The inspection report identifies the facility as Sheriden Woods Health Care Center Inc, located at 321 Stonecrest Drive.
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When a state inspector walked into the room at Mirage Post Acute on the morning of January 29, 2026, the resident was asleep.
A health examination conducted two days after readmission documented that the resident had no capacity to understand or make decisions.
The resident who fell 45 times is a woman whose diagnoses include sepsis, repeated falls, obesity, and muscle weakness.
Her physician's orders allowed oxygen through a nasal cannula, up to five liters per minute, as needed to keep her blood oxygen above 92 percent.
The facility's own policy required a copy of any proposed discharge notice to go to the ombudsman.
Federal inspectors documented the failures during a complaint inspection on January 30, 2026.
On January 27, 2026, nobody did it.
The complaint inspection found that staff failed to document enteral tube feedings in the facility's electronic medical records system.
The resident, identified as Resident #32 in inspection records, had filed an anonymous complaint saying they felt bored at the facility.
The aide, identified in federal inspection records only as NA B, admitted to striking Resident #1.
The date on the form was unclear.