Complaint Investigation

Mirage Post Acute

March 28, 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 →

Source Document

Official CMS Inspection Report (Medicare.gov)

Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.

Inspection Summary

MIRAGE POST ACUTE in LANCASTER, CA — inspection on March 28, 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

FF0580

Immediately tell the resident, the resident's doctor, and a family member of situations

medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident

jeopardy to resident health or safety 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;

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

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

056039 03/28/2025

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

FF0600

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical

During a review of the current facility-provided undated policy and procedure titled, Recognizing Signs and Symptoms of Abuse/Neglect, the policy and procedure indicated, All types of resident . neglect . are strictly prohibited.

The policy indicated, Neglect is defined as failure to provide goods and services as necessary to avoid physical harm, mental anguish, and mental illness.

During a review of the current facility-provided undated policy and procedure titled, Resident Rights, the policy and procedure indicated, Federal and state laws guarantee certain basic rights to all residents of this facility.

These rights include the resident ' s right to: c. be free from . neglect 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:

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;

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

056039 03/28/2025

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

FF0684

Provide appropriate treatment and care according to orders, resident?s preferences and goals.

lack of oxygen to the brain).

jeopardy to resident health or During a review of the current facility-provided undated policy and procedure titled, Change in safety 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

rights, etc.).

The policy also indicated:

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;

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

056039 03/28/2025

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

FF0842

Safeguard resident-identifiable information and/or maintain medical records on each resident that are

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.

FF600

Immediate change in mental status not normal from baseline). Few Resident 1 ' s vital signs approximately four to five times on Resident 1 ' s both arms, and the BP readings affected

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.

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 03/28/2025

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

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

FF684

Immediate vital signs approximately four to five times using both arms, and the BP readings were consistently low. CNA Few affected

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 03/28/2025

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.

More Reports

About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.