Inspection Reports for
Mirabella at ASU
65 E University Dr, Tempe, AZ 85281, AZ, 85281
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
1.5 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
59% better than Arizona average
Arizona average: 3.7 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 14, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide adequate supervision and environmental safeguards to prevent elopement of a resident (#105), which placed the resident at risk for serious injury, exposure to traffic injury, abduction, and death.
Complaint Details
The complaint investigation revealed that Resident #105 eloped from the facility on October 26, 2025, was found outside near a convenience store, and was returned safely. The resident had no prior history of elopement. The investigation included staff interviews, record reviews, and observation of the emergency exit door alarm system. The resident was assessed as moderate risk for wandering but no elopement risk assessment was completed prior to the incident. The facility implemented one-on-one observation and relocated the resident's room closer to the nurse station after the incident.
Findings
The facility failed to ensure adequate supervision and environmental safeguards to prevent elopement of Resident #105, who was found wandering outside the facility. The resident was assessed as moderate risk for wandering but no prior elopement risk assessment was available before the incident. The emergency exit door alarm system was found to be insufficient as the door could be opened without a key card after the alarm sounded. Staff interviews revealed lapses in supervision and knowledge of exit door security. The resident was placed on one-on-one observation after the incident and moved closer to the nurse station.
Deficiencies (1)
Failure to ensure adequate supervision and environmental safeguards to prevent elopement of Resident #105.
Report Facts
Wandering risk assessment score: 10
Date of elopement incident: Oct 26, 2025
Date of inspection: Nov 14, 2025
Alarm duration: 15
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 29, 2023
Visit Reason
The inspection was conducted due to allegations of abuse involving three residents (#65, #164, and #167) at the facility, focusing on whether these allegations were properly reported to the appropriate state agencies and investigated.
Complaint Details
The complaint investigation involved allegations of abuse for residents #65, #164, and #167. The facility did not provide evidence that these allegations were reported to all required state agencies or that thorough investigations were completed. The Administrator and Director of Nursing confirmed missing documentation of reports and investigations. The facility policy requires timely reporting of all alleged violations involving abuse, neglect, exploitation, or mistreatment.
Findings
The facility failed to ensure that allegations of abuse for three residents were reported to all required state agencies and that thorough investigations were completed. Interviews with staff and review of records revealed missing documentation of reports and investigations for these incidents.
Deficiencies (1)
Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities for residents #65, #164, and #167.
Report Facts
Date of survey completion: Nov 29, 2023
Date of alert note: Jul 3, 2023
Date of progress note: Oct 19, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Worker (staff #1) | Interviewed regarding resident #65 incident | |
| Administrator (staff #2) | Interviewed regarding missing documentation of reports | |
| Director of Nursing (DON/staff #4) | Interviewed regarding missing reports and facility expectations |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Oct 13, 2022
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to ensure proper advance directive documentation, adequate transfer/discharge documentation, and provision of necessary personal hygiene services to residents.
Complaint Details
The complaint investigation found substantiated deficiencies related to incomplete advance directive documentation, inadequate transfer/discharge documentation, and failure to provide personal hygiene care to residents.
Findings
The facility failed to obtain a physician order for a resident's DNR advance directive, did not provide adequate documentation and communication during resident transfer/discharge, and failed to ensure three residents received necessary bathing and grooming assistance as per their care plans and preferences.
Deficiencies (3)
Failed to ensure the advance directive process was complete for one resident by failing to obtain a physician order for DNR.
Failed to ensure one resident's clinical record included required information for transfer/discharge, resulting in unsafe transition of care.
Failed to ensure three residents received necessary services to maintain good grooming and personal hygiene.
Report Facts
Sample size: 3
Residents affected: 1
Residents affected: 1
Residents affected: 3
Days without shower: 9
Days without shower: 9
Days without shower: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Provided information on missing physician order for DNR and expectations for documentation and care |
| Administrator | Facility Administrator | Provided expectations regarding discharge documentation and shower/bath documentation |
| Staff #200 | Registered Nurse (RN) | Interviewed regarding nursing assistant admission checklist and shower documentation |
| Staff #201 | Director of Therapy | Provided information on occupational therapy shower provision and documentation |
| Staff #14 | Certified Nursing Assistant (CNA) | Interviewed about shower frequency and documentation practices |
Inspection Report
Deficiencies: 1
Date: Aug 24, 2021
Visit Reason
The inspection was conducted to evaluate the facility's compliance with pharmaceutical services regulations, specifically regarding the storage and reconciliation of controlled medications.
Findings
The facility failed to ensure controlled medications were stored and reconciled according to professional standards, with observations of unsecured medications and lack of proper counting and documentation, increasing the risk of loss or diversion.
Deficiencies (1)
Failure to ensure a controlled medication was stored and reconciled in accordance with professional standards of practice, including unsecured storage of hydrocodone-acetaminophen and lack of proper counting.
Report Facts
Medications in bags: 9
Unidentified pills: 100
Date of observation: Aug 23, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN/staff #19) | Interviewed regarding medication storage and handling | |
| Director of Nursing (DON/staff #61) | Interviewed regarding facility policies on controlled medications |
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