concurrent observation and interview on 1/14/2025 at 12:32 p.m., of Resident 249's menu ticket with DA 5, the menu ticket indicated Resident 249 was on large portion diet. Observed Resident 249 did not get 8 oz of milk. DA 5 stated they gave four (4) oz of juice as that was the preference of the resident.

During an interview on 1/14/2025 at 1:40 p.m. with the DS, the DS stated residents on large portion diets would get 8 oz of milk instead of 4 oz per the menu spreadsheet as long as it is not in the dislike list of the residents. The DS stated large portion diet was used for residents with weight loss and to cater to their food preferences. The DS stated, residents on large portions who did not get milk lose their nutrition and could potentially lose weight and for those who has it as food preference, they would get upset. The DS stated residents could have psychosocial harm as a potential outcome.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 97 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0803 During a review of the facility's diet manual titled, Regular Diet, dated 4/18/2025, the diet manual indicated, Large Portions: follow the regular diet. Increase calories by adding food from the dairy, protein, and grain Level of Harm - Minimal harm or groups. Addition of these foods will increase the sugars and fats in the diet. Calories will equal about potential for actual harm 2500-2800 calories per day, 120-130 grams protein, and 295-315 grams carbohydrates. If a resident request larger portions than are specified on the menu, increase specific food the resident enjoys. Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 98 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Level of Harm - Minimal harm or 47441 potential for actual harm Based on observation, interview, and record review, the facility failed to prepare food by methods that Residents Affected - Some conserved flavor and appearance for lunch when staff served mushy and overcooked broccoli, carrots, and peas.

This failure had a potential to result in 137 of 279 residents, including Resident 188, facility residents on regular texture (no restriction) at risk of unplanned weight loss, a consequence of poor food intake, getting food from the kitchen.

Findings:

During a review of Resident 188's Admission Record, the Admission Record indicated the facility admitted Resident 188 on 10/24/2023 with diagnoses including acute and chronic respiratory failure (define), type 2 diabetes (a chronic condition where the body does not use insulin effectively or does not produce enough insulin) and chronic obstructive pulmonary disease (COPD, a condition involving constriction of the airways and difficulty or discomfort in breathing).

During a review of Resident 188's Minimum Data Set (MDS- a resident assessment tool), dated 12/10/2024,

the MDS indicated Resident 188 made self understood and can understand others. The MDS further indicated Resident 188 required set up and clean up assistance with eating while a resident of the facility and within the last seven days.

During a review of Resident 188's Order Summary Report, dated 10/14/2024, the Order Summary Report indicated a physician's order for consistent carbohydrate diet (CCHO, diet used in management of blood sugar level by providing same amount of carbohydrates each meal), large portion (adding meat, carbohydrates and other food items on the tray to increase proteins and calories) regular thin texture (no restriction) consistency with meals.

During an interview on 1/14/2025 at 10:06 a.m. with Resident 188, Resident 188 stated the food does not taste and quality of food was not good.

During a review of the facility's cook's spreadsheet (a sheet that contains each diet and what food and portions each diet would get) titled, Winter Menus, dated 1/14/2025, the spreadsheet indicated residents on regular diet would include the following foods in the tray:

- Italian Lasagna 3x3 1/3 inches = 1 square

- Seasoned broccoli 1/2 cup ([c], household measurement)

- Parsley garnish- yes

- Garlic bread- yes

- Peanut butter cup pudding #12 scoop (1/3 c)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 99 of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0804 - Milk 4 ounces (oz - unit of measure)

Level of Harm - Minimal harm or During an observation on 1/14/2025 at 11:38 a.m. in trayline (an area where foods were assembled on the potential for actual harm trays), observed dark yellowish-green, overcooked, and mushy broccoli in the steamtable.

Residents Affected - Some During a test tray (a process of tasting, temping, and evaluating the quality of food) observation and interview

on 1/14/2025 at 2:17 a.m. with the Dietary Supervisor (DS), the DS stated the broccoli was overcooked as it was supposed to be batch-cooked (cook small portions throughout the meal period and serve as needed) but

it was not batch- cooked today. The DS stated batch cooking preserve color, quality, taste, and presentation of the food. The DS stated the green peas looked brown and the carrots were overcooked. The DS stated

the broccoli, carrots and peas were mushy, tasted watery and lost their taste and nutrients after tasting it.

The DS stated residents could lose weight for not getting vitamins and nutrients from overcooked vegetables.

