Inspection Reports for Mirabel Lodge

The inspection was an unannounced complaint investigation visit triggered by allegations that staff did not assist a resident with obtaining medical care in a timely manner and did not report the incident to appropriate parties.

The investigation found that the facility followed proper protocol regarding seeking timely medical care for the resident and reported the incident to one of the two responsible parties listed. Both allegations were determined to be unsubstantiated due to lack of preponderance of evidence.

The complaint involved two allegations: 1) staff did not assist a resident with obtaining medical care timely, and 2) staff did not report the incident to appropriate parties. Both allegations were found unsubstantiated after review of records, interviews, and police investigation.

The visit was an unannounced Case Management Visit to follow up on a self-death report dated 2025-07-21 involving a resident who choked and died while under the care of the facility.

The Licensing Program Analyst reviewed relevant medical and care records, confirmed that the facility followed adequate protocols including timely medical assistance, and found no deficiencies during the visit.

An unannounced complaint investigation was conducted following allegations that facility staff unlawfully confined a resident to their room, did not adhere to the resident care plan, and failed to provide oral hygiene.

The investigation found insufficient evidence to substantiate the allegations. The resident was isolated per facility protocol due to COVID-19 exposure, care plan supervision requirements were not clearly supported by documentation, and oral hygiene care had some gaps but was inconsistently documented due to staff oversight. All allegations were determined to be unsubstantiated.

The complaint investigation was unsubstantiated. Allegations included unlawful confinement of a resident to their room, failure to adhere to the resident's care plan, and failure to provide oral hygiene. Evidence did not prove violations occurred.

The inspection was an unannounced complaint investigation triggered by allegations of violations of personal rights and failure of facility staff to follow physician care orders.

The investigation substantiated that staff made inappropriate comments and failed to communicate intentions during resident transfers, violating personal rights. Staff also did not follow physician orders to use gait belts during transfers, posing immediate risk to residents. A civil penalty of $250 was assessed for repeated violations within 12 months.

The complaint investigation was substantiated. Allegations included personal rights violations and failure to follow physician care orders. The preponderance of evidence standard was met for both allegations. A civil penalty of $250 was assessed for repeated violations within 12 months.

The visit was an unannounced Case Management - Incident inspection to follow up on two self-incident reports dated 5/12/2025 and 6/2/2025 involving resident injuries.

The Licensing Program Analyst reviewed physician reports and care plans for the residents involved in the incidents, confirmed the call alert system was working properly, and observed adequate paper products in resident bathrooms. No deficiencies were cited during the visit.

The visit was an unannounced Case Management - Other inspection to update the facility's Fire Clearance received on 3/27/25.

The facility received an approved fire clearance dated March 27, 2025, allowing 34 non-ambulatory residents and 7 bedridden rooms. The updated fire clearance addressed previous concerns including the secured perimeter. No deficiencies were cited during the visit.

The inspection was an unannounced required 1-year annual inspection to assess compliance with licensing regulations and facility operations.

The inspection identified multiple deficiencies including fire clearance violations due to bedridden residents occupying non-cleared rooms, expired fire extinguishers, call alert system failures, medication administration errors, staff working without proper clearance, and sanitation and maintenance issues such as cracked toilets, feces in bathrooms, lack of hygiene supplies, and unpacked dry goods without expiration dates. Civil penalties totaling $1000 were issued for fire clearance and staff clearance violations.

The inspection was an unannounced complaint investigation conducted in response to allegations received on 07/24/2024 regarding medication administration and notification of resident condition changes at Mirabel Lodge.

The investigation substantiated that staff did not dispense medication to a resident as prescribed, including missed doses of Seroquel and improper medication crushing practices, posing an immediate risk to resident health. Another allegation that staff failed to inform the resident's authorized representative of a change in condition was found unsubstantiated due to insufficient evidence.

The complaint investigation was substantiated for the allegation that staff did not dispense medication to a resident as prescribed, confirmed by medication administration records and hospice documentation. The allegation that staff failed to inform the resident's authorized representative of a change in condition was unsubstantiated.

The visit was an unannounced Case Management visit to follow up on an incident report dated 7/13/24 involving resident aggression and subsequent hospital assessment.

The facility reviewed the incident involving resident aggression and developed a plan of action including behavior assessment, staff training, and engagement with responsible parties. No deficiencies were cited during the visit.

The visit was triggered by a complaint/incident report of resident (R1) aggression towards another resident (R2) on 7/13/24, resulting in hospital assessment for altered mental status and hypernatremia. The complaint remains under review with no physician response yet.

The visit was a Case Management Visit conducted unannounced to amend a report originally dated 05/23/2024 due to an error in reviewing the secured perimeter after a change of ownership.

