Mirabella

Facility failed to use an appropriate tool to assess dementia needs for 1 resident and failed to complete full assessments within 14 days of move-in for 2 residents.

Failed to ensure the Washington state background inquiry (BGI) for 1 of 2 sampled staff (Staff E) was renewed before the two-year expiration.

Facility failed to ensure Negotiated Service Agreements (NSA) contained necessary care information for 10 residents, including behavior monitoring, hospice services, medication management, wound care, fall prevention, and diabetic management.

Failed to ensure 1 of 3 sampled staff (Staff B) completed the required one-step tuberculosis (TB) skin test.

Facility failed to ensure staff were current on two-step TB testing.

Failed to ensure 2 of 3 sampled staff completed CPR/first aid training and 1 of 1 sampled staff completed required 12 hours of continuing education.

Facility failed to ensure proper and safe installation of side bed rails (SBR) for 2 residents, placing them at risk of entrapment.

Failed to complete the two-step TB skin test screening for 1 of 3 sampled staff (Staff D).

Facility failed to evaluate a side bed rail (SBR) as a safe bed mobility device and failed to ensure safe nurse delegation services were implemented for multiple residents.

The licensee failed to ensure that four staff members completed the required 12 hours of continuing education (CE).

The facility failed to ensure a staff member obtained a chest X-ray within seven days following a positive TB blood test result.

Failed to ensure three staff completed first aid training and four staff completed 12 hours of continuing education; previously cited on Nov 3, 2025.

Failed to implement safe Nurse Delegation (ND) services for one resident receiving insulin injections from non-licensed staff; previously cited on Nov 3, 2025.

Failed to ensure two staff members completed the required two-step TB skin test; previously cited on Nov 3, 2025.

Incomplete hood cleaning reports for 12/2/2024 and 9/2/2024; missing documentation of corrected deficiencies.

Monthly testing, maintenance, and documentation of CO alarms/detectors missing.

Annual fire alarm inspection report not provided.

Annual sprinkler system report not provided.

Missing annual fire door inspection documentation and records of repairs/modifications.

Missing semi-annual servicing records and documentation of deficiencies on main #2.

The facility failed to follow its Respiratory Protection Policy because medical evaluations for employees prior to respirator fit testing were not conducted or reviewed by a Licensed Health Care Professional (LHCP).

Facility failed to ensure Negotiated Service Agreements (NSA) contained information to meet care needs for 4 of 4 sampled residents, including lack of behavioral interventions, alternate plans for external caregivers, and monitoring plans for health risks.

Staff failed to wash hands or don gloves during meal preparation, placing 37 residents at risk for foodborne illness.

Facility failed to secure hazardous supplies including an unlocked medication cart, air freshener, kitchen knives/scissors, and cleaning chemicals in the Memory Care Unit.

Facility failed to update a resident's negotiated service agreement regarding necessary safety interventions for a resident prone to inserting their arm between their wheelchair's armrest and wheel.

Facility failed to implement safe Nurse Delegation services for residents, and failed to document that the RN delegator supervised or evaluated the medication administration competency of staff.

Staff A, B, and C did not complete required dementia and mental health specialty training.

Facility failed to implement systems for safe medication services, including missed insulin injections for Resident 6 and failure to transcribe a medication dosage increase for Resident 1.

Facility failed to coordinate care with primary care providers for residents, failed to perform pre-admission assessments, and failed to follow physician orders for wound care and blood sugar monitoring.

Facility failed to evaluate and take appropriate action for significant unintended/unplanned weight changes for a resident, failing to report weight changes to the physician per policy.

Facility failed to notify physicians or evaluate outcomes when residents repeatedly refused medications.

Facility failed to ensure newly hired staff completed required facility orientation before having routine interaction with residents.

Blocked electrical panel found in kitchen dish room

Memory care area in electrical room has penetrations

Fire alarm circuit breaker missing locking device

Facility did not provide schedule for inspection of Fire-Rated construction

Emergency lights not working in parking lot and AL balcony

Extension cord found in AL laundry room

Multiple doors failing to latch (rooms 345, 327, 328, 323, and AL trash shoot)

Facility did not provide schedule for inspection of Fire Doors

Exposed wires in memory care kitchen; Open junction box in AL trash room by elevator

Missing escutcheon ring; missed sprinkler testing; loaded sprinkler heads; bent sprinkler head