Mirage Post Acute

do so.

• Written information about the right to accept or refuse medical or surgical treatment, and the right

to formulate an advanced directive is provided in a manner that is easily understood by the resident or representative.

If the Resident Has an Advance Directive

• If the resident or the resident's representative has executed one or more advance directive(s), or

executes one upon admission, copies of these documents are obtained and maintained in the same section of the resident's medical record and are readily retrievable by any facility staff.

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Mirage Post Acute 44445 15th St W Lancaster, CA 93534

During a review of Resident 2's admission Records (the front page of the chart thatˆcontainsˆa summary of basic information about the resident), the admission Records indicated that the facility admitted Resident 2 on 2/21/2025, and readmitted on [DATE], with diagnoses including metabolic encephalopathy (a temporary, reversible brain dysfunction caused by chemical imbalances in the body), type two Diabetes Mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), and dysphagia (difficulty swallowing).

During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool) dated 3/2/2026, the MDS indicated that the resident`s cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts and make decisions) for daily decision making was severely impaired (never/rarely made decisions).The MDS indicated that Resident 2 was dependent (helper does all of the effort) to staff with toileting hygiene, shoer self, lower body dressing, putting on/taking off footwear, chair/bed-to-chair transfer, tub/shower transfer.

During a concurrent observation and interview on 4/22/2026 at 8:51 a.m. with Registered Nurse (RN) 1, RN 1 stated Resident 2's closet drawer was broken and hanging down. RN 1 stated the drawer had a broken handle and was nonfunctional. RN 1 stated that broken drawers should be addressed promptly to ensure residents maintain a homelike environment, dignity and ability to safely store and access personal belongings.ˆ

During an interview on 4/24/2026 at 3:25 p.m. with Director of Nursing (DON), the DON stated that when broken furniture is identified, it needs to be addressed to maintenance department immediately.

The DON stated that having nonfunctioning furniture can negatively affect resident's mood and psychosocial wellbeing, potentially leading to feeling frustration, decreased independence, and reduced quality of life.

During a review of facility's Policies and Procedures (P&P), titled Homelike Environment, dated 7/24/2025, the P&P indicated, Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.

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Mirage Post Acute 44445 15th St W Lancaster, CA 93534

During a concurrent interview and record review on 4/23/2026, at 9:40 a.m., with the DSD, Resident 80's OSR, FROA, Informed Consent, restraint assessment, and CP were reviewed.

The DSD stated there was no physician's order, informed consent, restraint assessment, and a care plan on the use of pillows tucked under the sheets.

The DSD stated they need all four components prior to applying the restraints to ensure their safe use.

The DSD stated the staff failed to obtain the four components and had the potential for the resident to develop pressure injury (localized damage to the skin and underlying tissue, usually over a bony area like the hip or heel) on the side where the resident was turned for a long period of time.

During an interview on 4/24/2026, at 2:51 p.m., with the DON, the DON stated placing a pillow tucked under the sheets for Resident 80 was a form of a restraint because it limits the residents option to turn on the bed to only one side hence limiting the resident's movement.

The DON stated before applying the restraint pillows tucked under the sheets the licensed staff should have obtained a physician's order, informed consent from the resident/representative, performed a restraint assessment, and developed and implemented a care plan on its use.

The DON stated staff failed to obtain all four components before applying the restraint and had predisposed the resident to development of pressure injury and decrease in function.

During a review of the facility's recent P&P titled, Use of Restraints, last reviewed on 1/27/2026, the P&P indicated restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tired successfully.

When the use of restraints is indicated, the least restrictive alternative will be used for the least amount of time necessary, and the ongoing re-evaluation for the need for restraints will be documented.

Policy Interpretation and Implementation

• Physical Restraints are defined as physical item attached resident's body that the individual cannot

remove easily, which restricts freedom of movement or restricts normal access to one's body.

• Restrained individuals shall be reviewed regularly (at least quarterly) to determine whether they are

candidates for restraint reduction, less restrictive methods of restraints, or total restraint elimination.

• Care plans for residents in restraints will reflect interventions that address not only the immediate

medical symptoms(s), but the underlying problems that may be causing the symptom(s).

• Care plans shall also include the measures taken to systematically reduce or eliminate the need for

restraint use.

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Mirage Post Acute 44445 15th St W Lancaster, CA 93534

medication administration records, and the drug regimen review from the consultant pharmacist.

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Mirage Post Acute 44445 15th St W Lancaster, CA 93534

During an interview on 4/23/2026 at 11:50 a.m. with Director of Nursing (DON), the DON stated on 4/11/2026, at around 11:00 a.m., RN 3 reported that Resident 23 sustained an unwitnessed fall in Resident 23's room, on 4/11/2026, around 8:05 a.m.

The DON stated she (DON) did not report Resident 23's alleged unwitnessed fall in the facility, who sustained lacerations with stitches on her (Resident 23) forehead and bridge of nose.

The DON stated Resident 23 was found on the floor within minutes of the incident.

The DON further stated that no staff directly observed how the injuries occurred.

During a concurrent interview and record review on 4/24/2026 at 10:40 a.m. with the DON, the facility's policies and procedures (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, last reviewed 1/27/2026, was reviewed.

The DON stated unobserved/unexplained lacerations with or without bleeding were required to be reported.

The DON stated the P&P indicated, If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law.

The DON stated the facility failed to report the incident to the SA.

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Mirage Post Acute 44445 15th St W Lancaster, CA 93534

During a review of Resident 5's Progress Notes (PN), datedˆ4/20/2026 and 4/21/2026, the PN indicatedˆthat Resident 5ˆwas beingˆmonitoredˆfor self-administration of hot/cold gel pack.ˆˆ During a concurrent interview and record review on 4/21/2026 at 2:16 p.m. with Licensed Vocational Nurse (LVN) 3, LVN 3ˆreviewedˆResident 5's Order Summary Report.ˆLVN 3 stated that there was noˆphysician orderˆindicatingˆthat Resident 5 may self-administerˆhot/cold gel packs.ˆLVN 3 reviewed Resident 5's care plans. LVN 3ˆstated thatˆthere was no documentation of comprehensive, person-centered care plan addressing Resident 5's Hot/cold gel pack self-administration. LVN 3 statedˆthat medicationˆself-administration wasˆrequiredˆa physician's orderˆand an individualized care plan. LVN 3ˆstatedˆnot having a physician's order and not developing a care plan for resident medication self-administration had the potential to result in unsafe use, medication errors, lack of monitoring and potential harm, such as burns, to Resident 5.ˆˆ During an interview on 4/24/2026 atˆ3:25ˆp.m.ˆwithˆthe Director of Nursing (DON), the DONˆstatedˆthat hot/cold gel packs areˆconsideredˆmedications.ˆThe DONˆstatedˆthat whenˆdeterminedˆthat a resident can safely self-administer, a physician's order must be obtained andˆinˆindividualized care plan must be developed.

The DONˆstatedˆthat failure to do so may result in medication errors, improper use, or potentialˆinjuryˆsuch as burns.ˆˆ During a review of facility's Policies and Procedures (P&P) titled Self-Administration of Medications, dated 7/24/2025, the P&P indicated, If it is deemed safe and appropriate for a resident to self-administer medications, this is documented inˆthe medical record and the care plan.ˆˆ During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, last reviewed and approved on 1/27/2026, the P&P indicated that 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.

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Mirage Post Acute 44445 15th St W Lancaster, CA 93534

During a review of Resident 212's History and Physical (H&P), dated 12/12/2025, the H&P indicated Resident 212 has the capacity to understand and make decisions.

During a review of Resident 212's Minimum Data Set (MDS - a resident assessment tool), dated 3/19/2026, the MDS indicated Resident 212 had the ability to make self- understood and to understand others.

The MDS further indicated that Resident 212 had intact cognitive function (normal thinking).

The MDS indicated the resident required partial/ moderate assistance with bed mobility, transfer, dressing, toilet use, and personal hygiene.

During a record review of Resident 212's Order Summary Report (OSR), dated 4/19/2026, the OSR indicated an order for oxygen at two (2) liters (a unit of measurement for volume) per minute via nasal canula (N/C - a small plastic tube with two tips that go in the nose to deliver oxygen from an oxygen source) continuously, every shift.ˆ During a review of Resident 212's Care Plan (CP) Report titled, [Resident 212] requires the use of continuous oxygen at four (4) liters via nasal cannula related to Chronic Obstructive Pulmonary Disease (COPD), revised on 12/12/2025, the CP indicated the goal included Resident 212 will have effective airway exchange as evidenced by no chest congestion or increased shortness of breath with an intervention administer oxygen at 4L via nasal cannula.

During a concurrent interview and record review on 4/24/2026 at 10:00 a.m. with Registered Nurse (RN) 5, Resident 212's OSR, dated 4/19/2026, and the CP, dated 12/12/2026, were reviewed. RN 5 stated the care plan needed to match the OSR and for Resident 212 the care plan does not match the OSR. RN 5 stated the care plan needed to be revised to administer 2 liters per minute of oxygen. RN 5 stated care plan is the guide to providing care to the residents.

During an interview on 4/24/2026 at 3:15 p.m. with Director of Nursing (DON), the DON stated the purpose of a care plan is to determine what care should be provided to the residents.

The DON stated a care plan needed to follow OSR and if incomplete then cannot be able to meet resident needs.

During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised on 3/2025 indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychological and functional needs is developed and implemented for each resident.

Policy Interpretation and Implementation 10.

