Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mirabella At Asu during CMS and state inspections, most recent first.
A resident with dementia and a history of wandering was able to exit the facility unsupervised through an emergency exit door, despite being identified as a moderate elopement risk. Staff failed to complete a risk assessment prior to the incident, and gaps in staff knowledge and door security allowed the resident to leave the premises and attempt to cross a street before being found and returned by staff.
Missing or Incomplete Advance Directive Documentation: The facility did not ensure current advance directive copies were in the chart for two residents. One resident had DNR-related documentation and cognitive impairment, but no signed current DNR directive was found after admission. Another resident had DNR/POLST-like forms signed by the POA, but required provider and witness sections were blank, and one form used the POA name in the resident signature area. Staff and the DON stated that advance directives must be completed and signed by both the resident/POA and the provider to be valid.
Missing Provider Acknowledgement of Monthly Pharmacy MRRs: The facility did not document provider acknowledgement of monthly pharmacy MRR recommendations for three residents. The consultant pharmacist identified concerns involving high-dose amiodarone and a drug interaction with apixaban for one resident, possible GDR needs for psychotropics for another resident, and a possible GDR or discontinuation of fluoxetine for a third resident. The DON and NP stated the pharmacy reports had not been reviewed on time and that provider notes were unavailable in the EMR.
Unlabeled food was found in the nourishment refrigerator, including a yogurt parfait, an unidentified white liquid, a protein drink, and a thermos with an unknown substance. Later, staff also found an RN’s lunch stored in the same refrigerator. The DON, an LPN, and the Nutritional Services Manager confirmed that resident food was required to be labeled with the resident’s name, room number, and date, and that staff food was not to be stored there.
Missing EBP Signage at Resident Room Doors: The facility failed to post precaution signs for two residents on EBP. One resident had an indwelling urinary catheter and later a suprapubic catheter, and another had a surgical wound with staples and dressing after a femur fracture. In both rooms, PPE drapes were present on the doors, but staff observed no signage identifying the precautions or entry instructions, and staff interviews confirmed the residents were on EBP and that signs should have been posted.
Unjustified quetiapine use for insomnia. A resident with Parkinson’s disease, CKD, depression, and cognitive impairment was ordered Seroquel/quetiapine for sleep despite no documented psychotic behaviors or clear evaluation supporting the antipsychotic. The MAR showed the medication was given, but the record lacked documented consent, target behavior monitoring, and a care plan entry identifying the psychotropic use. Interviews with the RN, LPN, and DON confirmed that consent, indication, and target behaviors were expected, and the DON stated quetiapine is an antipsychotic that should not be used for sleep.
Medication Error Rate Exceeded 5 Percent: Surveyors observed two medication administration errors during 35 opportunities, resulting in a 5.71% error rate. An LPN gave a resident Docusate 100 mg instead of the ordered 50 mg dose, and an RN administered Lactobacillus Rhamnosus GG from an order that lacked a strength/unit of measure. The DON stated staff were expected to clarify unclear orders before giving medications.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Environmental Safeguards
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and environmental safeguards to prevent the elopement of a resident with a history of wandering and cognitive impairment. The resident, who had diagnoses including seizures, depression, anxiety, unspecified dementia, and difficulty walking, was identified as being at moderate risk for wandering. Despite this, there was no documented elopement or wandering risk assessment completed prior to the incident, and the resident was able to exit the facility through an emergency exit door near his room. On the night of the incident, staff observed the resident wandering and attempting to leave the building, expressing a desire to go to a store and a bar. Although staff redirected the resident to his room and assisted him to bed, subsequent safety rounds revealed that the resident was missing. A facility-wide search was initiated, and the resident was found outside the facility, attempting to cross the street toward a nearby convenience store. The emergency exit door used by the resident was equipped with an alarm that sounded for 15 seconds before unlocking, but staff interviews indicated that the alarm might not be heard if staff were in resident rooms, and the door could remain unlatched if not properly secured. Interviews with staff revealed gaps in knowledge regarding the operation and security of the emergency exit doors, as well as a lack of awareness of the resident's risk for elopement. The facility's policy required all residents to be assessed for elopement risk upon admission, but this was not completed for the resident prior to the incident. The failure to implement individualized safeguards and ensure staff awareness of exit door security contributed to the resident's ability to leave the facility unsupervised.
