Inspection Reports for
Mirabella at ASU

The following deficiencies were found during the on-site compliance inspection and investigation of complaint 00104213, 00121852, 00155377, 00144545, 00141286, 00139051, 00122026, 00108636, 00108545, 00121819, 00105427, 00104883, 00124282, and 00155540 conducted on January 22, 2026.

This inspection resulted in no citations or deficiency findings.

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.

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.

An on-site investigation of complaint AZ00215611 was conducted on September 26, 2024, and the following deficiencies were cited.

Two deficiencies were cited related to documentation failures in resident medical records. The facility failed to document services provided and lacked required medical determinations for a resident confined to a bed or chair.

The following deficiencies were found during the on-site compliance inspection and investigation of complaint AZ00214798, AZ00215246, AZ00214915, and AZ00210889 conducted on August 30, 2024.

Two deficiencies were found related to tuberculosis screening documentation and evacuation drill records. The facility failed to provide evidence of freedom from infectious tuberculosis for two residents and did not document identification of residents needing assistance or those not evacuated during drills.

An on-site investigation of complaint AZ00200524, AZ00203543, and AZ00207572 was conducted on March 25, 2024 and additional documents were provided on March 26, 2024. No deficiency was cited.

No deficiencies were cited during this inspection.

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.

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.

A $1,500.00 penalty was assessed and paid in full on 21 October 2023.

No deficiencies were found during this inspection.

The following deficiencies were found during the on-site compliance inspection and investigation of complaint #AZ00192375 and #AZ00198296 conducted on August 17, 2023.

Two deficiencies were found related to employee fingerprint clearance cards and expired first aid and CPR certification for a manager, posing safety and health risks to residents.

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.

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.

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.