Health inspection·January 20, 2026

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to have an on-going, effective pest control management program (a program that monitors, identifies, controls, and prevents pest infestations in the facility). This deficient practice had the potential to spread infections and illnesses among residents. Findings:a. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 12/6/2022 with diagnoses including diabetes mellitus type two (DM II-a disorder characterized by difficulty in blood sugar control and poor wound healing), depression (mental health illness causing a persistent feeling of sadness, loss of interest, and can interfere with daily life), and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). During a review of Resident 2's History and Physical (H&P - a comprehensive assessment of a resident's medical condition), dated 4/7/2025, the H&P indicated Resident 2 had fluctuating capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS-a resident assessment tool), dated 12/16/2025, the MDS indicated that Resident 2 had intact cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks). The MDS indicated that Resident 2 required maximal assistance (helper does more than half the effort) from the facility staff with toileting hygiene and showers. The MDS indicated Resident 2 was dependent (helper does all the effort) on chair to bed transfers. During an interview on 1/16/2026 at 1:41 p.m. with Resident 2, Resident 2 stated that approximately one month ago, she (Resident 2) saw a cockroach in the hallway in front of Room A (Resident 2's room). Resident 2 stated that approximately two or three months ago (Resident could not indicate exact date), she (Resident 2) saw cockroaches in Room A. Resident 2 stated that she (Resident 2) informed facility staff (Resident 2 could not indicate the exact facility staff) regarding cockroaches in her room and hallway. Resident 2 stated that facility staff killed the cockroaches by stepping on them and threw them in the trash. b. During a review of Resident 3's admission Record, the admission Record indicated the facility admitted Resident 3 on 4/15/2024 with diagnoses including asthma (a chronic lung disease where airways become inflamed, swollen and narrow, making it hard to breathe), anxiety disorder (feeling of anxiousness that affects daily life), and muscle weakness. During a review of Resident 3's H&P, dated 5/28/2025, the H&P indicated Resident 3 had fluctuating capacity to understand and make decisions. During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 had intact cognitive functioning. Resident 3 required moderate assistance (helper does less than half the effort) from the facility staff with toileting hygiene, showers, transfers to toilet, and transfers from chair to bed. The MDS indicated Resident 3 was dependent (helper does all the effort) on chair to bed transfers.During an interview on 1/16/2026 at 1:50 p.m. with Resident 3, Resident 3 stated that approximately two to three weeks ago, she (Resident 3) saw cockroaches in Room B (Resident 3's room). Resident 3 stated she (Resident 3) was worried that the cockroaches would crawl on her bed. During a concurrent interview and record review on 1/16/2026 at 2:58 p.m. with the Maintenance Supervisor (MS), facility's Quality Assurance Report forms and Pesticide/Rodenticide Usage Log, dated 11/25/2024 to 12/29/2025 were reviewed. The Quality Assurance Report forms and Pesticide/Rodenticide Usage Log indicated the Pest Control Management Company (company hired by the facility to conduct inspection and treatment to prevent pest infestation in the facility) conducted inspections and treatment of the exterior of the facility. The MS stated the Pest Control Management Company conducted monthly inspection of the exterior of the facility. The MS stated that the Pest Control Management Company would be contacted to complete a localized inspection of the specific internal area of the facility if pest related issues were Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056039 If continuation sheet Page 2 of 3 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 01/20/2026 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 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete identified and reported by the facility staff or residents. During an interview on 1/16/2026 at 4:06 p.m. with the Pest Control Management Program Representative, the Representative stated that he was the representative who conducted monthly inspection of the facility as part of the Pest Control Management Program. The Representative stated that every month the facility's exterior was inspected for pest activity and treatment provided as necessary. The Representative stated that facility's interior was not included in the monthly inspection of the facility.During a concurrent interview and facility policy review on 1/16/2026 at 4:18 p.m. with the MS, facility-provided policy and procedure (P&P) titled, Pest Control, last revised on 11/6/2025, were reviewed. The P&P indicated, Our facility will maintain an effective pest control program. 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. The MS stated that there was no documented record to indicate that the facility's interior was routinely inspected as part of the pest control management program. The MS stated the failure to have an on-going, effective pest control program had the potential for pest infestation in the facility that could lead to infection and illness among residents. Event ID: Facility ID: 056039 If continuation sheet Page 3 of 3