Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Mirabella
SEATTLE, WA · 46 certified beds · Last Life Safety survey June 27, 2025
CMS Certification Number 505520 · first certified April 2009
Ownership
Independently operated (no chain recorded by CMS) · Non profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within WA
54 citations — more than 88% of the 193 certified nursing homes in WA. Compared within WA rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 18 citations; the earlier surveys in the window averaged 18. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Past the typical window (June 2026 to September 2026). Most WA facilities have been surveyed by October 2026. This facility’s last Life Safety survey was June 2025. Facilities in WA are typically surveyed 12–15 months after the last one (median 13), measured over 320 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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5 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
25 of the 54 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
5 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 54 Life Safety citations above. The Physical Environment Index
- F-0880 Provide and implement an infection prevention and control program.
- F-0908 Keep all essential equipment working safely.
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0909 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.
How that compares
Compared with the median facility in WA, and nationally. Surveyors differ markedly between states, so the WA figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 54 |
| Median facility in WA | 31 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| March 22, 2023 | 24 |
| June 28, 2024 | 12 |
| June 27, 2025 | 18 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0541 | Install properly constructed and protected linen or trash chutes. | 3 | 2025-06-27 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 2 | 2024-06-28 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 2 | 2025-06-27 |
| E-0039 | Conduct testing and exercise requirements. | 2 | 2025-06-27 |
| E-0031 | Provide emergency officials' contact information. | 2 | 2025-06-27 |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | 2 | 2024-06-28 |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | 2 | 2025-06-27 |
| E-0025 | Create arrangements with other facilities to receive patients. | 2 | 2025-06-27 |
What the citations cover
- Emergency Preparedness Deficiencies 25
- Smoke Deficiencies 12
- Services Deficiencies 8
- Gas, Vacuum, and Electrical Systems Deficiencies 4
- Other 5
| Category | Citations |
|---|---|
| Emergency Preparedness Deficiencies | 25 |
| Smoke Deficiencies | 12 |
| Services Deficiencies | 8 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 4 |
| Egress Deficiencies | 3 |
| Miscellaneous Deficiencies | 2 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
June 27, 2025 — 18 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (June 27, 2025) |
| E-0007 | Address patient/client population and determine types of services needed. | Deficient, Provider has date of correction (September 10, 2025) |
| E-0015 | Address subsistence needs for staff and patients. | Deficient, Provider has date of correction (July 17, 2025) |
| E-0020 | Establish policies and procedures including evacuation. | Deficient, Provider has date of correction (July 10, 2025) |
| E-0025 | Create arrangements with other facilities to receive patients. | Deficient, Provider has date of correction (October 9, 2025) |
| E-0030 | List the names and contact information of those in the facility. | Deficient, Provider has date of correction (August 12, 2025) |
| E-0031 | Provide emergency officials' contact information. | Deficient, Provider has date of correction (September 17, 2025) |
| E-0034 | Provide a means of sharing information on occupancy/needs. | Deficient, Provider has date of correction (July 16, 2025) |
| E-0035 | Provide family notifications of emergency plan. | Deficient, Provider has date of correction (July 10, 2025) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (September 17, 2025) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (July 2, 2025) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (July 10, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (July 10, 2025) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (September 10, 2025) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (October 3, 2025) |
| K-0541 | Install properly constructed and protected linen or trash chutes. | Deficient, Provider has date of correction (July 10, 2025) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (July 10, 2025) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (July 10, 2025) |
June 28, 2024 — 12 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0009 | Include a process for Emergency Preparedness collaboration. | Deficient, Provider has date of correction (August 6, 2024) |
| E-0013 | Develop Emergency Preparedness policies and procedures. | Deficient, Provider has date of correction (August 6, 2024) |
| E-0018 | Establish procedures for tracking staff and patients during an emergency. | Deficient, Provider has date of correction (August 6, 2024) |
| E-0024 | Establish policies and procedures for volunteers. | Deficient, Provider has date of correction (August 6, 2024) |
| E-0033 | Establish methods for sharing information. | Deficient, Provider has date of correction (August 6, 2024) |
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (August 6, 2024) |
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Deficient, Provider has date of correction (August 6, 2024) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (August 6, 2024) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (August 6, 2024) |
| K-0531 | Have elevators that firefighters can control in the event of a fire. | Deficient, Provider has date of correction (August 6, 2024) |
| K-0541 | Install properly constructed and protected linen or trash chutes. | Deficient, Provider has date of correction (August 6, 2024) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (August 27, 2024) |
March 22, 2023 — 24 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0001 | Establish an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (April 21, 2023) |
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (April 21, 2023) |
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (April 21, 2023) |
| E-0009 | Include a process for Emergency Preparedness collaboration. | Deficient, Provider has date of correction (April 21, 2023) |
| E-0015 | Address subsistence needs for staff and patients. | Deficient, Provider has date of correction (April 21, 2023) |
| E-0025 | Create arrangements with other facilities to receive patients. | Deficient, Provider has date of correction (April 21, 2023) |
| E-0031 | Provide emergency officials' contact information. | Deficient, Provider has date of correction (April 21, 2023) |
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (April 21, 2023) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (April 21, 2023) |
| K-0222 | 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. | Deficient, Provider has date of correction (April 21, 2023) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (April 21, 2023) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (April 21, 2023) |
| K-0324 | Provide properly protected cooking facilities. | Waiver has been granted (May 5, 2023) |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | Deficient, Provider has date of correction (April 21, 2023) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (May 5, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (April 21, 2023) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (April 21, 2023) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (April 21, 2023) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Waiver has been granted (May 5, 2023) |
| K-0531 | Have elevators that firefighters can control in the event of a fire. | Deficient, Provider has date of correction (April 21, 2023) |
| K-0541 | Install properly constructed and protected linen or trash chutes. | Deficient, Provider has date of correction (April 21, 2023) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (April 21, 2023) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (April 21, 2023) |
| K-0926 | Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Deficient, Provider has date of correction (April 21, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.