Mirage Post Acute
MIRAGE POST ACUTE in LANCASTER, CA — inspection on November 24, 2025.
Found 4 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
possible.1.
Staff provides person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences.2.
The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting.
These characteristics include:a. clean, sanitary and orderly environment;b. comfortable (minimum glare) yet adequate (suitable to the task) lighting;c. inviting colors and decor;d. personalized furniture and room arrangements;e. clean bed and bath linens that are in good condition;f. pleasant, neutral scents;g. plants and flowers, where appropriate;h. comfortable and safe temperatures; [NAME]. comfortable sound levels.
The DON stated homelike environment means room was clean and organized.
The DON stated the facility's P&P indicated to have a safe, clean, and comfortable environment.
The DON stated Resident 7's leaking room with containers was not a homelike environment.
The DON stated Resident 8's room being too cold was also not a homelike environment.
The DON stated the facility P&P was not followed.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/24/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Mirage Post Acute
44445 15th St W Lancaster, CA 93534
SUMMARY STATEMENT OF DEFICIENCIES
possible.During a concurrent interview, and record review on 11/21/2025, at 3:43 p.m., with the Minimum Data Set Nurse Assistant (MDSA), Resident 7's Care Plan dated 11/21/2025, regarding refusal of care was reviewed.
The Care Plan indicated the following interventions:-encourage active participation of care-Inform of risks and ramifications (a consequence of an action or event) of continued noncompliance.- Monitor the effectiveness of safety equipment.MDSA stated the care plan was generalized and did not indicate hourly rounding to check and observe for the progression of leaks if improving or not and to check if Resident 7 was safe and feels safe inside the room. MDSA stated the care plan should be individualized to address resident safety inside a room that had a leaking ceiling.
During an interview on 11/21/2025, at 4:12 p.m., with the Director of Nursing (DON), the DON stated Resident 7's Care Plan should be person centered or individualized to address her (Resident 7) safety inside the room that had a leaking ceiling.During a concurrent interview, and record review on 11/24/2025, at 11:09 a.m., with the DON, facility's policy and procedure (P&P), titled, Homelike Environment dated 2001, and last reviewed on 7/24/2025, the P&P indicated, Staff provides person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences.
The DON stated Resident 7's Care Plan should have an intervention that Resident 7 was being checked hourly to check for her (Resident 7) safety.
The DON stated without the person-centered care plan, there might be a delay in room change and placing Resident 7's safety at risk.
The DON stated the P&P for person-centered care was not followed.During a record review of facility's P&P, titled, Comprehensive Person-Centered Care Plans, dated 2001, and last reviewed on 3/2025, 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.6.
The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: (1) services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; .9.
When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/24/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Mirage Post Acute
44445 15th St W Lancaster, CA 93534
SUMMARY STATEMENT OF DEFICIENCIES
not provide proper care or meet the residents' (Residents 2, 3, and 4) needs by not changing their room when the ceiling was leaking with rainwater.
This failure meant residents were not comfortable or safe in their rooms.During a review of the facility policy and procedure titled, Homelike Environment, last review date of 11/6/2025, the policy and procedure indicated, Residents are provided with a safe, clean, comfortable and homelike environment The facility staff and management maximize to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting.
These characteristics include: a.
Clean, sanitary and orderly environment
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/24/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Mirage Post Acute
44445 15th St W Lancaster, CA 93534
SUMMARY STATEMENT OF DEFICIENCIES
Federal health inspectors cited MIRAGE POST ACUTE in LANCASTER, CA for a deficiency under regulatory tag F-F0880 during a complaint investigation conducted on 2025-11-24.
Category: Infection Control Deficiencies
The facility was found deficient in the following area: Provide and implement an infection prevention and control program.
Scope/Severity Level G: isolated, actual harm that is not immediate jeopardy.
Actual harm to residents was documented as a result of this deficiency.
This was one of 4 deficiencies cited during this inspection of MIRAGE POST ACUTE.
Correction Status: Deficient, Provider has no plan of correction.