The facility is operating under fire clearance approved on 11/16/2022 without a secured perimeter waiver. The Fire Department approval is pending. No citations were issued during this visit.

An unannounced complaint investigation was conducted due to an allegation that the facility does not maintain a proper fire clearance, specifically regarding locked and impassable gates preventing safe exit.

The investigation found that the facility had issues with the front and side gates being locked and impassable, posing an immediate health and safety risk. The gate maglock was faulty and was replaced promptly. The allegation was substantiated, and an immediate civil penalty of $500 was assessed. However, an amendment noted that the secured perimeter waiver was not approved, and the facility is operating under a previous fire clearance.

The complaint was substantiated based on evidence that the facility gates were locked and impassable, preventing safe exit. The licensee repaired the gate promptly. An immediate civil penalty of $500 was assessed.

An unannounced complaint investigation was conducted following an allegation received on 2024-04-09 regarding a resident's personal rights being violated by another resident.

The investigation found the allegation of personal rights violation unsubstantiated due to lack of evidence, despite incidents of resident-on-resident aggression. The facility followed its program plan by addressing issues with residents' responsible parties and consulting physicians as needed.

The complaint alleged that resident R2 entered resident R1's room at night and physically assaulted them. The Sheriff's report and facility records showed no injuries consistent with the allegation, resulting in an unsubstantiated finding.

The inspection was an unannounced required 1-year annual inspection conducted to assess compliance with licensing regulations.

The facility was found to have multiple deficiencies including fire clearance violations, maintenance and safety issues, medication administration errors, lack of activities, expired food items, incomplete care plans, insufficient staff training, and non-functional emergency alarm systems. An immediate civil penalty of $500 was issued for the fire clearance violation.

The inspection was an unannounced case management visit to follow up on death reports submitted to Community Care Licensing regarding two residents who passed away unexpectedly.

The investigation found that the facility followed all regulation and training requirements. However, the two residents were not receiving hospice services when they passed away. No deficiencies were found during the inspection.

An unannounced complaint investigation was conducted due to an allegation that staff did not ensure a resident received their medication as prescribed while in care.

The investigation substantiated that the facility failed to ensure resident R1 received their prescribed medication Sertraline for approximately six months due to errors in medication ordering and management. The designated medication technician was no longer employed, and the facility had not contacted a pharmacy for medication management review as required.

The complaint was substantiated. The allegation was that staff did not ensure a resident received their medication as prescribed, leading to behavioral issues. The investigation confirmed the medication was not administered from June 2023 until November 2023 due to ordering errors and inadequate medication management.

The inspection was an unannounced case management visit to follow up on two self-reported incident reports submitted to Community Care Licensing on 08/04/2023 and 08/18/2023.

The facility followed all regulations and training requirements related to the incidents. No deficiencies were cited during the inspection.

The inspection was an unannounced post-licensing and Non-Compliance inspection conducted to evaluate the facility's compliance with licensing requirements following a change of ownership.

The facility was found to have several deficiencies including maintenance issues such as missing face cover plates and drawers, hot water temperatures outside the regulated range, and admission agreements not updated after change of ownership. Staff training and resident care plans were generally compliant, but there were noted failures in timely medical attention and adequate direct care staffing.

The purpose of this office meeting was to discuss the non-compliance plan from the old facility Mirabel Lodge #496800941, which is being rolled over to the new facility number 496804122 due to change of ownership.

The facility has several ongoing non-compliance issues including failure to seek timely medical attention, inadequate staffing, failure to ensure resident rights and safety resulting in a resident's death, lack of observation of resident condition changes after falls, inability to provide resident care notes, and failure to notify the licensing agency about incidents after falls. No new deficiencies were cited at this time.

The visit was a pre-licensing continuation facility inspection to evaluate compliance for issuing a new license.

The facility met all requirements with no deficiencies cited. Exits were unobstructed and auditory alarms were operational. Pre-licensing deficiencies have been resolved and the inspection is complete.

Pre-licensing unannounced inspection conducted due to an application for Change of Ownership at the facility.

The facility was observed to have some deficiencies including non-operational auditory alarm systems in all resident rooms and obstructed exits in rooms 2, 4, and 6, which were immediately cleared. Other observations included compliance with fire safety, food storage, and emergency preparedness regulations.

The visit was conducted as a pre-licensing inspection and Component II (COMP II) evaluation by telephone to verify the applicant and administrator's understanding of Title 22 and facility operation requirements.

COMP II was successfully completed via telephone call with the applicant and administrator, confirming understanding of facility operation, staff qualifications, training, grievances, complaints, food service, medication management, and application document review. No deficiencies or violations were noted in the report.