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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to maintain complete and accurate medical
records for one of three sampled residents (Resident 1), when Licensed Vocational Nurse (LVN) 1 failed to
document Resident 1's apixaban (an anticoagulant-medication used to prevent and treat blood clots)
administration accurately when the medication was documented as administered instead of not
administered on 12/15/2025 at 9 a.m. This deficient practice had the potential for facility staff to not know if
the medication was administered or not.Findings: During a review of Resident 1's admission Record, the
admission Record indicated the facility admitted the resident on 12/14/2025 with diagnoses including
sepsis (a life-threatening blood infection), end stage renal disease (ESRD - irreversible kidney failure), and
diabetes mellitus type II (DM - a disorder characterized by difficulty in blood sugar control and poor wound
healing). During a review of Resident 1's Order Summary Report (OSR), dated 12/14/2025, the OSR
indicated apixaban oral tablet five (5) milligrams (mg - a unit of measurement), give 5 mg by mouth two
times a day for deep vein thrombosis (DVT - when a blood clot forms in a deep vein, usually in the leg or
thigh, blocking blood flow and causing pain, swelling, redness, and warmth) prophylaxis (prevention).
During a concurrent observation, interview, and record review on 12/16/2025 at 10:38 a.m. with LVN 1, LVN
1 stated she was assigned to Resident 1 today, 12/16/2025, and yesterday, 12/15/2025. Resident 1's
Medication Administration Record (MAR), for 12/2025, was reviewed and LVN 1 stated she has not given
Resident 1's 9 a.m. scheduled medications yet, but she will after. LVN 1 stated the check mark on the MAR
means that the medication was administered. LVN 1 stated she signed the apixaban yesterday, scheduled
12/15/2025 at 9 a.m. LVN 1 stated yesterday, 12/15/2025, Resident 1's 9 a.m. medications arrived during
the 11 p.m. to 7 a.m. shift before her shift started. Inside the medication cart, observed Eliquis (apixaban) in
bubble packs (packaging that have a preformed plastic pocket or shell where a product sits securely in
place) for morning shift. LVN 1 stated she has not given the apixaban yet and will give today. When LVN 1
was asked, how come the Eliquis (apixaban) was marked as administered but the apixaban tablet is still
inside the bubble pack?, LVN 1 did not provide an answer. Resident 1's Eliquis bubble pack was observed
and indicated the filled date as 12/14/2025 with quantity seven (7) of 7 tablets in the bubble pack. During a
concurrent interview and record review on 12/17/2025 at 10:22 a.m. with Assistant Director of Nursing
(ADON), Resident 1's [DATE]/2025, nursing progress notes and pharmacy delivery receipt, dated
12/14/2025, were reviewed and the ADON stated code 10 on the MAR means the resident was unavailable
and there is documentation the reason it was not given. The ADON stated the nursing progress notes
indicated on 12/15/2025 the resident went out to dialysis and metoprolol (medication for high blood
pressure), and amiodarone (heart rhythm medication) were documented as not given on the MAR. The
ADON stated she could not find any nursing notes on 12/15/2025 when the apixaban was marked as given
when Resident 1 was in dialysis at that time. During an
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
056039
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056039
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/17/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Mirage Post Acute
44445 15th St W
Lancaster, CA 93534
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
interview on 12/17/2025 at 11:16 a.m. with the Director of Nursing (DON), the DON stated the licensed
nurses need to make sure medications are given and to sign after they have administered the medication to
the residents. The DON stated Resident 1's apixaban medication was signed as administered but was held.
The DON stated she does not know if MAR documentation was a typographical error. The DON stated
when the licensed nurse signed the electronic MAR and the medication was not given, it creates a
discrepancy and gives a different message to the reader. The DON stated it is important that residents'
information and summary of care is complete and accurate and should be corrected when there is
inaccurate charting in order to minimize errors or issues. The DON stated when the information is not
accurate it would give incomplete information. During a review of the facility's policy and procedure (P&P)
titled, Charting and Documentation, dated 7/24/2025, 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 . 3. Documentation in the medical record will be objective (not opinionated or
speculative), complete, and accurate.
Event ID:
Facility ID:
056039
If continuation sheet
Page 2 of 2
