Mirador

In the surveyor’s words

From the most serious findings on record at Mirador, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Apr 25, 2025

  Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan, for one (Resident #1) of three residents reviewed for injuries. The facility failed when CNA A did not ensure Resident #1 was medically assessed before picking up Resident #1 off the floor after she fell off the bed and CNA A left her unattended and misaligned in bed on 09/07/2024. Resident #1 sustained a femur fracture and her feeding tube was dislodged as a result of the fall. An Immediate Jeopardy (IJ) was identified as past non-compliance on 04/25/25. The non-compliance began on 09/07/24 and ended on 09/07/24. […]

• Immediate jeopardy, isolatedF689Apr 25, 2025

  Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of four residents reviewed for accident hazards and supervision on 09/07/24. The facility failed to identify and eliminate a foreseeable fall. CNA A left Resident #1 unattended and did not ensure her body was positioned in a safe manner when providing incontinent care resulting in Resident #1 falling off her bed, sustaining a femur fracture, and her feeding tube to be dislodged. An Immediate Jeopardy (IJ) was identified as past non-compliance on 04/25/25. The non-compliance began on 09/07/24 and ended on 09/07/24. […]

• Immediate jeopardy, isolatedF580May 25, 2024

  Based on interviews and record review, the facility failed to consult/ notify the physician when the resident experienced a significant change in their physical status for one (Resident #1) of five residents reviewed for physician notification of changes. The facility failed to consult with/notify the physician after Resident #1 displayed significant changes in condition on [DATE] such as lethargy, vomiting, a decrease of oxygen saturation of 85%, irregular lung sounds and after requiring resuscitation efforts. Resident #1 expired on [DATE]. On [DATE] at 4:45 PM, an immediate jeopardy was identified. […]

• No harm, potential for more than minimal, widespreadF812May 29, 2025

  Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served under sanitary conditions for 1 of 1 kitchen reviewed for food served under sanitary conditions. The handwashing sink's water drainage box was dirty with a black substance and the drainage plug was loose. A large frying pan was on the kitchen floor beneath a cooking table and near the cooking stoves. These failures could place residents at risk for food contamination, food borne illness and a diminished quality of life. The findings included: Observation on 5/27/25 at 1:05 PM of the kitchen reflected a dirty drainage box at the location of the wash sink. […]

• No harm, potential for more than minimal, widespreadF812Mar 29, 2024

  Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. The facility failed to ensure dietary staff facial hair was fully covered by beard restraints. The facility failed to ensure dietary staff used proper hand hygiene during meal preparation. The facility failed to ensure refrigerated food items were dated and properly sealed. The facility failed to ensure pantry food items when opened were dated and properly sealed. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: Observation and interview on 03/26/2024 at 10:01 a.m. […]