Missing or Incomplete Advance Directive Documentation
Penalty
Summary
The facility failed to ensure that current copies of advance directives were present in the clinical record for 2 of 9 sampled residents. For Resident #31, the record showed a portable medical order indicating no CPR and no artificial means of nutrition, and other documentation identified the resident as having a DNR code status. The resident had been admitted with diagnoses including a displaced intertrochanteric fracture of the right femur, Parkinson's disease, hypertensive chronic kidney disease stage 3, and depression, and was described as oriented to person and place with short-term memory loss and mild cognitive impairment. Despite these references to code status, the record did not contain evidence that a current DNR advance directive had been signed by the resident since admission. For Resident #4, the record included documentation of DNR status and a POLST-like form in the electronic medical record. The orange Prehospital Medical Care Directive form was signed by the resident's POA, but the required sections for the healthcare provider signature and date, as well as the witness signature and date, were left blank. The form also had the POA's name written in the section designated for the resident's name. An undated pink portable medical order form also marked no CPR, do not attempt to resuscitate, and comfort-focused treatments, but it was signed only by the POA and not by the healthcare provider. Staff interviews confirmed that advance directives were expected to be obtained on admission and that both the resident or POA and the provider must sign the form for it to be valid. The CNA stated code status was typically documented in the clinical record and discussed during shift change, while the RN and LPN stated that if the provider signature was missing, the form was incomplete and the resident was considered full code. The DON also stated that staff were expected to obtain and complete advance directive forms on admission and acknowledged that the forms for Resident #4 were not signed by the provider and that a current advance directive for Resident #31 was not in the record.
Missing Provider Acknowledgement of Monthly Pharmacy MRRs
Penalty
Summary
The facility failed to ensure that the attending physician documented acknowledgement of monthly Medication Regimen Review (MRR) recommendations for three sampled residents. The consultant pharmacist completed MRRs and identified medication-related concerns, but no documented provider reply was found in the clinical record for Residents #8, #10, and #15. The facility policy stated that the consultant pharmacist would review each resident’s medication regimen at least once a month and that pharmacy medication review recommendations would be acted upon in a timely manner. Resident #8 was admitted with diagnoses including repeated falls, acute embolism, malnutrition, anxiety, and depression. The resident’s MDS showed a BIMS score of 12, indicating moderate cognitive impairment. The care plan identified fall risk, high-risk medications, and anticoagulant use. Orders were entered for Amiodarone HCL 200 mg, 2 tablets twice daily via G-tube, and Apixaban 5 mg twice daily via G-tube, and the MAR showed the medications were administered as ordered. The pharmacist’s MRR noted that Amiodarone was in the high range for the elderly and requested review and clarification, and also identified a significant interaction between Amiodarone and Apixaban with a note that dose adjustment or more frequent monitoring may be necessary; no documented reply was found. Resident #10 was admitted with diagnoses including a nondisplaced fracture of the fifth metacarpal bone, falls, mood disorder, and cerebral infarction. The resident’s MDS showed a BIMS score of 14, indicating cognitive intactness, and the care plan identified high-risk medication use. Orders included Buspirone 5 mg twice daily, Citalopram Hydrobromide 40 mg daily, and Duloxetine HCL 30 mg delayed-release sprinkles each morning, with administration documented as ordered. The pharmacist’s MRR recommended review to determine whether a gradual dose reduction for Buspirone, Citalopram, and Duloxetine was appropriate and requested the provider document a decision, but no documented reply was found. Resident #15 was admitted with diagnoses including displaced fracture of the lateral malleolus of the left fibula, sequelae of cerebral infarction, and hemiplegia/hemiparesis following cerebral infarction. The admission MDS showed a BIMS score of 15 and identified antidepressant and anticoagulant use; the EMR showed Fluoxetine HCl 60 mg daily for depression. The pharmacist’s MRR asked the physician to determine whether a gradual dose reduction or discontinuation of Fluoxetine could be attempted, but no acknowledgement was documented by the medical doctor.
Unlabeled Food Stored in Nourishment Refrigerator
Penalty
Summary
The facility failed to ensure that food stored in the nourishment refrigerator was labeled in accordance with facility policy. During an initial observation of the nourishment refrigerator, surveyors found a yogurt parfait, a cup containing an unidentified white liquid, a carton of protein drink, and a pink thermos containing an unknown substance, all without a resident name, room number, or open/received date. A CNA confirmed that the required identifying information was absent and stated the items would be discarded immediately. During a later observation, surveyors found a tan grocery bag with unidentified food items in the same refrigerator, again with no labels or dates visible. When the bag was removed, an RN stated it was his lunch and said the refrigerator was intended for resident food, not staff food. Interviews with the Nutritional Services Manager, an LPN, and the DON confirmed that resident food stored in the nourishment refrigerator was to be labeled with the resident’s name, room number, and date, and that staff food should not be stored there. The DON stated the findings did not meet her expectations and that the practice could cause residents to become ill from foodborne illness.