During a review of the facility's policies and procedures (P&P) titled, Food Preparation, dated 4/18/2024, the P&P indicated, POLICY: Food shall be prepared by methods that conserve nutritive value, flavor, and appearance. Procedure:

1. The facility will use approved recipes, standardized to meet the resident census. This count is to be kept current so that an accurate amount of food is prepared.

2. Recipes are specific as to portion yield, method of preparation, amounts of ingredients, and time and temperature guide.

3. Prepared food will be sampled. The Food and Nutrition Services employee who prepares the food will sample it to be sure the food has satisfactory flavor and consistency. Use a clean spoon or put a small portion of the food in a dish and taste from the dish.

4. Poorly prepared food will not be served. Such food is to either be improved, prepared again, or replaced with an appropriate substitution. May add increased amounts of herbs and spices (not salt) since potency of product may vary.

5. Prepare foods as close as possible to serving time in order to preserve nutrition, freshness and to prevent overcooking.

6. Process raw and uncooked foods in batches. Remove from refrigeration only the amount of product that can be processed within a 30-minute period.

The P&P further indicated, [NAME] vegetables on small amount of water for a short amount of time. Serve vegetables promptly. Do not hold on to the steam table for long period of time. (Maximum-1 hour prior to serving).

During a review of facility's recipe titled, Recipe: Seasoned Broccoli, dated 4/18/2024, the recipe indicated, Cooking Time: 10-20 minutes. Directions: (2) Boil or steam broccoli until tender. Drain well. Do not overcook, will turn brown and mushy.

During a review of the facility's recipe titled, Seasoned Peas, dated 4/18/2024, the recipe indicated, Cooking time: 10-15 minutes.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page100of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0804 During a review of the facility's recipe titled, Seasoned Carrots, dated 4/18/2024, the recipe indicated, Cooking time: about 10-20 mins. Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page101of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0805 Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47441

Residents Affected - Some Based on observation, interview, and record review, the facility failed to prepare foods in a form designed to meet individual needs when:

1. Puree pasta was too sticky and did not pass the spoon tilt test (a test used to determine the stickiness of

the food and the ability of the food to hold together) for residents on puree diet (foods that are smooth with pudding-like consistency)/International Dysphagia (difficulty swallowing) Diet Initiative ([IDDSI] a framework for categorizing food textures and drink thickness) level four (4).

2. Residents on soft mechanical diet (diet consisted of soft, chopped foods) received toasted garlic bread with hard crust.

These failures had the potential to result in difficulty in swallowing, chewing, decreased in food intake and nutrient intake to 18 of 18 residents on puree diet and 108 of 109 residents on soft mechanical diet, resulting to unintended weight loss and choking (when food gets stuck in your airway, blocking the flow of air to your lungs).

Findings:

1. During a review of the facility's cook's spreadsheet (a sheet that contains each diet and what food and portions each diet would get) titled, Winter Menus, dated 1/14/2025, the spreadsheet indicated residents on puree/IDDSI level 4 would include the following foods in the tray:

a. Puree Italian Lasagna one (1) cup ([c], household measurement).

b. Puree seasoned broccoli #12 scoop (1/3 c)

c. Parsley flakes garnish - yes

d. Puree garlic bread #16 (1/4 c)

e. Peanut butter cup pudding 1/3 c

f. Milk 4 ounces (oz - unit of measurement)

During an observation on 1/14/2025 at 11:38 a.m. of the puree Italian lasagna in a trayline (an area where foods were assembled on the trays) set up, observed the puree garlic bread looked sticky.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page102of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0805 During a concurrent test tray (a process of tasting, temping, and evaluating the quality of food) observation and interview with the Dietary Supervisor (DS), the DS stated he has never seen puree/IDDSI level 4 but Level of Harm - Minimal harm or always followed the recipe book. The DS stated puree diets are used for residents with swallowing problems potential for actual harm and the puree food should not be too shiny, pudding thick, mixed well with thickener, and a consistency of baby food. The DS performed the spoon tilt test and stated the puree Italian pasta did not pass the spoon tilt Residents Affected - Some test because it was too sticky, and the food did not fall off the spoon when tilted. The DS stated the cook might have put too much food thickener. The DS stated the food with too much thickener would not taste good resulting to residents refusing the tray and sticky food could cause choking to residents with difficulty in swallowing.

During a review of the facility's policy and procedure (P&P) titled, Food Preparation, dated 4/18/2024, the P&P indicated, The facility will use approved recipes, standardized to meet the resident census. This count is to be kept current so that an accurate amount of food is prepared. Recipes are specific as to portions, yield, methods of preparation, amounts of ingredients, and time and temperature guide.

