Inspection Reports for
Mirabella Portland
3550 S Bond Ave, Portland, OR 97239, United States, OR, 97239
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
13.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
101% worse than Oregon average
Oregon average: 6.7 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Capacity: 27
Deficiencies: 4
Date: Nov 25, 2024
Visit Reason
Facility failed to follow fall prevention techniques for a resident resulting in a fall. Multiple deficiencies were not corrected on revisit.
Findings
Facility failed to follow fall prevention techniques for a resident resulting in a fall. Multiple deficiencies were not corrected on revisit.
Deficiencies (4)
F0000 - INITIAL COMMENTS
F0689 - Free of Accident Hazards/Supervision/Devices
M0000 - Initial Comments
M9999 - STATE OF OREGON ADMINISTRATIVE RULES
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Nov 25, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction related to a nursing home inspection focused on ensuring the facility is free from accident hazards and provides adequate supervision to prevent accidents.
Findings
The facility failed to follow fall prevention techniques for one resident at high risk for falls, resulting in a fall during a standing transfer without the use of a gait belt. Staff were not fully aware of the specific fall prevention instructions for the resident.
Deficiencies (1)
F 0689: The facility failed to follow fall prevention techniques for Resident 16, who was observed falling backwards during a standing transfer without a gait belt. Staff confirmed the resident should have been assisted with a gait belt and turning clockwise to reduce fall risk.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff 4 (CNA) | Assisted Resident 16 during the fall and confirmed lack of gait belt use | |
| Staff 2 (DNS) | Confirmed CNA Pocket Guide updates and fall prevention instructions |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Aug 24, 2023
Visit Reason
The inspection was conducted following a complaint investigation regarding alleged physical abuse of Resident 76 by a staff member during an x-ray procedure.
Complaint Details
The complaint investigation was substantiated. Resident 76 was physically abused by Staff 13 during an x-ray procedure, as confirmed by multiple staff witnesses and the facility administrator.
Findings
The facility failed to protect Resident 76 from physical abuse by Staff 13, who was witnessed hitting and restraining the resident during an x-ray. Additionally, the facility had multiple overdue Minimum Data Set (MDS) assessments for residents, and failed to secure medication and treatment carts properly.
Deficiencies (4)
F 0600: The facility failed to protect Resident 76 from physical abuse by Staff 13, who hit the resident's forearm multiple times and restrained the resident's arm during an x-ray procedure. Witnesses confirmed the incident and the administrator acknowledged the abuse.
F 0636: The facility failed to complete admission or Annual MDS assessments in the required timeframe for 4 of 14 sampled residents, placing residents at risk for unassessed needs.
F 0638: The facility failed to complete Quarterly MDS assessments in the required timeframe for 10 of 14 sampled residents, placing residents at risk for unassessed needs.
F 0761: The facility failed to store drugs and biologicals in locked compartments for 1 medication cart and 1 treatment cart observed unlocked and unattended. This placed residents at risk for medication diversion and accidents.
Report Facts
Days overdue: 61
Days overdue: 61
Days overdue: 54
Days overdue: 41
Days overdue: 69
Days overdue: 68
Days overdue: 56
Days overdue: 49
Days overdue: 47
Days overdue: 37
Days overdue: 35
Days overdue: 27
Days overdue: 20
Days overdue: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff 13 | Former contracted radiology technician | Named in physical abuse of Resident 76 |
| Staff 10 | CNA | Witness to abuse incident involving Resident 76 |
| Staff 11 | CNA | Witness to abuse incident involving Resident 76 |
| Staff 12 | Agency CNA | Witness to abuse incident involving Resident 76 |
| Staff 4 | LPN | Assessed Resident 76 after abuse incident and intervened |
| Staff 1 | Administrator | Confirmed abuse of Resident 76 and stated expectations for medication cart security |
| Staff 8 | LPN | Observed unlocked medication cart |
| Staff 9 | RN | Observed unlocked treatment cart |
| Staff 2 | RNCM/DNS | Provided lists of residents with overdue MDS assessments and confirmed efforts to catch up |
| Staff 3 | Responsible for ensuring MDS assessments completion |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Aug 24, 2023
Visit Reason
The inspection was conducted following a complaint alleging physical abuse of Resident 76 by a staff member during an x-ray procedure.
Complaint Details
The complaint investigation substantiated that Resident 76 was physically abused by Staff 13 during an x-ray procedure. Multiple staff witnessed the abuse, and the administrator confirmed the abuse. No injuries were noted, but the resident was distressed. The facility initiated an incident report and notified appropriate personnel.
