Mirabella Portland

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF880May 14, 2021

  Based on observation, interview and record review, it was determined the facility failed to follow Centers for Disease Control and Prevention (CDC) guidelines for disposing, cleaning and storing of personal protective equipment (PPE) for 1 of 1 sampled resident (#184) reviewed for infection control related to COVID-19 and failed to follow manufacture's guidance related to use of disinfection products for infection control precautions in relation to COVID-19 prevention. This placed residents and staff at risk for infection and illness related to the COVID-19 virus. Findings include: 1. […]

• No harm, potential for more than minimal, patternF636Aug 24, 2023

  Based on interview and record review it was determined the facility failed to complete an Admission or Annual MDS (Minimum Data Set) assessment in the required time frame for 4 of 14 sampled residents (#s 6, 8, 16 and 77) reviewed for resident assessments. This placed residents at risk for unassessed needs. Findings include: The facility's 6/2022 MDS policy and procedure specified the following: -The facility would complete and maintain MDS assessments on every resident admitted to the facility in accordance with the current Centers for Medicare and Medicaid Services Resident Assessment Instrument manual, Version 3.0. -The purpose of the MDS was to assess residents using a comprehensive process in order to identify care needs and to develop an interdisciplinary care plan. […]

• No harm, potential for more than minimal, patternF638Aug 24, 2023

  Based on interview and record review it was determined the facility failed to complete a Quarterly MDS (Minimum Data Set) assessment in the required time frame for 10 of 14 sampled residents (#s 1, 4, 5, 10, 13, 15, 18, 20, 22, and 23) reviewed for resident assessments. This placed residents at risk for unassessed needs. Findings include: The facility's 6/2022 MDS policy and procedure specified the following: -The facility would complete and maintain MDS assessments on every resident admitted to the facility in accordance with the current Centers for Medicare and Medicaid Services Resident Assessment Instrument manual, Version 3.0. -The purpose of the MDS was to assess residents using a comprehensive process in order to identify care needs and to develop an interdisciplinary care plan. […]

• No harm, potential for more than minimal, patternF812Aug 2, 2022

  Based on observation and interview it was determined the facility kitchen staff failed to handle and prepare food in a sanitary manner for 1 of 3 kitchens reviewed. This placed residents at risk for foodborne illness. Findings include: On 7/28/22 at 11:34 AM Staff 18 (Cook) was observed to wear gloves and plate lunch meals for residents in the 2nd-floor kitchen. She opened the refrigerator, removed containers of meat, cheese, spread, and bread, and placed them on the counter while she wore the same gloves. Staff 18 did not change her gloves before she assembled grilled beef and cheese sandwiches. […]

• No harm, potential for more than minimal, patternF880Aug 2, 2022

  Based on observation and interview it was determined the facility failed to ensure hand hygiene was performed between tasks for 2 of 2 staff (#s 10 and 17) who were randomly observed for hand hygiene. This placed residents at risk for cross contamination. Findings include: 1. On 7/28/22 at 10:35 AM Staff 17 (Server) was observed to deliver food to room [ROOM NUMBER], left the room, did not perform hand hygiene and then delivered food to room [ROOM NUMBER]. Staff 17 stated she did not usually do hand hygiene when passing snacks. On 8/1/22 at 10:03 AM Staff 2 (DNS) indicated hand hygiene was to be performed upon leaving each resident room. 2. On 8/2/22 at 10:29 AM Staff 10 (LPN) was observed to remove gloves and walk to the medication cart. […]