During a review of the facility's diet manual titled, Regular Pureed Diet, dated 4/18/2024, the diet manual indicated, The pureed diet is a regular diet that has been designed for residents who have difficulty chewing and/or swallowing. The texture of the food should be of a smooth and moist consistency and able to hold its shape. All foods are prepared in a food processor or blender, with the exception of foods which are normally

in a soft and smooth state such as pudding, ice cream, applesauce, mashed potatoes.

During a review of the facility's recipe titled, Recipe: Italian Lasagna, dated 4/18/2024, the recipe indicated, Pureed/Dysphagia: can layer also with puree ingredients. Make one pan. Or puree: 1 cup/serving, small #6. Cut off any hard noodles before pureeing. Puree following the pureed recipes in the Food Safety/Misc. section of Book 1.

During a review of the facility's recipe titled, Recipe: Pureed (IDDSI LEVEL 4) Casserole, dated 4/18/2024,

the recipe indicated, (5) The finished pureed item should be smooth and free of lumps, hold its shape, while not being too firm or sticky, and should not weep. The finished pureed items must pass IDDSI level 4 testing requirements (i.e., the fork drip, fork pressure, and spoon tilt test).

During a review of the IDDSI guideline from the website titled, IDDSI, dated 7/2019, the IDSSI website indicated, Level 4 Pureed is usually eaten with spoon, falls off spoon in a single spoonful when tilted and continues to hold shape on the plate, no lumps, not sticky, and liquid must not separate from solid. Food testing method: Spoon tilt test and Fork drip test).

2. During a review of the facility's cook's spreadsheet titled, Winter Menus, dated 1/14/2025, the spreadsheet indicated residents on soft mechanical diet would include the following foods in the tray:

a. Italian Lasagna 3x3 1/3 inches = 1 square

b. Soft seasoned broccoli 1/2 c.

c. Parsley flakes garnish- yes

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page103of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0805 d. Soft-garlic bread, no hard crusts

Level of Harm - Minimal harm or e. Peanut butter cup pudding 1/3 c. potential for actual harm f. Milk 4 oz. Residents Affected - Some

During a review of Resident 35's Admission Record, the Admission Record indicated the facility admitted Resident 35 on 6/9/2021 with diagnoses including dementia (a progressive state of decline in mental abilities), peptic ulcer (open sores on the inner lining of the stomach and upper part of the small intestines) and anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness).

During a review of Resident 35's Minimum Data Set (MDS - a resident assessment tool), dated 12/18/2024,

the MDS indicated Resident 35 usually made self understood and can understand others. The MDS further indicated Resident 35 required set up and clean up assistance with eating. The MDS further indicated Resident 35 had mechanically altered diet (food texture that is intended to be safe and easy to swallow) while a resident of the facility and within the last seven days.

During a review of Resident 35's Order Summary Report, dated 4/10/2024, the Order Summary Report indicated a physician's order for regular, soft mechanical texture, thin liquid consistency, chopped meat and vegetables.

During a review of Resident 35's care plan titled, [Resident 35] has nutritional problems and potential for nutritional problems related to (wanting) meat to be chopped, to be mechanically altered diet due to visual loss to both eyes, last revised on 7/10/2023, the care plan indicated interventions including providing and serving diet, monitor intake and record every meal of regular soft chopped texture.

During an observation on 1/14/2025 at 11:59 a.m. of the trayline, Resident 35 got two (2) slices of garlic bread with hard crust on the tray.

During a review of Resident 134's Admission Record, the Admission Record indicated the facility admitted Resident 134 on 8/24/2023 with diagnoses including mild protein-calorie malnutrition (a nutritional status in which reduced ability of nutrients leads to changes in body composition and function), hypothyroidism (a condition where thyroid gland does not make enough thyroid hormones, leading to symptoms like fatigue, weight gain and feeling cold), and essential hypertension ([HTN], high blood pressure).

During a review of Resident 134's MDS, dated [DATE REDACTED], the MDS indicated Resident 134 did not make self understood and did not understand others. The MDS further indicated Resident 134 required set up and clean up assistance with eating. The MDS further indicated Resident 134 had mechanically altered diet while

a resident of the facility and within the last seven days.

During a review of Resident 134's Order Summary Report, dated 10/9/2023, the Order Summary Report indicated a physician's order for fortified (food with nutrients added to them), no added salt (NAS, no salt packet on the tray), mechanical soft with chopped meat texture, and thin liquid consistency.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page104of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0805 During a review of Resident 134's care plan titled, [Resident 134] was at risk for or potential for nutritional problems related to diet modification and/or restrictions with diet of regular diet, mechanical soft with Level of Harm - Minimal harm or chopped meat texture and thin liquid consistency, last revised on 8/24/2023, the care plan indicated potential for actual harm interventions including ensuring dental appliances are in good repair and in place for meals and activities to promote intake. Residents Affected - Some

During an observation on 1/14/2025 at 12:02 p.m. of Resident 134's tray, Resident 134 got 2 slices of garlic bread with hard crust on the tray.

During a review of Resident 32's Admission Record, the Admission Record indicated the facility originally admitted Resident 32 on 1/18/2023 and readmitted on [DATE REDACTED] and 12/14/2024 with diagnoses including type 2 diabetes (DM, a disorder characterized by difficulty in blood sugar control and poor would healing), mild protein-calorie malnutrition, and dysphagia, oropharyngeal phase (difficulty swallowing occurring in mouth or

in the throat).

During a review of Resident 32's MDS, dated [DATE REDACTED], the MDS indicated Resident 32 did not make self understood and did not understand others.

During a review of Resident 32's Order Summary Report, dated 12/14/2024, the Order Summary Report indicated a physician's order for consistent carbohydrate diet (CCHO, a diet used to manage blood sugar by serving the same amount of carbohydrates each meal), NAS diet, mechanical soft texture, thin liquids consistency.

During a review of Resident 32's care plan titled, [Resident 32] was at risk for or potential for nutritional problems related to diet modification and/or restrictions with diet of regular diet, mechanical soft with chopped meat texture and thin liquid consistency, last revised on 8/24/2023, the care plan indicated interventions including ensuring dental appliances are in good repair and in place for meals and activities to promote intake.

During an observation on 1/14/2025 at 12:18 p.m. of Resident 32's tray, Resident 32 got 2 slices of garlic bread with hard crust on the tray.

During a concurrent test tray observation and interview on 1/14/2025 at 2:22 p.m. with the Dietary Supervisor (DS), the DS stated the soft mechanical test tray had hard bread and crust. The DS stated the garlic bread must be soft with no hard crust as soft mechanical diets are used for residents with swallowing and chewing difficulties. The DS stated residents could potentially choke if the food they ate was not soft.

During a review of the facility's P&P titled, Menu Planning, dated 4/18/2024, the P&P indicated, (1) Menu service which provides the seasonal menus with corresponding recipes. (2) Menus and cook's spreadsheets are to be dated and posted in the kitchen and on consumer bulletin board in the entrance of the facility by the FNS director two weeks in advance. (4). The menus are planned to meet nutritional needs of residents in accordance with established national guidelines, physician's diet orders and, to the extent medically possible, in accordance to the most recent recommended dietary allowances of the Food and Nutrition Board of the National Research Council National Academy of Sciences. Menus are planned to consider: (f) texture and color of all foods in meals. Procedures: (1) The facility's diet manual and diets ordered by the physician should mirror the nutritional care provided by the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page105of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0805 During a review of the facility's diet manual titled, Regular Mechanical Soft Diet, dated 4/18/2024, the diet manual indicated, Description: The Mechanical Soft diet is designed for residents who experience chewing or Level of Harm - Minimal harm or swallowing limitations. The regular diet is modified texture to a soft, chopped or ground consistency as per potential for actual harm foods below. Other textures may be included such as a mechanical soft diet with pureed meats if further texture reduction is required. Residents Affected - Some

During a review of the facility's recipe titled, Recipe: Garlic Bread, dated 4/18/2024, the recipe indicated, Mechanical soft: may use soft French bread, no hard crusts, or cut crust off. Keep soft. Can cut off crusts if

they become hard or overdone.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page106of126 056039 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056039 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute 44445 15th St W Lancaster, CA 93534

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)

F 0808 Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47441

Residents Affected - Some Based on observation, interview, and record review, the facility failed to ensure residents receive and consume foods in the appropriate nutritive content as prescribed by a physician for regular fortified diet (addition of food to increase calories and proteins in the diet) when staff did not add cheese for seven of 46 sampled residents (Resident 135, Resident 213, Resident 104, Resident 96, Resident 129, Resident 145, and Resident 84) on fortified diet during lunch on 1/14/2025.

This deficient practice had the potential to cause weight loss for residents on fortified diets.

Cross reference