Findings
The facility was found to have failed to protect Resident 76 from physical abuse by Staff 13, who was witnessed hitting and restraining the resident. Additionally, the facility failed to complete timely admission, annual, and quarterly Minimum Data Set (MDS) assessments for multiple residents, and failed to ensure medication and treatment carts were locked when unattended.
Deficiencies (4)
F 0600: The facility failed to protect Resident 76 from physical abuse by Staff 13, who hit the resident's forearm multiple times and restrained the resident during an x-ray procedure. The incident was witnessed by multiple staff and confirmed by the administrator.
F 0636: The facility failed to complete admission or annual MDS assessments within the required time frame for 4 of 14 sampled residents, placing residents at risk for unassessed needs.
F 0638: The facility failed to complete quarterly MDS assessments within the required time frame for 10 of 14 sampled residents, placing residents at risk for unassessed needs.
F 0761: The facility failed to store drugs and biologicals in locked compartments for 1 of 1 medication carts and 1 of 1 treatment carts observed, placing residents at risk for medication diversion and accidents.
Report Facts
Days overdue: 61
Days overdue: 61
Days overdue: 54
Days overdue: 41
Days overdue: 69
Days overdue: 68
Days overdue: 56
Days overdue: 49
Days overdue: 47
Days overdue: 37
Days overdue: 35
Days overdue: 27
Days overdue: 20
Days overdue: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff 13 | Former contracted radiology technician | Named in physical abuse of Resident 76 |
| Staff 10 | CNA | Witnessed abuse of Resident 76 and reported incident |
| Staff 11 | CNA | Witnessed abuse of Resident 76 and reported incident |
| Staff 12 | Agency CNA | Witnessed abuse of Resident 76 |
| Staff 4 | LPN | Assessed Resident 76 after abuse incident and intervened |
| Staff 1 | Administrator | Confirmed abuse of Resident 76 and stated expectations for medication cart security |
| Staff 2 | RNCM / DNS | Provided lists of residents with overdue MDS assessments and confirmed efforts to catch up |
| Staff 3 | Responsible for MDS assessments | Confirmed responsibility for ensuring MDS assessments completion |
| Staff 8 | LPN | Observed medication cart unlocked |
| Staff 9 | RN | Observed treatment cart unlocked |
Inspection Report
Complaint Investigation
Capacity: 27
Deficiencies: 7
Date: Aug 24, 2023
Visit Reason
Facility failed to prevent abuse of a resident, failed to complete timely assessments, failed to store drugs properly, and had infection control issues. Many deficiencies were not corrected on revisit.
Findings
Facility failed to prevent abuse of a resident, failed to complete timely assessments, failed to store drugs properly, and had infection control issues. Many deficiencies were not corrected on revisit.
Deficiencies (7)
F0000 - INITIAL COMMENTS
F0600 - Free from Abuse and Neglect
F0636 - Comprehensive Assessments & Timing
F0638 - Qrtly Assessment at Least Every 3 Months
F0761 - Label/Store Drugs and Biologicals
M0000 - Initial Comments
M9999 - STATE OF OREGON ADMINISTRATIVE RULES
Inspection Report
Annual Inspection
Deficiencies: 9
Date: Aug 2, 2022
Visit Reason
The inspection was conducted as a regulatory annual survey of the nursing home facility to assess compliance with healthcare regulations and standards.
Findings
The facility was found to have multiple deficiencies including failure to maintain advance directives, unsafe environment with toxic plants, inadequate care planning, medication errors, poor infection control practices, and improper food handling. These deficiencies placed residents at risk for harm, including risks related to falls, infections, and medication adverse effects.
Deficiencies (9)
F 0578: The facility failed to obtain and maintain advance directives for 2 of 2 sampled residents, risking residents' healthcare wishes not being followed.
F 0584: The facility failed to maintain a homelike environment for 1 sampled resident due to a large stained carpet area not being cleaned timely.
F 0656: The facility failed to provide snacks as specified in the care plan for 1 sampled resident, risking unintended nutritional changes.
F 0679: The facility failed to provide group exercise activities to meet the needs of 1 sampled resident in the Health Center, limiting social engagement.
F 0684: The facility failed to monitor a resident after signs of UTI and failed to follow physician medication orders for 2 residents, risking delayed care and adverse reactions.
F 0689: The facility failed to ensure a safe environment free from toxic plants and failed to identify root causes of falls or implement fall interventions for 1 resident.
F 0812: The facility kitchen staff failed to handle and prepare food in a sanitary manner, risking foodborne illness for residents.
