Mirage Post Acute

Based on interview and record review, the facility failed to develop and implement a person-centered Care Plan (CP - a plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs) for one of three sampled residents (Resident 5) by failing to implement the Medication Regimen Review (a pharmacist's [a healthcare professional who specializes in the preparation and management of medications] systematic check of a resident's entire medication list to identify potential issues such as dangerous side effects or inappropriate doses) per Resident 5's CP.

This failure had the potential to delay care for Resident 5 and negatively affect Resident 1's well-being.

Findings: During a review of Resident 5's admission Record (AR), the AR indicated the facility admitted Resident 5 on 6/21/2025 with diagnoses including dementia (a progressive state of decline in mental abilities), cerebral infarction (damage to the area of the brain caused by lock of blood flow), psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), and repeated falls.

During a review of Resident 5's History and Physical (H&P), dated 6/23/2025, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions.

During a review of Resident 5's Minimum Data Set (MDS - a resident assessment tool), dated 6/27/2025, the MDS indicated Resident 5 had moderately impaired cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks).

The MDS indicated Resident 5 required maximal assistance (helper does more than half of the effort) from staff for toileting hygiene, showers, and lower body dressing.

During a review of Resident 5's Change of Condition (COC - major decline or improvement in a resident's status that will not resolve without intervention) form, dated 6/24/2025 and 6/25/2025, the COC forms indicated Resident 5 had an episode of fall on 6/24/2025 and 6/25/2025.

During a concurrent interview and record review on 8/21/2025 at 1:10 p.m. with the Director of Nursing (DON), Resident 5's CP, initiated on 6/24/2025, was reviewed.

The CP indicated Resident 1 had an unwitnessed fall and was at risk of recurrent falls, injury.

The CP interventions, initiated on 6/24/2025, indicated Resident 5's medications will be evaluated for side effects that may increase fall risk.

The DON stated Resident 5's medications were not reviewed by the pharmacist after Resident 5's fall incident on 6/24/2025 and 6/25/2025 as indicated in Resident 5's care plan.

The DON further stated the purpose of the medication regimen review by pharmacist after the fall incident was to identify medications that would potentially cause Resident 5 to fall.

The DON stated the failure to complete a medication regimen evaluation had the potential for Resident 5 to continue receiving medications that increased Resident 5's risk for fall.

During a record review of the facility-provided policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, last reviewed on 4/24/2025, 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.

During a review of the facility-provided P&P titled, Fall Risk Assessment, last reviewed on 4/24/2025, the P&P indicated, The nursing staff, attending physician, and consultant pharmacist will review for medications or medication combinations that could relate to falls or fall risk, such as those that have side effects of dizziness, ataxia, or hypotension.

During a review of the facility-provided P&P titled, Falls and Fall Risk, Management, last reviewed on 4/24/2025, the P&P indicated, .The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/21/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute

44445 15th St W Lancaster, CA 93534

SUMMARY STATEMENT OF DEFICIENCIES

During a review of Resident 5's AR, the AR indicated the facility admitted Resident 5 on 6/21/2025, with diagnoses including dementia, cerebral infarction, psychosis, and repeated falls.

During a review of Resident 5's H&P, dated 6/23/2025, the H&P indicated Resident 5 had fluctuating capacity to understand and make decisions.

During a review of Resident 5's MDS, dated [DATE], the MDS indicated Resident 5 had moderately impaired cognitive functioning.

The MDS indicated Resident 5 required maximal assistance from staff for toileting hygiene, showers, and lower body dressing.

During a review of Resident 5's COC forms, dated 7/26/2025 and 7/27/2025, the COC forms indicated on 7/26/2025 and 7/27/2025, Resident 5 sustained falls.

During an interview on 8/20/2025 at 12:14 p.m. with the DON, the DON stated Resident 5's CP was not revised after Resident 5 sustained falls on 7/26/2025 and 7/27/2025.

The DON further stated the facility should have revised Resident 5's CP after the fall incidents based on root and cause analyses of the incident.

The DON further stated the failure had the potential for Resident 5 to receive interventions based on incomplete and inaccurate CP.

During a review of the facility-provided policy and procedure titled, Care Plans, Comprehensive Person-Centered, last reviewed on 4/24/2025, the policy and procedure 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 interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change.

During a record review of the facility-provided policy and procedure titled, Falls and Fall Risk, Managing, last reviewed on 4/24/2025, the policy and procedure indicated, .Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling.If the individual continues to fall, the staff and physician will reevaluate the situation and reconsider possible reasons for the resident's falling (instead of, or in addition to those that have already been identified) and also reconsider the current interventions.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/21/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute

44445 15th St W Lancaster, CA 93534

SUMMARY STATEMENT OF DEFICIENCIES

During a review of the facility's P&P titled, Falling Star Program, last reviewed on 4/24/2025, the P&P indicated:

• To standardize our screening identification and falls prevention strategies in order to reduce both the

number and severity of falls in our facility.

• To successfully raise awareness about Falls Prevention throughout our facility.
• To arm our caregivers with the tools, proactive strategies and interventions, needed to be more vigilant

with all residents and especially with those who are at high risk.

Protocol:

• We adopted a Yellow Star to symbolize the following residents:

- who are new admit/readmit residents who score High Risk or with a history of fall/s within the last 30 days. - current residents who had fallen with no major injury in the last 30 days. - any resident who scored High Risk on Fall Risk Assessment.

To alert all members of our Health Care Team: - A Yellow Star is placed at the door by the name of these residents.

This star will follow with residents as room changes occur. - A Yellow Star is placed on the footboard of these residents.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/21/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute

44445 15th St W Lancaster, CA 93534

SUMMARY STATEMENT OF DEFICIENCIES

during tube feeding and at least one hour after feeding to prevent aspiration.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/21/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute

44445 15th St W Lancaster, CA 93534

SUMMARY STATEMENT OF DEFICIENCIES

medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/21/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Mirage Post Acute

44445 15th St W Lancaster, CA 93534

SUMMARY STATEMENT OF DEFICIENCIES

During a record review of the facility-provided policy and procedure (P&P) titled, Charting and Documentation, last reviewed on 4/24/2025, the P&P 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 record.

The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care .

Documentation of procedures and treatments will include care specific details, including. f. notification of family, physician or other staff.

During a record review of the facility-provided P&P titled, Change in a Resident's Condition or Status, last reviewed on 4/24/2025, the P&P indicated, Our facility promptly notified the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition.The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.

Facility ID: