Mirage Post Acute

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

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

our dialect because not all the resident speaks their dialect and they do not want them (residents) to feel that staff were talking about them.During an interview on 9/5/2025 at 1:30 p.m. with the DON, the DON stated the staff should talk in English all the time when around residents' area as a courtesy and respect to

the residents.During a review of the facility's policy and procedure titled, Courtesy, last review date of 4/24/2025, the policy and procedure indicated, Communication courtesy is required at all times. Establish and follow first language communication policy to follow at all times.

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

09/05/2025

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 - Minimal harm or potential for actual harm Residents Affected - Few

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

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Based on observation, interview, and record review, the facility failed to ensure a nasal spray (delivers a fine mist of medicine directly into your nose) was not left at a resident's bedside table and the resident was assessed for self-administration of medication for one of three sampled residents (Resident 5). This deficient practice had the potential to place the other residents at risk to misuse the medication.Findings:

During a review of Resident 5's admission Record, the admission Record indicated the facility admitted Resident 5 on 8/22/2025 with diagnoses including diabetes mellitus (a chronic condition where the body has trouble regulating blood sugar (glucose) levels) and hypertension (high blood pressure).During a review of Resident 5's Minimum Data Set (MDS - a resident assessment tool), dated 8/28/2025, the MDS indicated Resident 5's thought process was intact and required supervision from staff to complete activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily). During a concurrent observation and interview on 9/3/2025 at 12:40 p.m. with Resident 5 inside Resident 5's room, observed a bottle of nasal spray on the top of Resident 5's bedside table. Resident 5 stated she last used it

this morning and Resident 5's daughters were the ones who brought the medication to her for her nose.During a concurrent observation and interview on 9/3/2025 at 12:45 p.m. with Certified Nursing Assistant (CNA) 10, CNA 10 stated that a bottle of nasal spray was on top of Resident 5's bedside table.During a concurrent observation and interview on 9/3/2025 at 12:59 p.m. with License Vocational Nurse (LVN) 4, observed a bottle of nasal spray on top of Resident 5's bedside table. LVN 4 stated that she was not aware that Resident 5 had a bottle of nasal spray at the bedside table. LVN 4 stated that Resident 5 should not keep a medication at bedside table because other residents could take it and it is possible for other residents to have an adverse reaction that could lead to death from the medication.During an

interview on 9/5/2025 at 1:30 p.m. with the Director of Nursing (DON). The DON stated that it was important

the Resident 5 must be assessed first before allowing Resident 5 to self-administer her own medication.

The DON stated there is a potential it could cause an accident because other residents could access the medication from Resident 5's bedside table. The DON stated the medication must be stored in a secure location.During a review of the facility's policy and procedure titled, Self- Administration of Medications, last

review date of 4/29/2025, the policy and procedure indicated, Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Self- administered medications are stored in a safe and secure place, which is not accessible by other residents.

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

09/05/2025

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

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

received an endorsement from GACH that the first dose was already given from GACH 1. During a concurrent interview and record review on 9/5/2025 at 1 p.m. with RN 1, RN 2 and the Director of Nursing (DON), Resident 1's GACH Discharge summary dated [DATE REDACTED] was reviewed. RN 1 stated that GACH 1 did not give any report and Resident 1 just showed up in the facility with Resident 1's admission packet. RN 1 stated she (RN 1) just depended on the discharge packet given by GACH 1. RN 1 stated that antibiotic order must be carried out within four hours after receiving the order since the antibiotic was available in an emergency kit. RN 2 stated that the antibiotic of Resident 1 must be given and carried out within four to six hours. RN 1 stated Resident 1 stayed in the facility for eight hours before discharging back to GACH 1. RN 2 stated that the facility failed to follow the physician's order due to miscommunication, failure to clarify the order from GACH 1 if first dose of antibiotic was already given. During an interview on 9/5/2025 at 1:30 p.m. with the DON, the DON stated that this was a documentation error because Resident 1's medication was supposed to be scheduled the same day (8/28/2025) of the readmission of Resident 1. The DON stated RN 2 needed to call GACH 1 to clarify if the first dose of the ordered antibiotic was given in GACH 1. During a

review of the facility's policy and procedure titled, Physician's Medication and Treatment Orders, last review date of 4/29/2025, the policy and procedure indicated, Orders not specifying the number of doses, or duration of medication, shall be subject to automatic stop orders. One day prior to the date the stop order is to become effective, the nurse supervisor/charge nurse on duty must contact the prescriber or attending physician to determine if the medication is to be continued. During a review of the facility's policy and procedure titled, Reconciliation of Medications on Admission, last review date 4/29/2025, the policy and procedure indicated, The purpose of this procedure is to ensure medication safety by accurately accounting for the resident's medications, routes and dosages upon admission or readmission to the facility. Gather the information needed to reconcile the medication list most recent medication administration record (MAR), if

this is a readmission. Medication reconciliation reduces medication errors and enhances resident safety by ensuring that the medications the resident needs have been taking continue to be administered without interruption, in the correct dosages and routes, during the admission/transfer process. If a medication history has not been obtained from the resident or family, complete this first. Information from the medication history should include dose, route, frequency and last dose taken for all items.

