Health Inspection

Mirage Post Acute

January 17, 2025 · Lancaster, CA · 44445 15th St W

Citations 6

CMS Rating 1/5

Beds 299

Provider ID 056039

Healthcare Facility

Mirage Post Acute

Lancaster, CA · View full profile →

Inspection Summary

MIRAGE POST ACUTE in LANCASTER, CA — inspection on January 17, 2025.

Found 6 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF554

Minimal harm or environment and encouraged to use their personal belongings to the extent possible. Few the resident on 4/28/2024, with diagnoses including type 2 diabetes mellitus (a chronic disease that occurs affected

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.

056039

Form Approved OMB

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

FF658

Minimal harm or meals. Some at bedtime for DM 2. Give 12 units if blood sugar (BS) is more than (>) 350 and notify physician (MD). Inject affected

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:

056039

Form Approved OMB

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

FF689

Minimal harm or medication cups containing ointment. Resident 179 stated the medications were left by the nurse for him to Few various stages of healing. Resident 179 stated the nurse sometimes leaves the ointments for him to apply affected

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

056039

Form Approved OMB

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

FF760

Minimal harm or meals. Some at bedtime for DM 2. Give 12 units if blood sugar (BS) is more than (>) 350 and notify physician (MD). Inject affected

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 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:

056039

Form Approved OMB

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

FF803

Minimal harm or indicated Resident 135 required set up and clean up assistance with eating. The MDS further indicated Some affected

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)

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).

056039

Form Approved OMB

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

FF808

Minimal harm or indicated Resident 35 required set up and clean up assistance with eating. The MDS further indicated Some affected

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).

056039

Form Approved OMB

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

Frequently Asked Questions

What is an F-tag violation?

F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.

Were these violations corrected?

Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.

How often do nursing home inspections happen?

CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.

What should families do about these violations?

Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in LANCASTER, CA, (5) Report new concerns to state authorities.

Where can I see the full inspection report?

Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from MIRAGE POST ACUTE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.

Mirage Post Acute

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