Health inspection·August 21, 2025

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow its Policy and Procedures (P&P) titled, Grievances/Complaints, Filing, for one of four residents (Resident 2) when the facility failed to inform Family Member 1 (FM 1) verbally and in writing of the findings of the investigation and the actions that were taken to correct the identified problem.This deficient practice had the potential to violate the rights of Resident 1.Findings:During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 3/14/2012 and readmitted on [DATE] with diagnoses including type 2 diabetes mellitus (DM a disorder characterized by difficulty in blood sugar control and poor wound healing), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), and gastrostomy (GT - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 7/31/2025, the MDS indicated Resident 2 had the ability to rarely understand and was rarely understood. The MDS indicated Resident 1 was dependent (helper does all of the effort) with eating, oral hygiene, toileting, showering, upper and lower body dressing, putting on and taking off footwear, and personal hygiene. During a review of the facility Concern and Grievance Log for August, the Concern and Grievance Log indicated:- 8/6/2025 Resident 1's grievance was Resolved.- 8/15/2025 Resident 1's grievance was Resolved. During a review of Resident 1's Complaint and Grievance Form dated 8/6/2025, the Complaint and Grievance Form indicated Response to family and responsible party was left blank and was not signed by facility staff. During a review of Resident 1's Complaint and Grievance Form dated 8/15/2025, the Complaint and Grievance Form indicated Response to family and responsible party was left blank and was signed off by Director of Staff Development (DSD) on 8/18/2025. During a concurrent interview and record review of Resident 1's Complaint and Grievance form dated 8/6/2025 and 8/15/2025 on 8/19/2025 at 3:35 p.m. with the Social Services Director (SSD) stated for grievance they are done when resident and their representative have concerns, have 5 days to attend to the grievance get to the source and respond to the complainant and have 30 days to complete the resolution. The SSD reviewed the facilities Concerns and Grievances log for August and SSD stated the grievance log indicated resolved and means they are completed, and complainant was informed and satisfied with resolution. The SSD reviewed Resident 1's grievance for 8/6/2025 and stated grievance is against SSD therefore SSD cannot investigate it is still pending waiting for Administrator (Adm) to complete. The SSD stated for 8/15/2025 Complaint and Grievance form indicates resolved have scheduled an Interdisciplinary Team (IDTa group of professionals with different areas of expertise who work together to solve a complex problem or provide comprehensive care for a patient or client) but have not been able to meet with FM 1. During a concurrent interview and record review of Resident 1's Complaint and Grievance form dated 8/6/2025 and 8/15/2025 on Page 1 of 18 056039 056039 08/21/2025 Mirage Post Acute 44445 15th St W Lancaster, CA 93534

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 8/19/2025 at 4:06 p.m. with the Director of Nursing (DON) the DON stated we have 5 days to investigate and have a resolution within 30 days to complete any grievance. The DON verified Concern and Grievance Log for August and stated based on record indicates these grievances are resolved. The DON reviewed grievance on 8/62025 and 8/15/2025 and the DON stated the grievance is not resolved but it was resolved by SSD because he already addressed it to supervision. The DON stated the grievance should not indicate resolve, this is ongoing, will be resolved on 8/22/2025 with IDT. The DON stated this is inaccurately documented. During a review of the facility's P&P titled, Grievances/Complaints, Filing, last reviewed on 4/24/2025, the P&P indicated residents, and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances. The resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed (verbally and in writing) of the findings of the investigation and the actions that will be taken to correct any identified problems. 056039 Page 2 of 18 056039 08/21/2025 Mirage Post Acute 44445 15th St W Lancaster, CA 93534

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on interview and record review, the facility failed to develop and implement a person-centered Care Plan (CP - a plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs) for one of three sampled residents (Resident 5) by failing to implement the Medication Regimen Review (a pharmacist's [a healthcare professional who specializes in the preparation and management of medications] systematic check of a resident's entire medication list to identify potential issues such as dangerous side effects or inappropriate doses) per Resident 5's CP. This failure had the potential to delay care for Resident 5 and negatively affect Resident 1's well-being. Findings: During a review of Resident 5's admission Record (AR), the AR indicated the facility admitted Resident 5 on 6/21/2025 with diagnoses including dementia (a progressive state of decline in mental abilities), cerebral infarction (damage to the area of the brain caused by lock of blood flow), psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), and repeated falls. During a review of Resident 5's History and Physical (H&P), dated 6/23/2025, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions. During a review of Resident 5's Minimum Data Set (MDS - a resident assessment tool), dated 6/27/2025, the MDS indicated Resident 5 had moderately impaired cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks). The MDS indicated Resident 5 required maximal assistance (helper does more than half of the effort) from staff for toileting hygiene, showers, and lower body dressing. During a review of Resident 5's Change of Condition (COC - major decline or improvement in a resident's status that will not resolve without intervention) form, dated 6/24/2025 and 6/25/2025, the COC forms indicated Resident 5 had an episode of fall on 6/24/2025 and 6/25/2025. During a concurrent interview and record review on 8/21/2025 at 1:10 p.m. with the Director of Nursing (DON), Resident 5's CP, initiated on 6/24/2025, was reviewed. The CP indicated Resident 1 had an unwitnessed fall and was at risk of recurrent falls, injury. The CP interventions, initiated on 6/24/2025, indicated Resident 5's medications will be evaluated for side effects that may increase fall risk. The DON stated Resident 5's medications were not reviewed by the pharmacist after Resident 5's fall incident on 6/24/2025 and 6/25/2025 as indicated in Resident 5's care plan. The DON further stated the purpose of the medication regimen review by pharmacist after the fall incident was to identify medications that would potentially cause Resident 5 to fall. The DON stated the failure to complete a medication regimen evaluation had the potential for Resident 5 to continue receiving medications that increased Resident 5's risk for fall. During a record review of the facility-provided policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, last reviewed on 4/24/2025, 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. During a review of the facility-provided P&P titled, Fall Risk Assessment, last reviewed on 4/24/2025, the P&P indicated, The nursing staff, attending physician, and consultant pharmacist will review for medications or medication combinations that could relate to falls or fall risk, such as those that have side effects of dizziness, ataxia, or hypotension. During a review of the facility-provided P&P titled, Falls and Fall Risk, Management, last reviewed on 4/24/2025, the P&P indicated, .The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. 056039 Page 3 of 18 056039 08/21/2025 Mirage Post Acute 44445 15th St W Lancaster, CA 93534

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that the comprehensive care plan (CP, a plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs) was reviewed and revised by an interdisciplinary team (IDT-group of professionals from different disciplines who work together to provide coordinated care for residents) for one of three sampled residents (Residents 5) by failing to: 1. Ensure IDT meeting was held to review Resident 5's CP after Resident 5 sustained a fall on 6/24/2025 and 6/25/2025. 2. Ensure Resident 5's CP was revised after Resident 5 sustained a fall on 7/26/2025 and 7/27/2025. These practices had the potential to delay provision of person-centered care for Resident 5, placing Resident 5 at an increased risk for recurrent falls. Findings: a. During a review of Resident 5's admission Record (AR), the AR indicated the facility admitted Resident 5 on 6/21/2025, with diagnoses including dementia (a progressive state of decline in mental abilities), cerebral infarction (damage to the area of the brain caused by lock of blood flow), psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), and repeated falls. During a review of Resident 5's History and Physical (H&P), dated 6/23/2025, the H&P indicated Resident 5 had fluctuating capacity to understand and make decisions. During a review of Resident 5's Minimum Data Set (MDS-a resident assessment tool), dated 6/27/2025, the MDS indicated Resident 5 had moderately impaired cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks). The MDS indicated Resident 5 required maximal assistance (helper does more than half of the effort) from staff for toileting hygiene, showers, and lower body dressing. During a review of Resident 5's CP, revised on 7/2/2025, the CP indicated on 6/24/2025 Resident 5 had an unwitnessed fall. The CP further indicated Resident 5 had an unwitnessed fall on 6/25/2025. During a concurrent interview and record review on 8/19/2025 at 3:03 p.m. with the Assistant Director of Nursing (ADON), Resident 5's Change of Condition (COC -major decline or improvement in a resident's status that will not resolve without intervention) form dated 6/24/2025 and 6/25/2025 were reviewed. The COC form dated 6/24/2025 indicated on 6/24/2025 at approximately 11:30 a.m., Resident 5 was found on the floor in a sitting position. The COC form dated 6/25/2025 indicated on 6/25/2025, at approximately 3:30 p.m., Resident 5 was found sitting next to her wheelchair on the floor. The ADON stated facility did not hold an IDT meeting after Resident 5's fall incidents on 6/24/2025 and 6/25/2025. The ADON stated the purpose of the IDT meeting was to combine different specialties to discuss the care of Resident 5 to prevent further fall incidents. ADON stated the failure to hold an IDT meeting had the potential for Resident 5 to receive interventions that were not effective to prevent falls. During an interview on 8/20/2025 at 10:36a.m. with the Director of Nursing (DON), the DON stated facility failed to complete an IDT meeting to review care plan and interventions after Resident 5 sustained a fall on 6/24/2025 and 6/25/2025. The DON stated the IDT meeting was a collaboration of the team to revise and formulate Resident 5's care plan after fall incidents. The DON further stated the failure to hold an IDT meeting after Resident 5's fall incidents, had the potential for Resident 5's CP to be formulated based on incomplete or inaccurate information. The DON stated this failure placed Resident 5 at risk to receive care that was not person-centered. During a record review of the facility-provided policy and procedure titled, Care Plans, Comprehensive Person-Centered, last reviewed on 4/24/2025, the policy and procedure 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. The interdisciplinary 056039 Page 4 of 18 056039 08/21/2025 Mirage Post Acute 44445 15th St W Lancaster, CA 93534

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change. b. During a review of Resident 5's AR, the AR indicated the facility admitted Resident 5 on 6/21/2025, with diagnoses including dementia, cerebral infarction, psychosis, and repeated falls. During a review of Resident 5's H&P, dated 6/23/2025, the H&P indicated Resident 5 had fluctuating capacity to understand and make decisions. During a review of Resident 5's MDS, dated [DATE], the MDS indicated Resident 5 had moderately impaired cognitive functioning. The MDS indicated Resident 5 required maximal assistance from staff for toileting hygiene, showers, and lower body dressing. During a review of Resident 5's COC forms, dated 7/26/2025 and 7/27/2025, the COC forms indicated on 7/26/2025 and 7/27/2025, Resident 5 sustained falls. During an interview on 8/20/2025 at 12:14 p.m. with the DON, the DON stated Resident 5's CP was not revised after Resident 5 sustained falls on 7/26/2025 and 7/27/2025. The DON further stated the facility should have revised Resident 5's CP after the fall incidents based on root and cause analyses of the incident. The DON further stated the failure had the potential for Resident 5 to receive interventions based on incomplete and inaccurate CP. During a review of the facility-provided policy and procedure titled, Care Plans, Comprehensive Person-Centered, last reviewed on 4/24/2025, the policy and procedure 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. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change. During a record review of the facility-provided policy and procedure titled, Falls and Fall Risk, Managing, last reviewed on 4/24/2025, the policy and procedure 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.If the individual continues to fall, the staff and physician will reevaluate the situation and reconsider possible reasons for the resident's falling (instead of, or in addition to those that have already been identified) and also reconsider the current interventions. 056039 Page 5 of 18 056039 08/21/2025 Mirage Post Acute 44445 15th St W Lancaster, CA 93534

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure: A. That one of seven sampled residents (Resident 5), who had a history of multiple falls in the facility (6/24/2025, 6/25/2025, 7/19/2025, 7/20/2025, 7/26/2025, 7/27/2025, 8/3/2025, and 8/10/2025), was assessed as having moderately impaired cognitive function (a decline in a resident's mental abilities, impacting their ability to think, learn, remember, reason, and make decisions), and required moderate assistance (helper does more than half the effort) from staff for toilet transfers and mobility (movement), was free from accidents and was provided with supervision (refers to the ongoing monitoring and guidance provided by staff to ensure the safety and well-being of a resident) by failing to: A1. Initiate the facility's Falling Star Program (a resident safety initiative that uses a visual symbol, like a falling star, to identify residents at high risk for falls in healthcare settings) on 6/24/2025 when Resident 5 was identified as being at higher risk for falls following a fall incident on 6/24/2025. A fall risk assessment was completed for Resident 5 on 6/24/2025, however Resident 5 was not added to the facility's Falling Star Program until 7/21/2025 (nearly a month later). A2. Follow the facility's Falling Star Program procedures after Resident 5's falls on 6/24/2025 and 6/25/2025, which requires an Interdisciplinary Team (IDT - a group of professionals from different disciplines who work together to provide coordinated care for residents) Meeting to be held to determine whether Resident 5 should be placed on the Facility Star Program. A3. Implement close supervision interventions as indicated in the facility's Falling Star Program to provide close supervision for resident on the falling star program by increasing frequency of rounds (scheduled checks by healthcare staff to assess resident status, manage needs, and collaborate on care plans, often at the resident's bedside) to hourly. During hourly rounds, staff will ask or check . Potty Evaluating . if they need to go to the bathroom. A4. Ensure Resident 5's wheelchair alarm (a safety device that alerts facility staff when a resident attempts to stand up or exit the wheelchair, used to prevent falls) was functioning, when on 8/13/2025 at 6 p.m. Resident 5 stood up from her wheelchair and entered Room A's bathroom without triggering her (Resident 5's) wheelchair alarm. These deficient practices resulted in a fall on 8/13/2025 at 6 p.m. when Resident 5 was left unsupervised in her wheelchair by Certified Nursing Assistant 4 (CNA 4) after being provided with a dinner meal tray. Resident 5 was then later found on the toilet in the bathroom of Room A with a posterior scalp (back portion of the scalp {hair-covered area of the head}) laceration (a deep cut or tear in the skin), posterior scalp hematoma (a collection of blood that has pooled outside of blood vessels {a tube through which the blood circulates in the body}, usually due to trauma or injury that damages a blood vessel) and bleeding. Resident 5's laceration measured two centimeters (cm - unit of measurement) in length, one cm in width, and 0.2 cm in depth and the hematoma on the posterior side of the scalp measured three cm in length and 3 cm in width. Licensed Vocational Nurse 6 (LVN 6) applied a dressing (a pad or cover applied to an injury or wound to protect it, promote healing and prevent infection) on Resident 5's laceration to control the bleeding. On 8/13/2025 at 6:30 p.m., Resident 5 was transferred to General Acute Care Hospital 1 (GACH 1) for further evaluation. B. Fall prevention interventions were implemented for one of four sampled residents (Resident 3) when Resident 3's Falling Star Program interventions to place a yellow star in front of Resident 3's door and footboard were not in place. This deficient practice had the potential to place Resident 3 at risk for falls. Findings: A. During a review of Resident 5's admission Record, the admission Record indicated the facility admitted Resident 5 on 6/21/2025 with diagnoses including dementia (a progressive state of decline in mental abilities), cerebral infarction (damage to the area 056039 Page 6 of 18 056039 08/21/2025 Mirage Post Acute 44445 15th St W Lancaster, CA 93534

F 0689 of the brain caused by lack of blood flow), psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), and repeated falls. Level of Harm - Actual harm Residents Affected - Few During a review of Resident 5's History and Physical (H&P - a comprehensive assessment of a resident's medical condition), dated 6/23/2025, the H&P indicated that Resident 5 had fluctuating capacity to understand and make decisions. During a review of Resident 5's Fall Risk Observation/Assessment form, dated 6/24/2025, after Resident 5 had a fall on 6/24/2025, the Fall Risk Observation/Assessment form indicated that Resident 5 had a fall risk score of 24 (a score ranging from 16 to 42 signifies a high risk for falls). During a review of Resident 5's Care Plan for fall, initiated on 6/24/2025, the Care Plan indicated that on 6/24/2025 Resident 5 had an unwitnessed fall (an instance where a person falls but no one was present to see the event occur) and was identified as being at risk for recurrent falls and injury. During a review of Resident 5's Minimum Data Set (MDS – a resident assessment tool), dated 6/27/2025, the MDS indicated Resident 5 had moderately impaired cognitive functioning. The MDS indicated Resident 5 required moderate assistance from staff for toilet transfers and mobility. The MDS indicated Resident 5 required maximal assistance (helper does more than half of the effort) from staff with toileting hygiene, showers, and lower body dressing. The MDS also indicated Resident 5 had a fall prior to admission to the facility. During a review of Resident 5's Physician's Order dated 7/21/2025, the Physician's Order indicated to increase staff supervision for safety. During a review of Resident 5's Physician's Order dated 7/23/2025, the Physician's Order indicated that a chair (wheelchair) alarm was to be used while Resident 5 was in a wheelchair for safety purposes. The Physician's Order further indicated for staff to monitor the functionality of the chair alarm every shift and at each opportunity the resident is observed to ensure continued safety. During a review of Resident 5's Care Plan for fall, initiated on 8/13/2025, the Care Plan indicated that on 8/13/2025 Resident 5 had an unwitnessed fall. The Care Plan interventions included anticipating and addressing the resident's needs, and the use of a chair alarm to ensure resident safety. During a review of Resident 5's Situational Background Assessment and Recommendation (SBAR – a communication tool used to provide concise, clear, and effective information regarding a resident's condition) Communication Form, dated 8/13/2025, timed at 6:32 p.m., the SBAR form indicated that on 8/13/2025 (time not indicated), CNA 4 reported that Resident 5 attempted to go to the bathroom unassisted and had an unwitnessed fall. The SBAR further indicated to transfer Resident 5 via 911 (a universally recognized and designated emergency telephone number in the United States used to request immediate assistance in an emergency) for further evaluation. During a review of Resident 5's Progress Note (written summary by a healthcare professional detailing a resident's condition, care, treatments, and response to interventions during a specific encounter), dated 8/13/2025, timed at 6:05 p.m., the Progress Note indicated that on 8/13/2025, at approximately 6:05 p.m., Registered Nurse (RN 2) was informed of an unwitnessed fall involving Resident 5. The Progress Note indicated that Resident 5 reported hitting her (Resident 5) head and had a visible laceration on the back of her (Resident 5) head. The Progress Note indicated a dressing was applied 056039 Page 7 of 18 056039 08/21/2025 Mirage Post Acute 44445 15th St W Lancaster, CA 93534

F 0689 to Resident 5's head and the bleeding was controlled. The Progress Note further indicated that on 8/13/2025 at 6:30 p.m., Resident 5 was transferred to GACH 1 for further evaluation. Level of Harm - Actual harm Residents Affected - Few During a review of Resident 5's Physician's Order dated 8/15/2025, the Physician's Order indicated to cleanse Resident 5's posterior scalp laceration with normal saline (NS – a salt and water solution), pat dry, apply xeroform (a moist yellow dressing that covers the wound and promote wound healing), cover with gauze (a thin, light, and loosely woven fabric used for wound dressings) and wrap with stretch gauze (a flexible, absorbent bandage used to secure dressings, provide compression, and offer support for wounds) every day or as needed for 21 days. During an interview on 8/19/2025 at 12:09 p.m., with Licensed Vocational Nurse 4 (LVN 4), LVN 4 stated that on 8/13/2025, at approximately 6 p.m., she (LVN 4) entered the bathroom in Room A and found Resident 5 sitting on the toilet without any assistance from facility staff. LVN 4 stated that there was no audible sound from Resident 5's wheelchair alarm at the time. LVN 4 further stated that Resident 5 had sustained a head injury and was subsequently transferred to GACH 1 on 8/13/2024 at 6:30 p.m. for further evaluation and treatment. During a concurrent interview and record review on 8/19/2025 at 1:18 p.m., with LVN 6, Resident 5's Comprehensive Skin Evaluation/Assessment form dated 8/13/2025 was reviewed. The form indicated that on 8/13/2025 (time not indicated) Resident 5 was observed with moderate sanguineous drainage (leakage of fresh blood from an open wound, characterized by a bright red color and a syrup like consistency) from a laceration located on the posterior scalp, measuring two cm in length, one cm in width, and 0.2 cm in depth. The form indicated Resident 5 had a purple-colored hematoma, on the posterior scalp measuring three cm in length and three cm in width. The form indicated that Resident 5's posterior scalp injury was cleansed, and treatment was provided in accordance with the Physician's Order. LVN 6 stated that on 8/13/2025, at approximately 6:30 p.m., she (LVN 6) was asked to assist with Resident 5's treatment. LVN 6 stated that upon entering Room A, LVN 6 observed Resident 5 sitting on the toilet. LVN 6 further stated that Resident 5 was repeatedly grabbing her head and had visible blood on her (Resident 5) hand. During a concurrent interview and record review on 8/19/2025 at 1:58 p.m. with the Assistant Director of Nursing (ADON), Resident 5's Care Plan for fall, initiated on 7/20/2025 was reviewed. The Care Plan indicated that Resident 5 was at risk for falls related to altered balance (difficulty keeping a stable and upright position) while standing and walking, decreased muscular coordination (ability of multiple muscle to work together accurately to produce a desired movement or action), history of multiple falls, and an unsteady gait (pattern of walking that lacks stability and coordination resulting in increased risk of falls). The Care Plan indicated that Resident 5 sustained falls on 7/19/2025, 7/20/2025, 8/3/2025, and 8/10/2025. The care plan interventions included Resident 5 was added to the facility's Falling Star Fall Prevention Program as of 7/21/2025 and to keep Resident 5 within supervised view as much as possible. The ADON stated that the purpose of the Falling Star Program was to alert and inform facility staff of residents identified as high risk for falls. The ADON further stated that the Falling Star Fall Prevention Program should have been initiated for Resident 5 on 6/24/2025, when Resident 5 was assessed and identified as being at high risk for falls. During an interview on 8/19/2025 at 3:58 p.m., with RN 2, RN 2 stated that on 8/13/2025, at approximately 6 p.m., she (RN 2) was informed by facility staff (unable to recall who) that Resident 5 had sustained a fall. RN 2 stated that upon entering Room A, she (RN 2) observed Resident 5 sitting on the toilet in the bathroom with a visible head injury. RN 2 stated that Resident 5 stated she (Resident 5) had hit her (Resident 5) head but could not recall where the fall occurred. RN 2 further 056039 Page 8 of 18 056039 08/21/2025 Mirage Post Acute 44445 15th St W Lancaster, CA 93534

F 0689 Level of Harm - Actual harm Residents Affected - Few stated that Resident 5's wheelchair alarm did not activate when Resident 5 got up from the wheelchair to go to the bathroom. RN 2 stated that the purpose of the wheelchair alarm is to alert staff when a resident attempts to stand, in order to prevent falls. RN 2 stated that facility staff failed to ensure the wheelchair alarm was functioning properly, as no alarm was triggered during the fall incident on 8/13/2025. RN 2 stated that this failure had the potential for Resident 5 to stand without staff assistance and sustain a fall resulting in injury or hemorrhage (a heavy, uncontrolled loss of blood, either externally from a wound or internally). During an interview on 8/20/2025 at 10:36 a.m., with the Director of Nursing (DON), the DON stated that the facility failed to conduct an IDT Meeting to review and update Resident 5's care plan and interventions following the falls that occurred on 6/24/2025 and 6/25/2025. The DON stated that the purpose of the IDT Meeting is to facilitate collaboration among team members to revise and develop an appropriate care plan in response to significant incidents such as multiple falls. The DON further stated that the failure to hold an IDT meeting after Resident 5's fall incidents had the potential to result in a care plan that was based on incomplete or inaccurate information placing Resident 5 at continued risk for harm. The DON stated that the facility's Falling Star Program serves as a communication tool to enhance staff awareness of residents identified as being at risk for falls. The DON stated that the goal of the Falling Star Program is to implement close supervision interventions including increased monitoring such as hourly rounding, particularly for residents placed in the Red Star category, indicating resident had two or more falls within a one-month period. The DON further stated that the Falling Star Program should have been initiated for Resident 5 on 6/24/2025, following completion of a fall risk assessment that identified Resident 5 as being at high risk for falls. The DON stated Resident 5 sustained multiple falls on 6/24/2025, 6/25/2025, 7/19/2025, 7/20/2025, 7/26/2025, 7/27/2025, 8/3/2025, and 8/10/2025. During a follow-up interview on 8/20/2025 at 12:14 p.m., with the DON, the DON stated that the facility staff (did not specify) did not inform her of the specific details regarding Resident 5's fall on 8/13/2025 at 6 p.m. The DON stated Resident 5 returned to the facility from GACH 1 the same night, 8/13/2025, Resident 5 was transferred. The DON further stated that facility staff failed to verify the functionality of Resident 5's wheelchair alarm while Resident 5 was seated in the wheelchair. The DON stated that Resident 5 was added to the facility's Falling Star Program on 7/21/2025 as part of the fall prevention interventions (nearly one month after Resident 5's initial fall on 6/24/2025). The DON stated there was no documented evidence that facility staff provided Resident 5 with supervision and hourly monitoring on 8/13/2025, as indicated in the facility's Falling Star Program. During an interview on 8/20/2025 at 4:50 p.m., with CNA 4, CNA 4 stated that on 8/13/2025, during dinner service (unable to recall specific time), she (CNA 4) provided a meal tray to Resident 5, who was seated in her (Resident 5) wheelchair next to her (Resident 5) bed in Room A. CNA 4 stated that after she (CNA 4) provided the meal tray to Resident 1, she (CNA 4) proceeded to distribute meal trays to other residents. CNA 4 stated approximately 20 minutes after she (CNA 4) last observed Resident 5 in Room A, CNA 4 was called by LVN 4 to assist in Room A. CNA 4 further stated that upon entering Room A, CNA 4 observed Resident 5 seated on the toilet in the bathroom. CNA 4 stated that Resident 5's wheelchair was positioned outside the bathroom door. CNA 4 stated that she (CNA 4) did not hear Resident 5's wheelchair alarm activate when Resident 5 stood up, indicating that the alarm did not function as intended. During an interview on 8/21/2025 at 12 p.m., with LVN 4, LVN 4 stated that Resident 5's injury on 8/13/2025, which included a posterior scalp laceration and hematoma could have been prevented if Resident 5's wheelchair alarm had been functioning properly. LVN 4 stated had the alarm sounded, a staff 056039 Page 9 of 18 056039 08/21/2025 Mirage Post Acute 44445 15th St W Lancaster, CA 93534

F 0689 member could have responded promptly, assisted Resident 5, and potentially prevented the fall and resulting injury. Level of Harm - Actual harm Residents Affected - Few During an interview on 8/21/2025 at 1:10 p.m., with the DON, the DON stated that facility staff (did not specify) were under the impression that Resident 5 had sustained an unwitnessed fall. The DON further stated that it was possible Resident 5 may have struck her (Resident 5) head on the metal grab bars attached to the toilet. The DON stated that if Resident 5's wheelchair alarm was functioning properly, Resident 5's wheelchair alarm should have been heard from Hallway A and Nursing Station 1 when Resident 5 stood up from the wheelchair. The DON stated Resident 5's injury could have been prevented if facility staff had ensured that the wheelchair alarm was both operational and appropriately positioned. The DON stated that the facility does not have a policy and procedure (P&P) in place for the use and monitoring of chair alarms. During a review of the current facility-provided P&P titled, Falls and Fall Risk, Managing, last reviewed on 4/24/2025, the P&P indicated, Based on previous evaluations and current data, that staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. 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. During a review of the facility-provided P&P titled, Falling Star Program, last reviewed on 4/24/2025, the P&P indicated, Our ultimate goals are: To arm our caregivers with the tools, proactive strategies and interventions, needed to be more vigilant with all residents and especially with those who are at high risk. Residents that qualify to be in the Falling Star Program are: Residents scoring high risk based on most recent Fall Risk Assessment. We adopted a red star to symbolize the following residents: Current, new admissions . with fall incidents of two or more in a month. IDT will be held to discuss residents to be placed on the Falling Star program. In addition, staff will use the following proactive strategies to resident under the Falling Star Program and reflected on resident's care plan: 1. Close supervision for resident on the falling star program by increasing frequency of rounds to hourly. 2. During hourly rounds staff will ask or check . Potty – Evaluating them . if they need to go to the bathroom. B. During a review of Resident 3's admission Record, the admission Record indicated the facility admitted Resident 3 on 8/14/2025 with diagnoses including metabolic encephalopathy (any condition that damages or impairs the brain, leading to changes in brain function or structure), muscle weakness (generalized), and rhabdomyolysis (a condition where muscle tissue breaks down, releasing harmful substances from within the muscle cells into the bloodstream, which can cause kidney damage and other serious problems). During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3's cognitive functioning for daily decision making was independent (decisions consistent and reasonable). The MDS indicated Resident 3 required substantial assistance (helper does more than half the effort) with toileting, showering, upper and lower body dressing, putting on and taking off footwear, and with personal hygiene and required supervision or touch assistance (helper provides verbal cues, and touching and or steadying and or contact guard assistance) with eating and oral hygiene. During a review of Resident 3's Fall Risk Observation/Assessment form, dated 8/14/2025, at 9:24 p.m., the Fall Risk Observation/Assessment indicated Resident 3 had a fall risk score of 20 (a score of 16 to 42 is a high risk for fall). 056039 Page 10 of 18 056039 08/21/2025 Mirage Post Acute 44445 15th St W Lancaster, CA 93534

F 0689 During a review of Resident 3's SBAR Communication Form, dated 8/14/2025, the SBAR Communication Form indicated at 11:40 p.m., Resident 3 had a fall and was found on the floor at the bedside, sitting up. Level of Harm - Actual harm Residents Affected - Few During a review of Resident 3's Fall Risk Observation/Assessment, dated 8/14/2025, at 11:40 p.m., the Fall Risk Observation/Assessment indicated Resident 3 had a fall risk score of 22. During a review of Resident 3's Care Plan for risk for falls, initiated on 8/14/2025, the Care Plan indicated Resident 3 is at risk for falls with and without injury related to altered balance while standing or walking, and unsteady gait. The Care Plan interventions included Falling Star Program: yellow star and keep within supervised view as much as possible. During a review of Resident 3's Care Plan for falls, initiated 8/15/2025, the Care Plan indicated Resident 3 had an unwitnessed fall and is at risk for injury and recurring falls. The Care Plan interventions included Falling Star Program: yellow star and anticipate and meet needs. During a review of Resident 3's IDT Note, dated 8/15/2025 at 1:34 p.m., the IDT Note indicated an IDT meeting was conducted to discuss Resident 3's enrollment in the falling star program following recent fall. The IDT indicated: - A fall risk assessment was performed on Resident 3 on 8/14/2025 and identified Resident 3 as high-risk status. - Resident 3 meets the criteria for a yellow star designation under the falling star program. - A yellow star has been placed on Resident 3's door and footboard per protocol. During a concurrent observation, record review, and interview on 8/19/2025 at 12:08 p.m. inside Resident 3's room, with the ADON, Resident 3's Fall Risk Observation/Assessment and Resident 3's Care Plans for falls were reviewed. The ADON stated the Falling Star Program identifies residents with any falls in the last 30 days with a yellow star. The ADON stated residents that are identified as a high risk for falls get a star on the outside of the door by their names and at the end of their foot board. The ADON reviewed Resident 3's Fall Risk Observation/ Assessment, dated 8/14/2025, and stated Resident 3 had a fall risk score of 20. The ADON stated Resident 3's Fall Risk Observation/Assessment, dated 8/14/2025, indicated Resident 3 had another fall and Resident 3's score went up to 22. The ADON stated Resident 3 is at high risk for falls. The ADON reviewed Resident 3's Care Plan for unwitnessed fall and stated the interventions indicate for Resident 3 to be on the falling star program. The ADON observed Resident 3's door and footboard and stated Resident 3 does not have a star on the resident's door and footboard. The ADON stated residents on the falling star program should have a star on their door and footboard. The ADON stated Resident 3 should have a star on his footboard and by the door to ensure facility staff sees who the residents at risk for falls are. The ADON stated the falling star program should have been implemented after Resident 3's fall on 8/14/2025. The ADON stated if the facility is not implementing interventions like the falling star program, the staff will not be able to identify the fall risk residents, and staff will not be able to be vigilant with checking on the residents. During an interview on 8/19/2025 at 4:06 p.m. with the DON, the DON stated Resident 3 was a fall risk and had a fall on 8/14/2025. The DON stated the falling star program makes the staff aware of high fall risk residents by identifying residents with a yellow star outside the residents' door and 056039 Page 11 of 18 056039 08/21/2025 Mirage Post Acute 44445 15th St W Lancaster, CA 93534

F 0689 Level of Harm - Actual harm Residents Affected - Few footboard. The DON stated the purposes of the stars at the footboard and outside the door are to provide staff with awareness, minimize falls, allow staff to identify immediately who is a fall risk, and provide a form of communication. The DON stated she is aware Resident 3 did not have yellow star outside door or footboard. The DON stated not implementing the falling star program can be a potential contributing factor for resident falls. During a review of the facility's P&P titled, Falling Star Program, last reviewed on 4/24/2025, the P&P indicated: 1. To standardize our screening identification and falls prevention strategies in order to reduce both the number and severity of falls in our facility. 2. To successfully raise awareness about Falls Prevention throughout our facility. 3. To arm our caregivers with the tools, proactive strategies and interventions, needed to be more vigilant with all residents and especially with those who are at high risk. Protocol: 2. We adopted a Yellow Star to symbolize the following residents: - who are new admit/readmit residents who score High Risk or with a history of fall/s within the last 30 days. - current residents who had fallen with no major injury in the last 30 days. - any resident who scored High Risk on Fall Risk Assessment. To alert all members of our Health Care Team: - A Yellow Star is placed at the door by the name of these residents. This star will follow with residents as room changes occur. - A Yellow Star is placed on the footboard of these residents. 056039 Page 12 of 18 056039 08/21/2025 Mirage Post Acute 44445 15th St W Lancaster, CA 93534

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents receiving enteral feeding (also known as tube feeding, the delivery of nutrients through a feeding tube directly into the stomach, duodenum, or jejunum) received appropriate care and services to prevent complications of enteral feeding for one of four sampled residents (Resident 2) when Certified Nursing Assistant (CNA) 1 failed to notify nursing staff to turn off Resident 2's enteral feeding pump (a device that delivers nutrient fluids into a resident's stomach, at a controlled rate) on 8/10/2025. This deficient practice placed Resident 2 at risk for aspiration (accidental inhalation of foreign materials, such as food or liquid, into the lungs). Findings: During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 3/14/2012 and readmitted on [DATE] with diagnoses including type two diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), and gastrostomy (GT - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 7/31/2025, the MDS indicated Resident 2 had the ability to rarely understand and was rarely understood. The MDS indicated Resident 2 was dependent (helper does all of the effort) with eating, oral hygiene, toileting, showering, upper and lower body dressing, putting on and taking off footwear, and personal hygiene. During a review of Resident 2's Physician Orders (PO), dated 2/10/2025, the PO indicated enteral feed order every shift continuous GT feeding of Jevity 1.5 (a type tube feeding formula) formula at 44 milliliters (ml - unit of measurement for volume) for 20 hours to provide 900 and or 1350 kilocalorie (kcal - a unit of measurement for energy commonly used in nutrition) pump to run from 1 p.m. to 9 a.m. or until dose limit met. During a review of Resident 2's Situational Background Assessment and Recommendation (SBAR situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) Communication Form dated 8/10/2025, the SBAR Communication Form indicated sudden onset of coughing episodes. During an interview on 8/14/2025 at 1:53 p.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated on 8/10/2025, LVN 2 did not recall the exact time, Family Member (FM) 1 called LVN 2 to turn off the GT because CNA 1 was going to change Resident 2. LVN 2 stated when LVN 2 entered Resident 2's room, Resident 2 was lying down but not completely flat and CNA 1 was just starting to do care. LVN 2 stated the GT feeding was still running. LVN 2 stated when residents have a GT feeding running, residents should be up at a 45-degree angle to avoid aspiration. LVN 2 stated Resident 2's bed cannot be flat and Resident 2 could have potentially aspirated. LVN 2 stated Resident 2 was not flat in bed, but Resident 2's head of bed was not at a 45-degree angle. LVN 2 stated she was concerned about aspiration. LVN 2 stated CNAs are not able to turn off tube feeding and only licensed nurses can turn off the tube feeding. LVN 2 stated the tube feeding must be done prior to doing any care with residents. During an interview on 8/14/2025 at 4:06 p.m. with Director of Nursing (DON), the DON stated if the tube feeding is running during Activities of Daily Living (ADLs activities such as bathing, dressing and toileting a person performs daily) care, the CNA must notify the nurse to stop the feeding because the resident will be turned on their side and/or lay flat. The DON stated running the tube feeding during ADL care can place residents at risk for aspiration. During a review of the facility's policies and procedures (P&P) titled, Enteral Feeding-Safety Precautions, last reviewed on 4/24/2025, the P&P indicated to elevate the head of bed (HOB) at least 30 degrees 056039 Page 13 of 18 056039 08/21/2025 Mirage Post Acute 44445 15th St W Lancaster, CA 93534

F 0693 during tube feeding and at least one hour after feeding to prevent aspiration. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 056039 Page 14 of 18 056039 08/21/2025 Mirage Post Acute 44445 15th St W Lancaster, CA 93534