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

09/05/2025

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 0919

Make sure that a working call system is available in each resident's bathroom and bathing area.

Level of Harm - Minimal harm or potential for actual harm

Based on observation, interview and record review, the facility failed to ensure that one of nine sample resident's (Resident 2) call light was working properly.This deficient practice had the potential to place Resident 2 at risk for an accident like a fall due to not being able to call for help/assistance.Findings: During

a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2

on 8/26/2025 with a diagnosis of hypertension (high blood pressure) and history of falling.During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 9/1/2025, the MDS indicated Resident 2 had intact thought process and required moderate assistance from staff to complete activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily). During a concurrent observation and interview on 9/3/2025 at 11:40 a.m. with Resident 2 inside Resident 2's room, Resident 2 stated that her call light was not working since she got admitted and was using her roommate's call light for Resident 2 to call for help. Resident 2 demonstrated to use her call light and observed that after pressing the call light button the call light was not turning on outside Resident 2's room.During a concurrent

observation and interview on 9/3/2025 at 11:47 a.m. with License Vocational Nurse (LVN) 1, observed LVN 1 tried to use Resident 2's call light and observed that the light was not turning on. LVN 1 stated that Resident 2's call light did not turn on outside Resident 2's room. LVN 1 stated that it was important that the call light was working all the time to be able to attend to Resident 2's needs right away and if not, there was

a risk of Resident 2's decline that could lead to injury. During an interview on 9/5/2025 at 1:30 p.m. with the Director of Nursing (DON), the DON stated that it was important that the call light was working all the time and this could potentially have a lapse in communication between staff and residents. The DON stated that

the staff might not be able to meet the residents' needs immediately.During a review of the facility policy and procedure titled, Call System, Resident, last review date of 4/29/2025, the policy and procedure indicated, The resident call system remains functional at all times. If audible communication is used, the volume is maintained at an audible level that can be easily heard. If visual communication is used, the lights remain functional. The resident call system is routinely maintained and tested by maintenance department.

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

09/05/2025

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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and

the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview, and record review, the facility failed to obtain a written authorization or approval from

the Department of Healthcare Access and Information (HCAI, previously known as the Office of Statewide Health Planning and Development of OSHPD) prior to the use of portable air-conditioning (AC- a machine that forces cool air into a building) unit. HCAI is the state agency that reviews and approves plans for construction, repairs, renovations, and remodeling made in healthcare facilities to comply with State Building Codes. In addition, the facility failed to notify the Department (Licensing/Certification), within five days of the commencement of any construction/alterations to the skilled nursing facility.This deficient practice placed residents at risk for any safety issues related to the unauthorized use of the portable AC unit. Findings: During an observation on 9/4/2025, at 10:18 a.m., observed room [ROOM NUMBER] with a portable air conditioner (AC) unit actively operating. Observed the portable AC units' ducts (tubes or pipes that carry air in and out of the building) going through the window to the exterior of the building. During a concurrent observation and interview on 9/4/2025 at 10:20 a.m., with Maintenance Assistant (MA), in room [ROOM NUMBER], the MA stated there was a portable AC unit installed with vent attached to the wall secured to window paneling with duct tape.During an interview on 9/4/2025 at 10:28 a.m. with Maintenance Supervisor (MS), the MS stated that per Administrator there was no permit from HCAI, and the Heating, Ventilation, and Air Conditioning (HVAC - refers to the integrated system of equipment that controls the temperature and quality of air within a building) was installed temporarily due to the hot weather. The MS stated that there were 9 units of HVACs in the whole building. The MS stated that the facility did not have any problem with the AC but was just blowing low air and they will just need to check the duct. The MA stated that there was only one portable AC installed in the whole facility. The MA also stated that the AC of

the facility was working and has no problem. The MA stated the portable AC was installed due to resident request. During an interview on 9/4/2025 at 12:07 p.m., with the Administrator and Operation Assistant 1,

the Administrator stated that HVAC had no permit from HCAI and did not contact HCAI. The Administrator stated he did not know what HCAI was and who was HCAI. The Administrator stated that the facility started using the HVAC on 4/22/2025 after receiving the heat advisory. During an interview on 9/4/2025 at 2:57 p.m., the Administrator stated that around 12 p.m. he contacted HCAI and spoke to HCAI Staff 1 who informed him (Administrator) that if the HVAC was only in a temporary use the facility does not need a HVAC permit from HCAI. The Administrator stated there was no documented evidence that HCAI stated that the facility does not permit HVAC use due to temporary use only of the HVAC.During a review of a facility-provided policy and procedure titled, Use of Portable HVACS, last revised on 4/24/2025, indicated potable HVAC systems should only be considered during power outages as outlined in the emergency preparedness plan or extreme weather conditions.During a review of a facility-provided policy and procedure titled, Maintenance Service, last revised on 4/24/2025, indicated maintenance personnel shall follow established safety regulations to ensure the safety and well-being of all concerned.

Event ID:

Facility ID:

If continuation sheet