Mirage Post Acute

F-F600.

Findings:

During a review of Resident 1 ' s Admission Record, undated, the Admission Record indicated the facility admitted Resident 1 on 3/4/2025 with diagnoses including unspecified hypothyroidism (unidentified cause for thyroid gland [a large ductless gland in the neck] to not produce thyroid hormone [hormone regulating growth and development], causing weakness), essential hypertension (persistent elevated blood pressure), and occlusion and stenosis of left carotid artery (complete blockage and narrowing of carotid artery, a major blood vessel supplying the brain).

During a review of Resident 1 ' s Minimum Data Set (MDS - a resident assessment tool), dated 3/12/2025,

the MDS indicated Resident 1 was severely impaired with thought process and required substantial assistance from staff to complete activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily).

During a review of Resident 1 ' s record titled, eInteract Change of Condition Evaluation, dated 3/12/2025 at 11:40 p.m., the evaluation indicated Resident 1 had a change of condition of Abnormal vital signs and altered mental status (a change in a resident ' s mental state, including changes in awareness, alertness, and mental function). The evaluation indicated on 3/12/2025 at 5 p.m., Resident 1 ' s BP on a sitting position taken on Resident 1 ' s right arm was 86/57 mmHg and HR of 111 bpm. The evaluation indicated there were no other BP and HR assessments collected for Resident 1 after 5 p.m. on 3/12/2025.

During a review of the physician ' s Progress Notes (PN) for Resident 1, dated 3/13/2025 at 1:06 a.m., the PN indicated Resident 1 ' s Medical Doctor (MD) 1 called RN 1 after multiple times before RN 1 answered.

The PN indicated MD 1 instructed RN 1 to check and examine Resident 1, then call back MD 1. The PN indicated RN 1 called back and told MD 1, Resident 1 ' s BP was 86/57 mmHg and HR was 111 bpm (these vital signs were the same readings taken on 3/12/2025 at approximately 5 p.m.). The PN indicated RN 1 told MD 1 that it was unclear if Resident 1 was responsive (able to respond or reply) or not, so MD 1 ordered Resident 1 to be transferred to a GACH.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 30 056039 Department of Health & Human Services Printed: 08/31/2025 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 03/28/2025

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 0684 During a review of Resident 1 ' s Physician ' s Orders (PO), dated 3/13/2025 at 6:48 a.m., the PO indicated Resident 1 was sent out to the GACH for abnormal vital signs and for altered level of consciousness (a Level of Harm - Immediate change in mental status not normal from baseline). jeopardy to resident health or safety During an interview on 3/25/2025 at 3:54 p.m. with CNA 1, CNA 1 stated she was working on 3/12/2025

during the 3 p.m. to 11 p.m. shift and was assigned to care for Resident 1. CNA 1 stated she checked Residents Affected - Few Resident 1 ' s vital signs approximately four to five times on Resident 1 ' s both arms, and the BP readings were consistently low (did not state the other low BP readings). CNA 1 stated she informed LVN 1, who was assigned to Resident 1 about Resident 1 ' s vital sign readings of low BP and increased HR. CNA 1 stated LVN 1 told her (CNA 1) that she (LVN 1) will recheck Resident 1 ' s vital signs. CNA 1 stated, To be honest, I don ' t know if she (LVN 1) checked since I went to my other residents

During an interview on 3/26/2025 at 7:05 a.m. with RN 1, RN 1 stated RN 1 was working on 3/12/2025 and arrived at the facility at approximately 11:35 p.m. for the 11 p.m. to 7 a.m. shift. RN 1 stated RN 1 received a call from MD 1 (on 3/12/2025 at approximately 11:40 p.m.). RN 1 stated he was being asked by MD 1 if RN 1 was the supervisor on duty, and to provide a report on Resident 1 ' s condition. RN 1 stated, upon observing Resident 1, I was stunned, like he (Resident 1) was dying or towards the end of life RN 1 stated the previous shift staff failed to act to save the resident (Resident 1). RN 1 stated the previous shift staff (LVN 1) should have notified the RN on duty (RN 2), or by calling a code blue. RN 1 stated, When I saw the resident (Resident 1), to me, it looked like he (Resident 1) was gone. RN 1 stated the previous shift staff failed to notify Resident 1 ' s physician about the decreased blood pressure, and that staff also failed to call emergency services (the paramedics) sooner for Resident 1.

During a concurrent interview and record review on 3/26/2025 at 7:47 a.m. with LVN 2, Resident 1 ' s eInteract Change of Condition Evaluation, dated 3/12/2025 at 11:40 p.m., was reviewed. LVN 2 stated she worked on 3/12/2025 for the 11 p.m. to 7 a.m. shift and was assigned to care for Resident 1. LVN 2 stated

she cannot recall if Resident 1 was receiving any oxygen. LVN 2 stated LVNs are to notify the RN on duty first for any residents with a COC. LVN 2 stated (on 3/12/25 at approximately after 11 p.m.) From what I saw,

he (Resident 1) was in code blue (an emergency code typically indicating a resident experiencing a life-threatening medical emergency that requires immediate medical attention) status because of his shallow breathing. LVN 2 stated Resident 1 ' s COC, dated 3/12/2025 documented at 11:40 p.m., indicated Resident 1 ' s last assessed BP of 86/57 mmHg and HR of 111 bpm recorded at 5 p.m. LVN 2 stated, For his (Resident 1 ' s) blood pressure, it was very low. LVN 2 stated when the emergency personnel (paramedics) came to the facility (on 3/13/2025 at 12:28 a.m.), she (LVN 1) mentioned it (BP and HR) was taken around 6 p.m. LVN 2 stated the paramedics arrived after midnight (3/13/25, after 12 a.m.). LVN 2 stated that would be 7 hours from the last collected vital signs. LVN 2 stated per the nursing progress notes, LVN 1 failed to notify RN 2 regarding Resident 1 ' s COC. LVN 2 stated there were no RN notification, no doctor (physician) notification, no code blue announced, and no interventions done on records (Resident 1 ' s medical records). LVN 2 stated, The LVN (LVN 1) stated to the emergency personnel that it (the BP of 86/57 mmHg and HR of 111 bpm) was the resident ' s (Resident 1 ' s) baseline. From what I saw, that was not the resident ' s (Resident 1) baseline. LVN 2 stated, The LVN (LVN 1) failed to notify the RN on duty (RN 2)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 30 056039 Department of Health & Human Services Printed: 08/31/2025 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 03/28/2025

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 0684 During an interview on 3/26/2025 at 2:16 p.m. with LVN 1, LVN 1 stated she was informed of Resident 1 ' s change in vital signs approximately at 5 p.m. on 3/12/2025. LVN 1 stated she did not discuss Resident 1 ' s Level of Harm - Immediate COC with the on-duty RN (RN 2), and she (LVN 1) did not inform Resident 1 ' s physician of Resident 1 ' s jeopardy to resident health or low vital signs. LVN 1 stated she did not call emergency services for Resident 1 and that it was the incoming safety night shift (11 pm. to 7 a.m.) staff (LVN 2) that notified emergency services for Resident 1 ' s COC.

Residents Affected - Few During a phone interview on 3/26/2025 at 4:20 p.m. with MD 1, MD 1 stated MD 1 called the facility to get an update on Resident 1 on 3/12/2025 approximately after 11:30 p.m. MD 1 stated that no facility staff had reached out to MD 1 earlier in the day. MD 1 stated MD 1 was concerned about Resident 1 ' s kidney function, so MD 1 called the facility for an update on Resident 1. MD 1 stated staff knew of Resident 1 ' s vital signs recorded on 3/12/2025 at 5 p.m. were a BP of 86/57 mmHg and a HR of 111 bpm, but staff did not make MD 1 aware of Resident 1 ' s condition timely. MD 1 stated (on 3/12/25, at approximately 11:30 pm) MD 1 spoke to an RN (RN 1) who told MD 1 The patient does not look good. MD 1 stated, MD 1 expected

the nurses in general, evaluate Resident 1 when Resident 1 ' s BP was that low (86/57 mmHg).

During an interview on 3/28/2025 at 10:15 a.m. with Unit Manager 1 (LVN), Unit Manager 1 indicated Resident 1 had no nursing progress notes from the 3 p.m. to 11 p.m. shift, no documented interventions. Unit Manager 1 stated the vital signs provide an internal baseline or anything happening for the residents, like blood pressures dropping or an increase in temperature could be related to possible infection, so vital signs help notify nursing staff an indication of how the resident is doing, or to identify if any changes need to be addressed. Unit Manager stated there was about six hours and 40 minutes from when MD 1 was informed of

the Resident 1 ' s condition. Unit Manager 1 stated, For this case, after finding the vital signs at 5 p.m., the LVN (LVN 1) failed to reassess the resident ' s (Resident 1 ' s) vital signs, failed to notify the RN to assess

the resident, and failure to notify the doctor of the COC. Unit Manager 1 stated Resident 1 had a care plan for hypertension initiated on 3/4/2025, upon admitted . Unit Manager 1 stated the interventions by licensed nurses (LVNs and RNs) are to observe for signs and symptoms of abnormal blood pressure and complications related to hypertension, and notify physician as needed. Unit Manager 1 stated, In this scenario, the LVN (LVN 1) failed to implement this (Resident 1) care plan ' s intervention.

During a concurrent interview and record review on 3/28/2025 at 11:30 a.m., Resident 1 ' s eInteract Change of Condition Evaluation, dated 3/12/2025 at 11:40 p.m., was reviewed with MD 1. MD 1 stated MD 1 called

the facility on 3/12/2025 at approximately after 11:30 p.m. MD 1 stated MD 1 did not realize the vital signs provided to MD 1 over the phone were Resident 1 ' s BP of 86/57 mmHg and HR of 111 bpm per minute were the same collected vital signs from 5 p.m. earlier in the day (3/12/2025). MD 1 stated, I ' m talking to them on the phone, so I didn ' t know they (RN 1) used the same vital signs from 5 p.m. I thought it was a recent set of vital signs.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 30 056039 Department of Health & Human Services Printed: 08/31/2025 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 03/28/2025

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 0684 During a concurrent interview and record review on 3/28/2025 at 5:50 p.m., Resident 1 ' s paramedics ' report, dated 3/13/2025 at 12:19 a.m., and the facility ' s policy titled, Change in a Resident ' s Condition or Level of Harm - Immediate Status, were reviewed with the DON. The DON stated on 3/12/2025, for Resident 1, from staff knowing the jeopardy to resident health or changes in vital signs for Resident 1 at 5 p.m., to the time the physician called the facility at approximately safety 11:40 p.m., that was almost seven hours of no interventions. The DON stated the paramedics ' report indicated that the paramedics were contacted on 3/13/2025 at 12:19 a.m., arrived at the facility by 12:28 a.m. Residents Affected - Few , at bedside with the Resident 1 at 12:30 a.m., and left the facility with Resident 1 by 12:37 a.m. The DON stated the report described Resident 1 as having decreased breath sounds and the vital signs collected by

the paramedics on 3/13/2025 at 12:30 a.m. were a BP of 74/50 mmHg, HR of 56 beats per minute, RR of 4 breaths per minute, and oxygen saturation (percentage of oxygen to the blood measuring how well the lungs deliver oxygen to the body) of 74 percent (% - per one hundred, typically ranges from 95% to 100%). The DON stated the paramedics described Resident 1 as lying in bed with the current concern of respiratory failure (occurs when the lungs are unable to adequately perform their primary function: taking in oxygen and removing carbon dioxide [a colorless, odorless gas formed when people breathe out] from the blood). The DON stated the report indicated Resident 1 was found in severe respiratory distress and had a nasal cannula (a small plastic tube which fits into nostrils to provide supplemental oxygen) and staff were standing by with no interventions to Resident 1 ' s decreased RR. The DON stated the report indicated Resident 1 was assisted by the paramedics with a bag valve mask (a handheld device used to deliver breaths to someone who cannot breathe on their own) and transported on advanced life support (ALS - a set of life-saving protocols and skills to provide urgent care during critical conditions) to the nearest GACH 1. The DON stated,

This resident passed away on 3/13/2025. During further record review of the policy titled Change in a Resident ' s Condition or Status with the DON, the DON was asked to clarify what Promptly meant as stated

in the policy. The DON stated, For the policy titled Change in a Resident ' s Condition or Status, there is no date on this policy. For the notification of promptly, whatever the change of condition was from the resident ' s baseline, licensed staff (LVNs & RNs) need to assess and inform the attending physician.

During a review of Resident 1 ' s GACH records titled, Discharge Summary, reviewed on 3/28/2025, the GACH records indicated Resident 1 passed away on 3/13/2025 at 4:27 p.m. The preliminary cause of Resident 1 ' s death was septic shock. The Discharge Summary also indicated additional pertinent diagnoses of acute respiratory failure with hypoxia (when the lungs fail to provide oxygen to the body ' s tissues, leading to low oxygen levels in the blood) and anoxic brain damage (brain injury caused by lack of oxygen to the brain).

During a review of the current facility-provided undated policy and procedure titled, Change in Resident ' s Condition or Status, the policy and procedure indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident ' s medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). The policy also indicated:

1. The nurse will notify the resident ' s attending physician or physician on call when there has been a (an):

d. significant change in the resident ' s physical/emotional/mental condition;

g. need to transfer the resident to a hospital/treatment center;

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 30 056039 Department of Health & Human Services Printed: 08/31/2025 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 03/28/2025

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 0684 2. A Significant change of condition is a major decline or improvement in the resident ' s status that:

Level of Harm - Immediate a. will not normally resolve itself without intervention by staff or by implementing standard disease-related jeopardy to resident health or clinical interventions (is not Self-limiting); safety b. impacts more than one area of the resident ' s health status; Residents Affected - Few c. requires interdisciplinary review and/or revision of the care plan

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 30 056039 Department of Health & Human Services Printed: 08/31/2025 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 03/28/2025

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 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm 37861

Residents Affected - Few Based on interview and record review, the facility failed to maintain accurate clinical records in accordance with accepted professional standards and practices for one of nine sampled residents (Resident 1) when Licensed Vocational Nurse (LVN) 1 added documentation entries in Resident 1 ' s medical record to show that Resident 1 was doing a little bit better. Resident 1 had a change of condition (COC - a major decline in a resident ' s status) on 3/12/2025 at approximately 5 p.m. when Resident 1 had a low blood pressure (BP - measurement of the pressure or force of blood inside your arteries [the elastic, muscular tubes or blood vessels responsible for carrying the blood away from the heart and distributing it to several other organs and tissues]) reading of 86/57 millimeters of mercury (mmHg - unit of measurement used to measure BP and is abnormal if less than 90/60 mmHg or greater than 139/89 mmHg) and increased heart rate (HR - the number of heartbeats per unit of time) of 111 beats per minute (bpm - considered abnormal if less than 60 bpm or greater than 100 bpm). LVN 1 added on 3/26/2025 at 9:07 a.m. and 9:51 a.m. made-up (invented or not true) documentation entries in Resident 1 ' s medical record regarding Resident 1 ' s vital signs (measurements of

the body ' s most basic functions), LVN 1 notifying Registered Nurse (RN) 1, and RN 1 notifying Resident 1 ' s Medical Doctor (MD) 1.

