Mirage Post Acute

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

8/19/2025 at 4:06 p.m. with the Director of Nursing (DON) the DON stated we have 5 days to investigate and have a resolution within 30 days to complete any grievance. The DON verified Concern and Grievance Log for August and stated based on record indicates these grievances are resolved. The DON reviewed grievance on 8/62025 and 8/15/2025 and the DON stated the grievance is not resolved but it was resolved by SSD because he already addressed it to supervision. The DON stated the grievance should not indicate resolve, this is ongoing, will be resolved on 8/22/2025 with IDT. The DON stated this is inaccurately documented. During a review of the facility's P&P titled, Grievances/Complaints, Filing, last reviewed on 4/24/2025, the P&P indicated residents, and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances. The resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed (verbally and in writing) of the findings of the investigation and the actions that will be taken to correct any identified problems.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/21/2025

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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/21/2025

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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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. b. 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 REDACTED], 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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/21/2025

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 Level of Harm - Actual harm Residents Affected - Few

footboard. The DON stated the purposes of the stars at the footboard and outside the door are to provide staff with awareness, minimize falls, allow staff to identify immediately who is a fall risk, and provide a form of communication. The DON stated she is aware Resident 3 did not have yellow star outside door or footboard. The DON stated not implementing the falling star program can be a potential contributing factor for resident falls.

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

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

number and severity of falls in our facility.

2. 2. To successfully raise awareness about Falls Prevention throughout our facility.
3. 3. 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:

4. 2. 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.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/21/2025

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

Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/21/2025

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

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

Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/21/2025

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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

was incomplete and had the potential to result in Resident 5 receiving interventions that were not person-centered and accurate.

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.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet