Mirage Post Acute

that severely impairs health and limits mobility) and right knee pain.During a review of Resident 2's

Plan indicated an intervention to keep bed in low position with brakes locked.During a review of

of acquiring knowledge and understanding) skills for daily decisions were intact.

The MDS indicated Resident 2 required moderate assistance from staff for toileting and lower body dressing.During a review of Resident 2's Fall Risk Observation/Assessment, dated 12/16/2025, the Fall Risk Observation/Assessment indicated Resident 2 was a high risk for fall.During an observation on 1/29/2026, at 9:18 a.m., outside of Resident 2's room, Resident 2 was asleep with the bed on a high position.During a concurrent interview, and record review on 1/29/2026, at 9:42 a.m., with the Assistant Director of Nursing (ADON), Resident 2's Care Plans were reviewed.

The ADON stated there were no care plans on Resident 2's bed in a high position.

The ADON stated Resident 2 can possibly fall and cause injury if bed were high.

The ADON stated if Resident 2 would have preferred to have a bed with a high position the facility should have developed a care plan.

During an interview on 1/29/2026, at 10:54 a.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated it was the first time she observed Resident 2's bed on high position. CNA 1 stated Resident 2 could fall off the bed if left too high.

During an interview on 1/29/2026, at 11:11 a.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated he (LVN 1) just found out today 1/29/2026, that Resident 2 prefers her (Resident 2) bed high. LVN 1 stated care plan for Resident 2's preference to have a high bed should have been developed to prevent fall.During a concurrent interview, and record review on 1/29/2026, at 11:22 a.m., with the Director of Nursing (DON), Resident 2's Fall Risk Observation/Assessment, dated 12/16/2025, was reviewed.

The DON stated Fall Risk Observation/Assessment, dated 12/16/2025, indicated Resident 2 was a high risk for fall.

The DON stated Resident 2 did not have a care plan developed for high position bed.

The DON stated Resident 2 put her bed up high and the facility should have care planned it as resident preference.

The DON stated Resident 2 was at a high risk for fall and could potentially fall and cause injury if bed was in a high position.During a review of facility's policy and procedure (P&P), titled, Comprehensive Person-Centered Care Plans', dated 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.10.

Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change.11.

The resident has the right to refuse to participate in the development of his/her care plan and medical and nursing treatments.

Such refusals are documented in the resident's clinical record in accordance with established policies.During a review of facility's policy and procedure (P&P) titled, Falls/Accident/Fall Management Prevention, dated 7/24/2025 was reviewed.

The P&P 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.

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prevent accidents.

residents (Resident 2), who was assessed as high risk (a person is significantly more likely to fall

fall, was asleep on a bed in high position.This deficient practice had the potential to place Resident 2's at risk of fall and injury.Findings:During a review of Resident 2?s admission Record, the admission Record indicated the facility admitted Resident 2 on 6/8/2024, with diagnoses that included left shoulder primary osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), morbid obesity (a serious, chronic disease involving an excessive accumulation of body fat that severely impairs health and limits mobility) and right knee pain.During a review of Resident 2's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 6/10/2025, the H&P indicated Resident 2 had fluctuating capacity to understand and make decisions.During a review of Resident 2's Care Plan, dated 6/10/2024, about risk for fall, the Care Plan indicated an intervention to keep bed in low position with brakes locked.During a review of Resident 2's Minimum Data Set (MDS-a resident assessment tool), dated 12/16/2025, the MDS indicated Resident 2's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact.

The MDS indicated Resident 2 required moderate assistance from staff for toileting and lower body dressing.During a review of Resident 2's Fall Risk Observation/Assessment, dated 12/16/2025, the Fall Risk Observation/Assessment indicated Resident 2 was at a high risk for fall.During an observation on 1/29/2026, at 9:18 a.m., outside of Resident 2's room, Resident 2 was asleep with the bed on a high position.During a concurrent interview, and record review on 1/29/2026, at 9:42 a.m., with the Assistant Director of Nursing (ADON), Resident 2's Care Plans were reviewed.

The ADON stated there were no care plans on Resident 2's bed in a high position.

The ADON stated Resident 2 can possibly fall and cause injury if bed were high.

The ADON stated if Resident 2 would have preferred to have a bed with a high position the facility should have developed a care plan.During an interview on 1/29/2026, at 10:54 a.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated it was the first time she (CNA 1) observed Resident 2's bed was too high. CNA 1 stated Resident 2 can fall off the bed if left too high.During a concurrent interview, and record review on 1/29/2026, at 11:22 a.m., with the Director of Nursing (DON), Resident 2's Fall Risk Observation/Assessment, dated 12/16/2025, was reviewed.

The DON stated Fall Risk Observation/Assessment, dated 12/16/2025, indicated Resident 2 was a high risk for fall.

The DON stated Resident 2 did not have a care plan developed for high position bed.

The DON stated Resident 2 put her bed up high and the facility should have care planned it as resident preference.

The DON stated Resident 2 was at a high risk for fall and could potentially fall and cause injury if bed was in a high position.During a review of facility's policy and procedure (P&P) titled, Falls/Accident/Fall Management Prevention, dated 7/24/2025 was reviewed.

The P&P 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.

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amount of oxygen a resident receives to keep their blood oxygen levels within a specific, healthy

observed Resident 1's oxygen was set at five liters per minute. LVN 1 stated Resident 1 had history

the Director of Nursing (DON), the DON stated nurses should follow the physician order for continuous oxygen administration of only two liters per minute.