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

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Mirage Post Acute 44445 15th St W Lancaster, CA 93534

During a review of the facility's recent P&P titled, Insulin Administration, last reviewed on 1/27/2026, the P&P indicated to provide guidelines for the safe administration of insulin.

General Guidelines 5.

Insulin injections sites are routinely rotated.

Steps in the Procedure (Insulin Injections via Syringe) 13.

Select an injection site. a.

Insulin may be injected into the subcutaneous tissue of the upper arm and anterior or lateral areas of the thighs and abdomen.

Avoid the area approximately 2 inches around the navel. b.

Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm).

During a review of the facility-provided Highlights of Prescribing Information (HPI) on the use of Basaglar (insulin glargine) injection, for subcutaneous use, with initial U.S. approval in 2015, the HPI indicated to rotate injection sites into the abdominal area, thigh, or deltoid to reduce the risk of lipodystrophy and localized cutaneous amyloidosis.

During a review of the facility-provided HPI, on the use of Insulin Aspart injection, for subcutaneous or intravenous use, with initial U.S. approval in 2000, the HPI indicated under dosage and administration, Subcutaneous injection: -Inject subcutaneously within 5-10 minutes before a meal into the abdominal area, thigh, buttocks or upper arm. -Rotate injection sites within the same region from one injection to the next to reduce the risk of lipodystrophy and localized cutaneous amyloidosis.

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Mirage Post Acute 44445 15th St W Lancaster, CA 93534

During an interview on 4/24/2026 at 2:50 p.m. with the Director of Nursing (DON), the DON stated that licensed nurses and the SSD are the ones responsible for receiving and documenting when residents have arrived back at the facility from their appointments.

The DON stated that the SSD is also responsible for making a follow-up on the residents' appointments, to be able to carry out new orders.

The DON stated that Resident 53's eyesight could deteriorate and failure to follow-up on change of condition or new orders could affect resident's quality of life.

During a review of the facility's Policy and Procedure (P&P), titled Ancillary Services (Dental, Podiatry, Hearing, Vision), revised on 12/2013, the P&P indicated, Upon conducting an ancillary examination, a resident needing ancillary services will be promptly referred to a personal doctor or facility's consulting provider.

During a review of the facility's P&P, titled Change in a Resident's Condition or Status, revised on 6/26/2025, the P&P indicated, Our facility promptly notifies the resident, his or her attending physicians, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in the level of care, billing/payments, resident rights, etc.). 1.

The nurse will notify resident's attending physician or physician on call when there has been a(an): a.

Changes in the resident's condition declined and improved. 2.

Regardless of the resident's current mental or physical condition, a nurse or healthcare provider will inform the resident of any changes in his/her medical care or nursing treatments. 3.

The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.

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Mirage Post Acute 44445 15th St W Lancaster, CA 93534

During a review of the facility's policy and procedure (P&P) titled, Restorative Nursing Services, dated 1/27/2026, the P&P indicated that Residents will receive restorative nursing care as needed to help promote optimal safety and independence. 3.

Restorative goals and objectives are individualized and resident-centered, and are outlined in the resident's plan of care. 5.

Restorative goals may include, but are not limited to supporting and assisting the resident in: a. adjusting or adapting to changing abilities; b. developing, maintaining or strengthening his/her physiological and psychological resources; c. maintaining his/her dignity, independence and self-esteem; and d. participating in the development and implementation of his/her plan of care.

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Mirage Post Acute 44445 15th St W Lancaster, CA 93534

establish resident-centered falls prevention plan based on relevant assessment information .

and room layout.

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(CAUTIs).

Documentation 1.

Document (per facility protocol or as ordered) the following information:

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Mirage Post Acute 44445 15th St W Lancaster, CA 93534

During a concurrent interview and record review on 4/23/2026, at 2:02 p.m., with the RD, Resident 3's

The RD stated she did not update the previous care plan to reflect the resident's current weight loss

the resident was out, she should have updated the care plan even though the resident was not in the facility.

The RD stated they do monthly weight loss assessment on the first of the month including calculations of weight loss and gains, after 72 hours they should have created the Dietary Notes and updated the care plan to prevent potential further weight loss of the resident.

During an interview and record review on 4/24/2026, at 2:51 p.m., with the Director of Nursing (DON), reviewed the facility-provided policy and procedure (P&P) titled, Weight Assessment, Intervention and Management.

The DON stated the RD should have performed her monthly assessment on the 1st of April and updated the care plan immediately to ensure the resident will not sustain potential further weight loss.

During a review of the facility's recent P&P titled, Weight Assessment, Intervention and Management, last reviewed on 1/27/2026, the P&P indicated resident weights are monitored for weight loss or gain.

Weight Assessment 1.

Residents are weighed upon admission and at intervals established by the interdisciplinary team. 3.