F 0880: The facility failed to ensure hand hygiene was performed between tasks by staff, risking cross contamination.
F 0881: The facility failed to review and document rationale for continued prophylactic antibiotic use for 1 resident, risking adverse medication consequences.
Report Facts
Number of falls: 8
Medication administration days: 24
Medication maximum dose: 16
Medication administered dose: 24
Creatinine level: 0.79
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff 9 | Social Services Director | Confirmed lack of advance directives for residents 8 and 23. |
| Staff 19 | Dietary Manager | Confirmed snack pass sheets showed resident 80 was offered fewer snacks than care plan. |
| Staff 6 | LPN | Reported on monitoring and medication administration issues for residents 17, 18, and 19. |
| Staff 2 | Director of Nursing Services (DNS) | Acknowledged monitoring and documentation deficiencies and infection control issues. |
| Staff 1 | Administrator | Acknowledged incident report delays and infection control issues. |
| Staff 8 | RN Care Manager | Acknowledged medication order errors and antibiotic stewardship deficiencies. |
| Staff 12 | Memory Care Coordinator | Provided list of plants and confirmed toxic plants in Memory Care Unit. |
| Staff 18 | Cook | Observed failing to follow proper glove use and hand hygiene in kitchen. |
| Witness 4 | Pharmacist | Discussed risks of long-term antibiotic use and lack of review for resident 23. |
Inspection Report
Complaint Investigation
Capacity: 27
Deficiencies: 10
Date: Aug 2, 2022
Visit Reason
Multiple deficiencies including failure to maintain advance directives, safe environment, comprehensive care plans, infection control, and antibiotic stewardship. Many deficiencies were not corrected on revisit.
Findings
Multiple deficiencies including failure to maintain advance directives, safe environment, comprehensive care plans, infection control, and antibiotic stewardship. Many deficiencies were not corrected on revisit.
Deficiencies (10)
F0000 - INITIAL COMMENTS
F0578 - Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir
F0584 - Safe/Clean/Comfortable/Homelike Environment
F0656 - Develop/Implement Comprehensive Care Plan
F0677 - ADL Care Provided for Dependent Residents
F0679 - Activities Meet Interest/Needs Each Resident
F0684 - Quality of Care
F0689 - Free of Accident Hazards/Supervision/Devices
F0812 - Food Procurement,Store/Prepare/Serve-Sanitary
F0880 - Infection Prevention & Control
Inspection Report
Capacity: 27
Deficiencies: 1
Date: Aug 2, 2022
Visit Reason
Facility failed to report complete COVID-19 information to CDC's NHSN during a required reporting period.
Findings
Facility failed to report complete COVID-19 information to CDC's NHSN during a required reporting period.
Deficiencies (1)
F0884 - Reporting - National Health Safety Network
Inspection Report
Capacity: 27
Deficiencies: 1
Date: Sep 10, 2021
Visit Reason
No deficiencies noted during state licensure survey.
Findings
No deficiencies noted during state licensure survey.
Deficiencies (1)
M0000 - Initial Comments
Inspection Report
Re-licensure
Capacity: 27
Deficiencies: 8
Date: May 14, 2021
Visit Reason
Facility failed to identify restraints, develop baseline care plans, and follow infection prevention protocols. Some deficiencies were corrected on revisit, others were not.
Findings
Facility failed to identify restraints, develop baseline care plans, and follow infection prevention protocols. Some deficiencies were corrected on revisit, others were not.
Deficiencies (8)
E0000 - Initial Comments
F0000 - INITIAL COMMENTS
F0604 - Right to be Free from Physical Restraints
F0655 - Baseline Care Plan
F0880 - Infection Prevention & Control
M0000 - Initial Comments
M9999 - STATE OF OREGON ADMINISTRATIVE RULES
Z0000 - General Comments
Inspection Report
Complaint Investigation
Capacity: 27
Deficiencies: 5
Date: Mar 9, 2021
Visit Reason
Facility failed to prevent abuse, failed to prevent falls, and had multiple uncorrected deficiencies related to abuse and accident hazards.
Findings
Facility failed to prevent abuse, failed to prevent falls, and had multiple uncorrected deficiencies related to abuse and accident hazards.
Deficiencies (5)
F0000 - INITIAL COMMENTS
F0600 - Free from Abuse and Neglect
F0689 - Free of Accident Hazards/Supervision/Devices
M0000 - Initial Comments
M9999 - STATE OF OREGON ADMINISTRATIVE RULES
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