The DON stated higher oxygen administration could result in Resident 1's hyperventilation (rapid and deep breathing).During a concurrent interview, and record review on 1/30/2026, at 12:29 p.m., with the DON, facility's policy and procedure (P&P), titled, Administering Medications, dated 7/24/2025, was reviewed.

The P&P indicated, 4.

Medications are administered in accordance with prescriber orders, including any required time frame.

The DON stated with the use of oxygen the facility follows the P&P for medication administration since oxygen is considered a medication and should be administered according to the physician order.During a review of facility's policy and procedure (P&P) titled, Oxygen Administration, dated 7/24/2025, was reviewed.

The P&P indicated, The purpose of this procedure is to provide guidelines for safe oxygen administration. 5.

Adjust the oxygen delivery device so that it is comfortable for the residents and the proper flow of oxygen is being administered.

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Medications, dated 7/24/2025, was reviewed.

The P&P indicated, Medications are administered in

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in accordance with accepted professional standards.

interview and record review, the facility failed to maintain accurate and complete medical record for

Member 1 (FM 1) with Social Service Assistant 1 (SSA 1) about Resident 1's medication.This failure had the potential to cause confusion in care and the medical records containing inaccurate documentation.Findings: During a review of Resident 1?s admission Record, the admission Record indicated the facility admitted Resident 1 on 12/19/2025, with diagnoses that included orthopedic aftercare (medical care and precautions a person needs to take after a bone or joints procedure to ensure proper healing), unspecified (unconfirmed) psychosis ((a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) and history of fall.During a review of Resident 1's History and Physical (H&P-a medical examination that involves a doctor taking a resident's medical history, performing a physical exam, and documenting their findings), dated 12/19/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 12/25/2025, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact.

The MDS indicated Resident 1 required supervision from staff for hygiene, toileting, and showering.

The MDS indicated Resident 1 was on antipsychotic (medication used to treat psychosis) medication.

During an interview on 1/29/2026, at 9:01 a.m., with FM 1, FM 1 stated on the second day of admission [DATE]) he (FM 1) had found pills in a clear plastic bag, and he (FM 1) took a picture and texted (an electronic written message) to SSA 1. FM 1 stated nothing was done about it.

During an interview on 1/29/2026, at 10:59 a.m., with SSA 1, SSA 1 stated on 12/29/2025, FM 1 spoke to her (SSA 1) to discuss Resident 1's medications. SSA 1 stated Resident 1 approved FM 1's visit but refused to share medical status with FM 1. SSA 1 stated FM 1 showed a picture of a clear plastic bag with pills that was found in the General Acute Care Hospital (GACH). SSA 1 stated FM 1 reported that Resident 1 was caught with pills in the GACH. SSA 1 stated she (SSA 1) did not document conversation with FM 1 on 12/29/2025.

During an interview on 1/30/2026, at 10 a.m., with SSA 1, SSA 1 stated she (SSA 1) did not document in Resident 1's medical record that FM 1 showed a picture of a clear plastic bag with pills.During a concurrent interview, and record review on 1/30/2026, at 12:29 p.m. with the Director of Nursing (DON), facility's policy and procedure (P&P), titled, Charting and Documentation, dated 7/24/2025, was reviewed.

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.

The following information is to be documented in the resident medical record: a.

Objective observations; . e.

Events, incidents or accidents involving the resident; . 3.

Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.

The DON stated SSA 1 should have document concerns and conversation with FM 1.

The DON stated if it was not documented, Resident 1's medical record was incomplete.

The DON stated it is the facility policy to have a complete and accurate medical record.

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touching the floor.

This failure had the potential for Resident 1 to get infection.Findings:During a

Resident 1 on 12/19/2025, with diagnoses that included orthopedic aftercare (medical care and precautions a person needs to take after a bone or joints procedure to ensure proper healing), unspecified (unconfirmed) COPD, and acute (sudden in onset) and chronic (a health condition or disease that persists for an extended period, typically lasting three months to one year or longer) respiratory failure (a serious condition that happens when the lungs cannot get enough oxygen into the blood) with hypoxia (a medical emergency where tissues and organs do not receive enough oxygen to function properly, potentially causing rapid damage to the brain and heart).During a review of Resident 1's History and Physical (H&P-a medical examination that involves a doctor taking a resident's medical history, performing a physical exam, and documenting their findings), dated 12/19/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 12/25/2025, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact.

The MDS indicated Resident 1 required supervision from staff for hygiene, toileting, and showering.During an observation on 1/29/2026, at 9:19 a.m., at Resident 1's bedside, observed Resident 1 asleep, with oxygen concentrator (a medical device that filters surrounding room air, compresses it, and removes nitrogen to deliver concentrated, high-purity oxygen typically 90-95 percent (%) to individuals with breathing disorders) at five liters per minute via nasal cannula.

Observed the nasal cannula not connected to Resident 1 and was hanging on the portable emergency light on top of Resident 1's rolling table.

Observed oxygen tubing touching the floor.

During an interview on 1/29/2026, at 9:42 a.m., with the Assistant Director of Nursing (ADON), the ADON stated oxygen tubing should not be touching the floor for infection control.

During an interview on 1/29/2026, at 11:22 a.m., with the Director of Nursing (DON), the DON stated Resident 1 could get infection if oxygen tubing was touching the floor.During an interview on 1/30/2026, at 12:29 p.m., with the DON, the DON stated the facility does not have a specific policy that oxygen tubing should not touch the floor.

The DON stated the facility practices that oxygen tubing should be kept off the floor for infection control.