As a result, Resident 1 ' s medical record had inaccurate documentation to misrepresent (give a false or misleading representation of usually with an intent to deceive) Resident 1 ' s vital signs to show his BP of 86/57 mmHg on 3/12/2025 at approximately 5 p.m. was better on 3/12/2025 at 9 p.m. with BP of 97/60 mmHg (considered within the normal range). Resident 1 experienced severe respiratory distress (a life-threatening condition characterized by difficult breathing, rapid breathing, and low oxygen levels, often requiring immediate medical intervention) was transferred to a General Acute Care Hospital (GACH) on 3/13/2025 at 12:37 a.m., and pronounced dead on 3/13/2025 at 4:27 p.m.

Cross Reference

F-F684.

Findings:

During a review of Resident 1 ' s Admission Record, the Admission Record indicated the facility admitted Resident 1 on 3/4/2025 with diagnoses including unspecified hypothyroidism (unidentified cause for thyroid gland to not produce thyroid hormone, causing weakness), essential hypertension (persistent elevated blood pressure), and occlusion and stenosis of left carotid artery (complete blockage and narrowing of carotid artery, a major blood vessel supplying the brain).

During a review of Resident 1 ' s Minimum Data Set (MDS - a resident assessment tool), dated 3/12/2025,

the MDS indicated Resident 1 was severely impaired with thought process and required substantial assistance from staff to complete activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 30 056039 Department of Health & Human Services Printed: 08/31/2025 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 03/28/2025

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 0842 During a review of Resident 1 ' s record titled, eInteract (a tool used in healthcare that helps care teams prevent unnecessary hospitalization s and improve resident outcomes to alert staff to changes in a resident ' Level of Harm - Minimal harm or s condition) Change of Condition Evaluation, dated 3/12/2025 at 11:40 p.m., the evaluation indicated potential for actual harm Resident 1 had a change of condition of Abnormal vital signs and altered mental status (a change in a resident ' s mental state, including changes in awareness, alertness, and mental function). The evaluation Residents Affected - Few indicated on 3/12/2025 at 5 p.m., Resident 1 ' s BP on a sitting position taken on Resident 1 ' s right arm was 86/57 mmHg and HR of 111 beats per minute. The evaluation indicated LVN 1 added a documentation entry

on 3/26/2025 at 9:51 a.m. that on 3/12/2025 LVN 1 assessed Resident 1 with BP of 97/60, PR of 99, RR of 16, and HR of 96 and that LVN 1 called RN on duty to assess Resident 1, and RN on duty called MD 1 who ordered to send out Resident 1 to the GACH.

During a review of Resident 1 ' s Weights and Vitals Summary, dated 3/12/2025 at 9 p.m., Resident 1 ' s BP was 97/60 mmHg. The Summary indicated LVN 1 entered this documentation entry on 3/26/2025 at 9:07 a.m.

During a review of Resident 1 ' s GACH records titled, Discharge Summary, the GACH records indicated Resident 1 passed away on 3/13/2025 at 4:27 p.m., and the preliminary cause of Resident 1 ' s death was septic shock (a life-threatening condition that happens when the BP drops to a dangerously low level after an infection). The Discharge Summary also indicated additional pertinent diagnoses of acute respiratory failure with hypoxia (when the lungs fail to provide oxygen to the body ' s tissues, leading to low oxygen levels in the blood) and anoxic brain damage (brain injury caused by lack of oxygen to the brain).