Unless notified of significant weight change, the dietician will review the unit weight record monthly to follow individual weight trends over time.

Care Planning

• Individualized care plans shall address, to the extent possible: a. the identified causes of weight

loss; b. goals and benchmarks for improvement; and c. time frames and parameters for monitoring and reassessment.

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Mirage Post Acute 44445 15th St W Lancaster, CA 93534

oxygen is being administered.

7/24/25, the P&P indicated, orders for medications and treatment will be consistent with principles of

Policy Interpretation and implementation

• Medications shall be administered only upon the written order of a person duly licensed and

authorized to prescribe such medications in this state.

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Mirage Post Acute 44445 15th St W Lancaster, CA 93534

c. the alternatives that were attempted but failed to meet the resident's needs; and

d.

The alternatives that were considered but not attempted and the reasons.

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Mirage Post Acute 44445 15th St W Lancaster, CA 93534

may solve the problem.ˆ

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Mirage Post Acute 44445 15th St W Lancaster, CA 93534

During a review of the facility's recent P&P titled, Dental, last

making necessary dental appointments. 4.

All requests for routine and emergency dental services

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Mirage Post Acute 44445 15th St W Lancaster, CA 93534

During a review of the facility's policy and procedure (P&P) titled, Menus, last reviewed on 1/27/2026, the P&P indicated menus are developed and prepared to meet resident choices including religious, cultural and ethnic needs while following established national guidelines for nutritional adequacy.

The P&P further indicated menus meet the nutritional needs of residents in accordance with the recommended dietary allowances.

During a review of the facility's P&P titled, Therapeutic Diets, last reviewed on 1/267/2026, the P&P indicated that therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his ir her goals and preferences.

The P&P further indicated: - Diet will be determined in accordance with the residents' informed choices, preferences, treatment goals and wishes. - A therapeutic diet is considered a diet ordered by a physician, practitioner or dietitian as part of treatment for a disease in clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet.

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Mirage Post Acute 44445 15th St W Lancaster, CA 93534

sealed containers that are swelled or leaking to be adulterated and actionable under the Federal Food,

and Utensils, air-drying required.

After cleaning and sanitizing equipment and utensils: (A) Shall be

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Mirage Post Acute 44445 15th St W Lancaster, CA 93534

anything on top of the medication carts.

The DON stated that either RN 1, LVN 2, or LVN 12 should

medication administration.

The DON stated it had the potential to spread infection among other

Program (IPCP), last reviewed on 1/27/2026, the P&P indicated the IPCP is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

The P&P further indicated that some of the important facets of infection prevention include identifying possible infections or potential complications or dissemination, instituting measures to avoid complications or dissemination, educating staff and ensuring they adhere to proper techniques and procedures, and communicating the importance of standard precautions and respiratory hygiene.

f.

Progress toward or changes in the care plan goals and objectives.

Documentation of procedures and treatments will include care-specific details, including: a.

The date and time the treatment/procedure was provided b.

The name and title of the individual(s) who provided the care c.

The assessment date and/or any unusual findings obtained during the procedure/treatment d.

How the resident tolerated the procedure/treatment e.

Whether the resident refused the procedure/treatment f.

Notification of family, physician, or other staff, if indicated g.

The signature and title of the individual documenting

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Mirage Post Acute 44445 15th St W Lancaster, CA 93534

During a concurrent interview and observation of Resident 41on 4/20/2026 at 11:44 a.m., Resident 41 stated the resident had been calling to be changed, but no one would go to the room. Resident 41 pushed the call light and the light on outside of the door was not lighting up or ringing at nurse's station.ˆ During an observation on 4/20/2026 at 11:50 a.m. with CNA 7 and Assistant Director of Nursing (ADON) 2, observed Resident 41 press the call light and the light outside Resident 41's room would not turn on.

During an interview on 4/20/2026 at 12:20 p.m. with CNA 7, CNA 7 stated that CNA 7 observed the call light was not working in the morning. CNA 7 stated if the call light is not working then the resident would not be able to call. CNA 7 stated the resident can fall, choke, or have a life-or-death situation, and the resident would not be able call for assistance.

During an interview on 4/22/2026 at 8:18 a.m. with ADON 2, ADON 2 stated Resident 41's call light was not working 4/20/2026. ADON 2 stated if Resident 41 needed something, Resident 41 would not be able to call for help.

During a review of the facility's P&P titled, Call System, Residents, last reviewed on 1/27/2026, the P&P indicated residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized work station.

Policy Interpretation and Implementation

• Each resident is provided with a means to call staff directly for assistance from his/her bed, from

toileting/bathing facilities and from the floor.

• Call system communication may be audible or visual.

The system may be wired or wireless.

• 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.

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Mirage Post Acute 44445 15th St W Lancaster, CA 93534