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1) received medication as prescribed by the physician when the resident did not receive his prescribed as needed (PRN) albuterol (a medicine used to help people with asthma [a lung condition that makes it hard to breathe] and other lung problems breathe better). This deficient practice had the potential for Resident 1 to be negatively affected. Findings:During a review of Resident 1's admission Record (AD), the AD indicated the facility admitted Resident 1 on 8/5/2025, with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (a type of stroke where blood flow to a part of the brain is blocked, causing brain cells to die from lack of oxygen and nutrients), and dysphagia (difficulty swallowing). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 8/6/2025, the MDS indicated Resident 1 cognitive skill (the brain's abilities that allow us to think, learn, remember, and solve problems) for daily decision making were modified impendence (some difficulty in new situations only). The MDS indicated Resident 1 was dependent (helper does all the effort) on staff for oral hygiene, upper and lower body dressing, putting on taking off footwear, and personal hygiene. During a review of Resident 1 Physician Orders, dated 8/5/2025, the Physician Orders indicated albuterol sulfate inhalation nebulization solution five (5) milligrams (mg- unit of measurements) in one milliliter (ml-unit of measurements), one (1) ml inhale orally via nebulizer every four hours as needed for shortness of breath (SOB) and wheezing. During a review of Resident 1's Situational Background Assessment and Recommendation (SBAR-a communication tool that provides a consistent framework for sharing critical information, especially in healthcare, by breaking down the message into four parts: Situation [what is happening?], Background [relevant context], Assessment [your analysis and understanding], and Recommendation [what you want done]) Communication Form dated 8/6/2025, the SBAR Communication Form indicated Resident 1 had low oxygen saturation. The SBAR Communication Form indicated at 4:30 a.m. Resident 1`s oxygen saturation was 81 percent (%) on two liters of oxygen, breathing treatment administered, 15 liters of oxygen via non-rebreather mask was administered. However, Resident 1 was still desaturating. During a review of Resident 1's Medication Administration Records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for August 2025, the MAR indicated albuterol sulfate inhalant nebulizer solution 0.5 %, one (1) ml inhale orally via nebulizer every four (4) hours as needed for SOB and wheezing. The MAR indicated that albuterol sulfate inhalation was not administered or signed for on 8/6/2025. During an interview on 8/19/2025 at 1:43 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated that on 8/6/2025, not recalling the time, LVN 1 was notified that Resident 1`s oxygen saturation was low. LVN 1 stated that LVN 1 had given Resident 1 a nebulizer treatment of albuterol which was ineffective. LVN 1 stated Resident 1 was transferred to hospital via 911 around 4:30 a.m. During a concurrent interview and record review of Resident 1's MAR on 8/19/2025 at 4:06 p.m. with the Director of Nursing (DON), the DON stated Resident 1 was transferred out to the hospital due to low oxygen levels. The DON reviewed Resident 1's MAR and stated Resident 1's MAR was not signed off for the albuterol on 8/6/2025 even though the medication was given. The DON stated this would be considered inaccurate documentation. The DON stated medications should be signed off after administration. The DON stated the potential outcome is the inaccurate documentation. During a review of the facility's Policies and Procedures (P&P) titled, Administering Medication, last reviewed on 4/24/2025, the P&P indicated medications are administered in a safe and timely manner, and as prescribed. The individual administering the 056039 Page 15 of 18 056039 08/21/2025 Mirage Post Acute 44445 15th St W Lancaster, CA 93534

F 0755 medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 056039 Page 16 of 18 056039 08/21/2025 Mirage Post Acute 44445 15th St W Lancaster, CA 93534

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on interview and record review, the facility failed to ensure the medical records were maintained in accordance with accepted professional standards and practice, complete, and accurately documented for one of three sampled residents (Resident 5) by: 1. Failing to document a summary of observation and evaluation of Resident 5's Change of Condition (COC -major decline or improvement in a resident's status that will not resolve without intervention) form. 2. Failing to document the physician notification on Resident 5's COC form. 3. Failing to ensure accurate documentation on Resident 5's skin evaluation on the COC form. These deficient practices had the potential for inaccurate documentation and inaccurate medical interventions for Resident 5. Findings: During a review of Resident 5's admission Record (AR), the AR indicated the facility admitted Resident 5 on 6/21/2025 with diagnoses including dementia (a progressive state of decline in mental abilities), cerebral infarction (damage to the area of the brain caused by lack of blood flow), psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), and repeated falls. During a review of Resident 5's History and Physical (H&P), dated 6/23/2025, the H&P indicated Resident 5 had fluctuating capacity to understand and make decisions. During a review of Resident 5's Minimum Data Set (MDS - a resident assessment tool), dated 6/27/2025, the MDS indicated Resident 5 had moderately impaired cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks). The MDS indicated Resident 5 required maximal assistance (helper does more than half of the effort) from staff for toileting hygiene, showers, and lower body dressing. During a review of Resident 5's Comprehensive Skin Evaluation/Assessment form, dated 8/10/2025, the form indicated on 8/10/2025, Resident 5 sustained a laceration (a tear in the skin and underlying tissue) on her face. During a review of Resident 5's Comprehensive Skin Evaluation/Assessment form, dated 8/13/2025, the form indicated on 8/13/2025, Resident 5 was noted with moderate sanguineous drainage (pink watery discharge consisting of a mix of blood and clear liquid part of blood) from the laceration on the posterior side of the scalp measuring two centimeters (cm - unit of measurement) in length, one cm in width, and 0.2 cm in depth. The form further indicated Resident 5 had a purple-colored hematoma (a localized collection of blood outside of blood vessels, often resulting in a swollen, painful lump or bruise [an injury where blood vessels under the skin break, causing blood to leak into surrounding tissues]), on the posterior side of the scalp measuring three cm in length and three cm in width. The form indicated Resident 5's posterior scalp injury was cleansed and treatment provided per physician order. During a concurrent interview and record review on 8/20/2025 at 10:36 a.m. with the Director of Nursing (DON), Resident 5's COC forms, dated 6/25/2025, 8/10/2025, and 8/13/2025 were reviewed. The COC form, dated 6/25/2025, indicated Resident 5 had an episode of fall. The DON stated the COC form did not contain documentation of summary of observations and evaluation of the incident. The COC forms, dated 8/10/2025 and 8/13/2025, indicated Resident 5 had an episode of fall. The COC forms further indicated Resident 5's Skin Evaluation was not clinically applicable to the change in condition being reported and did not indicate Resident 5's injuries. The DON stated the purpose of the COC form was to provide a comprehensive and complete assessment of the incident which was used as a communication tool with resident's physician. The DON further stated the documentation on Resident 5's COC form 056039 Page 17 of 18 056039 08/21/2025 Mirage Post Acute 44445 15th St W Lancaster, CA 93534

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was incomplete and had the potential to result in Resident 5 receiving interventions that were not person-centered and accurate. During a record review of the facility-provided policy and procedure (P&P) titled, Charting and Documentation, last reviewed on 4/24/2025, 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 . Documentation of procedures and treatments will include care specific details, including. f. notification of family, physician or other staff. During a record review of the facility-provided P&P titled, Change in a Resident's Condition or Status, last reviewed on 4/24/2025, the P&P indicated, Our facility promptly notified the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition.The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. 056039 Page 18 of 18