Inspection Reports for Mirabella at ASU
65 E University Dr, Tempe, AZ 85281, AZ, 85281
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Inspection Report
Complaint Investigation
Capacity: 47
Deficiencies: 6
Sep 26, 2024
Visit Reason
State-compiled facility profile showing 6 inspections from 2023-01-27 to 2024-09-26 with deficiency history and complaint investigations.
Findings
Across six inspections, including complaint and annual compliance investigations, six deficiencies were cited involving documentation failures in resident care, tuberculosis screening, evacuation drill documentation, employee fingerprint clearance, and expired first aid/CPR certification. Three inspections found no deficiencies.
Complaint Details
Multiple complaint investigations were conducted including complaint AZ00215611 on 2024-09-26, AZ00214798, AZ00215246, AZ00214915, AZ00210889 on 2024-08-30, AZ00200524, AZ00203543, AZ00207572 on 2024-03-25/26, and #AZ00192375 and #AZ00198296 on 2023-08-17, with deficiencies cited in some investigations.
Deficiencies (6)
| Description |
|---|
| C. A manager shall ensure that: 1. A caregiver or an assistant caregiver: g. Documents the services provided in the resident's medical record; and - Failed to ensure the caregiver documented the services provided in the resident's medical record for one of two residents reviewed. |
| C. In addition to the requirements in R9-10-808(A)(3), a manager shall ensure that the service plan for a resident receiving directed care services includes: 2. If applicable, the determination in R9-10-814(B)(2)(b)(iii); - Manager retained a resident confined to a bed or chair without required determination documentation. |
| A. Except as provided in R9-10-808(B)(2), a manager shall ensure that a resident provides evidence of freedom from infectious tuberculosis: 1. Before or within seven calendar days after the resident's date of occupancy, and 2. As specified in R9-10-113. - Failed to ensure resident records contained evidence of freedom from infectious tuberculosis for two of two residents sampled. |
| A. A manager shall ensure that: 6. Documentation of each evacuation drill is created, is maintained for at least 12 months after the date of the evacuation drill, and includes: c. If applicable: i. An identification of residents needing assistance for evacuation, and ii. An identification of residents who were not evacuated; - Failed to ensure evacuation drill documentation included identification of residents needing assistance and those not evacuated. |
| A. A governing authority shall: 9. Ensure compliance with A.R.S. § 36-411. - Failed to ensure employees had valid fingerprint clearance cards or applications within 20 working days of hire for two of six personnel records reviewed. |
| A. A manager shall ensure that: 10. Before providing assisted living services to a resident, a manager or caregiver provides current documentation of first aid training and cardiopulmonary resuscitation training certification specific to adults. - Failed to ensure one sampled personnel record had current first aid and CPR certification; certification expired July 2023. |
Report Facts
Inspections on page: 6
Total deficiencies: 6
Complaint inspections: 5
Total capacity: 47
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Manager | Named in findings related to documentation failures and expired first aid/CPR certification |
| E5 | Maintenance Technician | Named in fingerprint clearance card deficiency |
| E6 | Housekeeper | Named in fingerprint clearance card deficiency |
| E4 | Interviewed regarding evacuation drill participation and documentation |
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