Mirage Post Acute
MIRAGE POST ACUTE in LANCASTER, CA — inspection on April 28, 2026.
Found 2 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
During a review of the facility's Policy and Procedure (P&P) titled, Care Plan, Comprehensive Person-Centered, last reviewed on 1/27/2026, the P&P indicated 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.
056039 04/28/2026
Mirage Post Acute 44445 15th St W Lancaster, CA 93534
During a concurrent interview and record review on 4/28/2026 at 2:24 p.m., Resident 3's SBAR Communication form, dated 4/2/2026, was reviewed with Licensed Vocational Nurse (LVN) 3. LVN 3 stated that on 4/2/2026 CNA 1 notified her (LVN 3) that Resident 3 was found on the floor. LVN 3 reviewed SBAR Communication form, dated 4/2/2026, and stated she (LVN 3) was the one who did the SBAR. LVN 3 stated the physician's recommendations were to have an X-ray.
LVN 3 stated she cannot recall if the X-ray was ordered. LVN 3 reviewed Resident 3's physician orders and stated there was no order for the X-ray for Resident 3. LVN 3 stated she should have placed the order. LVN 3 stated if X-ray is not ordered, there can be a potential risk for a fracture the facility would not which would result in a delay in Resident 3's care.
During an interview on 4/28/2026 at 3:22 p.m. with LVN 3, LVN 3 stated she went back and found a text message from the physician and stated she (LVN 3) documented on the SBAR the recommendation of an X-ray prior to communicating with the physician. LVN 3 stated it was her (LVN 3) recommendation and assumed the physician would order an X-ray, but the physician did not order an X-ray. LVN 3 stated the physician only ordered for wound care treatment. LVN 3 stated she should have gone back and made a note indicating her SBAR was inaccurate to ensure there was no inaccurate information.During a concurrent interview and record review on 4/28/2026 at 3:44 p.m., Resident 3's SBAR Communication Form, dated 4/2/2026, physician orders and care plans were reviewed with the ADON.
The ADON stated the SBAR indicated the physician ordered X-ray to Resident 3's right arm and elbow.
The ADON reviewed Resident 3's physician orders and stated there was no order for Resident 3 regarding physician's recommendations.
The ADON stated that if this was an error by the nurse then there should have been a progress note indicating this was an error.
The ADON reviewed Resident 3's progress notes and stated there was no notes regarding the X-ray.
The ADON stated there was a potential for delay in care and the facility staff would not know if Resident 3 had an injury.
The ADON stated there was a potential for Resident 3 to have continued pain if he had an unidentified fracture.
The ADON reviewed Resident 3's care plan for witnessed falls, initiated on 4/2/2026, and stated the care plan indicated it was a witnessed fall.
The ADON stated the SBAR, dated 4/2/2026, indicated CNA 1 found Resident 3 on the floor.
The ADON stated the care plan was not accurate, and there was a potential for misinformation.
During an interview on 4/28/2026 at 4:15 p.m. with the DON, the DON stated for the SBAR dated 4/2/2026 LVN 3 stated it was recommended by the staff and not by the physician to get an X-ray.
The DON stated there should have been documentation that the physician did not order the X-ray.
The DON stated this is considered inaccurate documentation.
The DON stated there is a potential for communication to not be accurate and would appear the order was not done and there was a delay in care.
The DON stated that Resident 3's SBAR, dated 4/2/2026, was also inaccurate.
The DON stated CNA 1 witnessed the fall.
The DON stated the SBAR and care plan do not coincide with each other and they should.
The DON stated there is a potential that the plan of care and the documentation will be inaccurate.
During a review of the facility's Policy and Procedure (P&P) titled, Charting and Documentation, last reviewed on 1/27/2026, the P&P indicated the documentation in the medical record will be objective, complete and accurate.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.