During a phone interview on 3/26/2025 at 4:20 p.m. with MD 1, MD 1 stated on 3/12/2025 approximately

after 11:30 p.m., she called the facility to get an update on Resident 1. MD 1 stated no facility staff notified her (MD 1) earlier in the day. MD 1 stated she was concerned about Resident 1 ' s kidney function, so MD 1 called the facility for an update on Resident 1. MD 1 stated staff knew on 3/12/2025 at 5 p.m., Resident 1 ' s BP was 86/57 mmHg and HR of 111 beats per minute. MD 1 stated doctors (in general) should be made aware of this. MD 1 stated she spoke to an RN (RN 1) who told her The patient does not look good. MD 1 stated, I would expect the nurses in general, when the BP is that low, the RN should evaluate the resident (Resident 1). MD 1 stated she was not informed of Resident 1 ' s COC on 3/12/2025 at 5 p.m. and the facility should have informed her (MD 1).

During a phone interview on 3/27/2025 at 11:45 a.m. with LVN 1, LVN 1 stated the Director of Nursing (DON) asked her (LVN 1) to report to the facility to update the documentation for Resident 1. LVN 1 stated the vital signs she added for Resident 1 on 3/12/2025 at 9 p.m., per the DON ' s instruction, was made-up to show that Resident 1 was doing a little bit better. LVN 1 stated she tried calling RN 1 but RN 1 was busy and LVN 1 never called MD 1 regarding the condition of Resident 1 (the added documentation entry on 3/26/2025 at 9:51 p.m. indicated LVN 1 called RN 1 then RN 1 called MD 1).

During an interview on 3/27/2025 at 4:01 p.m. with the Medical Records Director (MRD), the MRD stated that any late entry in the documentation of a resident ' s medical records can be added about 72 hours later.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 30 056039 Department of Health & Human Services Printed: 08/31/2025 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 03/28/2025

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 0842 During a concurrent interview and record review with the DON on 3/28/2025 at 5:50 p.m., Resident 1 ' s paramedics ' report, dated 3/13/2025 at 12:19 a.m., was reviewed. The DON stated the paramedics ' report Level of Harm - Minimal harm or indicated the paramedics were contacted on 3/13/2025 at 12:19 a.m., arrived at the facility by 12:28 a.m., at potential for actual harm bedside with Resident 1 at 12:30 a.m., and left the facility with Resident 1 by 12:37 a.m. The DON stated the report described Resident 1 as having decreased breath sounds and the vital signs collected by the Residents Affected - Few paramedics on 3/13/2025 at 12:30 a.m. were a BP of 74/50 mmHg, HR of 56 beats per minute, RR of 4 breaths per minute, and oxygen saturation (percentage of oxygen to the blood measuring how well the lungs deliver oxygen to the body) of 74 percent (% - per one hundred). The DON stated the paramedics described Resident 1 as lying in bed with the current concern of respiratory failure (occurs when the lungs are unable to adequately perform their primary function: taking in oxygen and removing carbon dioxide [a colorless, odorless gas formed when people breathe out] from the blood). The DON stated the report indicated Resident 1 was found in severe respiratory distress and had a nasal cannula (a small plastic tube which fits into nostrils to provide supplemental oxygen) and staff were standing by with no interventions to Resident 1 ' s decreased RR. The DON stated the report indicated Resident 1 was assisted by the paramedics with a bag valve mask (a handheld device used to deliver breaths to someone who cannot breathe on their own) and transported on advanced life support (ALS - a set of life-saving protocols and skills to provide urgent care

during critical conditions) to the nearest GACH 1. The DON stated, This resident passed away on 3/13/2025.

During a review of the current facility-provided undated policy and procedure titled, Charting Errors and/or Omissions, the policy and procedure indicated, Accurate medical Records shall be maintained by this facility.

During a review of the current facility-provided undated policy and procedure titled, Charting and Documentation, the policy and procedure indicated, All services provided to the resident, progress toward

the care plan goals, or any changes in the resident ' s medical, physical, functional or psychosocial condition, shall be documented in the resident ' s medical records. The medical record should facilitate communication between the interdisciplinary team regarding the resident ' s condition and response to care The following information is to be documented in the resident medical record: a. Objective observation; b. Medications administered; c. Treatments or services performed; d. Changes in the resident ' s condition 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 30 056039