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Deficiency Records for Mirabella Seattle
A list of the most recent deficiencies for Mirabella Seattle. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Mirabella Seattle. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2024-06-27 | 2024-08-27 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2024-06-28 | 2024-08-09 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2024-06-28 | 2024-08-09 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2024-06-28 | 2024-08-09 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-06-28 | 2024-08-09 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2024-06-28 | 2024-08-09 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-06-28 | 2024-08-09 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-06-28 | 2024-08-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-06-28 | 2024-08-09 | N |
| 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. | Health | 2024-06-28 | 2024-08-09 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-06-28 | 2024-08-09 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2024-06-28 | 2024-08-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-06-28 | 2024-08-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-06-28 | 2024-08-09 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2024-06-28 | 2024-08-09 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2024-06-27 | 2024-08-06 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2024-06-27 | 2024-08-06 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2024-06-27 | 2024-08-06 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2024-06-27 | 2024-08-06 | N |
| Establish methods for sharing information. | Fire Safety | 2024-06-27 | 2024-08-06 | N |
| Establish staff and initial training requirements. | Fire Safety | 2024-06-27 | 2024-08-06 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2024-06-27 | 2024-08-06 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-06-27 | 2024-08-06 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-06-27 | 2024-08-06 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2024-06-27 | 2024-08-06 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2024-06-27 | 2024-08-06 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-03-20 | 2023-05-05 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-03-20 | 2023-05-05 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-03-20 | 2023-05-05 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-03-22 | 2023-05-01 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-03-22 | 2023-05-01 | N |
| Assess the resident when there is a significant change in condition | Health | 2023-03-22 | 2023-05-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-03-22 | 2023-05-01 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-03-22 | 2023-05-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-22 | 2023-05-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-22 | 2023-05-01 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-03-22 | 2023-05-01 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2023-03-22 | 2023-05-01 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-03-22 | 2023-05-01 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-03-22 | 2023-05-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-22 | 2023-05-01 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2023-03-20 | 2023-04-21 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-03-20 | 2023-04-21 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-03-20 | 2023-04-21 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2023-03-20 | 2023-04-21 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-03-20 | 2023-04-21 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2023-03-20 | 2023-04-21 | N |
| Provide emergency officials' contact information. | Fire Safety | 2023-03-20 | 2023-04-21 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-03-20 | 2023-04-21 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-03-20 | 2023-04-21 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-03-20 | 2023-04-21 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-03-20 | 2023-04-21 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-03-20 | 2023-04-21 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-03-20 | 2023-04-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-20 | 2023-04-21 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-03-20 | 2023-04-21 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-03-20 | 2023-04-21 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2023-03-20 | 2023-04-21 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2023-03-20 | 2023-04-21 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-03-20 | 2023-04-21 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-03-20 | 2023-04-21 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2023-03-20 | 2023-04-21 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-04-14 | 2022-05-31 | Y |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2020-01-14 | 2020-03-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-01-14 | 2020-03-10 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2020-01-14 | 2020-03-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-01-14 | 2020-03-10 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-01-14 | 2020-03-10 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2020-01-14 | 2020-03-10 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2020-01-14 | 2020-03-10 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2020-01-14 | 2020-03-10 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2020-01-14 | 2020-03-10 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2020-01-14 | 2020-03-10 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2020-01-14 | 2020-03-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-01-14 | 2020-03-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-01-14 | 2020-03-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-06 | 2020-01-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-01-06 | 2020-01-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-01-06 | 2020-01-17 | N |
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