Missing EBP Signage at Resident Room Doors
Penalty
Summary
The facility failed to ensure that enhanced barrier precautions (EBP) signage was posted for two residents who were on precautions. One resident had an indwelling urinary catheter and later a suprapubic catheter with a leg bag, and the other resident had staples and a surgical dressing on the right trochanter after a femur fracture. In both rooms, PPE drapes were hanging on the doors, but no signs were posted to identify the type of precautions or the required instructions for entry. For the resident with the urinary catheter, clinical records showed the resident had a Foley catheter, then a suprapubic catheter, and continued to have catheter-related care and monitoring. During multiple observations, staff found a blue drape with PPE at the door, but no EBP sign was present. A CNA, the registry nurse, and an RN all stated the resident was on EBP because of the indwelling catheter and that a sign should have been posted with the drape. For the resident with the surgical wound, the record showed staples and a surgical dressing on the right trochanter and an order for EBP every shift for wounds. An observation found a yellow drape with PPE on the door, but no signage was posted. Staff interviews confirmed the resident was on EBP and that signs should be posted at the doorway to identify the precautions and PPE requirements. The facility policy stated that a sign would be used to alert staff of EBP or other transmission-based precautions and that signage should be placed at the doorway for the duration of the illness.
Unjustified quetiapine use for insomnia
Penalty
Summary
The facility failed to ensure there was adequate indication for the use of quetiapine for one resident who was admitted with diagnoses including displaced intertrochanteric fracture of the right femur, Parkinson’s disease without dyskinesia, hypertensive chronic kidney disease, stage 3 chronic kidney disease, and depression. Hospital discharge documentation showed quetiapine 50 mg at bedtime and quetiapine 25 mg at bedtime as needed for sleep, but there was no evidence in the hospital discharge summary that the resident had psychotic behaviors such as hallucinations or delusions. On admission, the resident was documented as following commands, oriented to person and place, with short-term memory loss, mild cognitive impairment, a pleasant mood, no unwanted behaviors, insomnia, and no wandering at night. The clinical record did not show that an evaluation was completed to determine whether quetiapine was justified. The physician order entered on August 1, 2025 included Seroquel 25 mg, 2 tablets at bedtime for insomnia, plus 1 tablet every 24 hours as needed for insomnia to be combined with the 50 mg dose if needed, and quetiapine 50 mg at bedtime for sleep with an additional 0.5 tablet as needed to total 75 mg. The order was transcribed to the MAR and administered beginning August 2, 2025. Although the MAR showed monitoring for side effects, there was no evidence that the risk and benefits of quetiapine were explained to the resident or resident representative before administration, and there was no evidence that the target behavior for which it was prescribed was monitored. The baseline care plan did not identify that the resident was receiving a psychotropic or antipsychotic medication. Subsequent documentation described the resident as confused at times, alert and oriented to self and place, frail, in good spirits, and oriented to self only, with diagnoses including dementia and anxiety, but the record still did not show psychotic behaviors such as hallucinations, delusions, or disorganized thinking or speech. Interviews with nursing staff and the DON confirmed that consent, indication, target behavior, and monitoring were expected for psychotropic medications, and the DON stated that quetiapine is an antipsychotic and should not be used for sleep. The facility policy also required documented rationale, diagnosis, indication for use, and therapeutic goal, and stated that residents admitted on psychotropics without clear indication should have the medication justified through a comprehensive medical evaluation.
Medication Error Rate Exceeded 5 Percent
Penalty
Summary
The facility failed to ensure that the medication error rate remained below 5 percent. During medication administration observations, surveyors identified two medication administration errors out of 35 opportunities, resulting in a 5.71% error rate. The report states this deficient practice involved two residents and could result in further medication administration error. For one resident with Parkinson’s disease without dyskinesia, essential hypertension, and unspecified dementia, an LPN administered one Docusate 100 mg capsule even though the MAR and physician order specified Docusate Sodium 50 mg, 1 capsule by mouth twice daily to soften stool. The LPN confirmed the error and stated she should have administered half of the dose as ordered. For another resident with cognitive communication deficit, need for assistance with personal care, and history of falling, an RN administered two Lactobacillus Rhamnosus GG capsules; the order listed Lactobacillus Rhamnosus (GG) oral capsule, 2 capsules by mouth daily, but did not include a strength or unit of measure. The RN stated the order did not have units and that she would ask the doctor about it, and the DON confirmed staff were expected to clarify unclear orders before administration.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Tempe
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Plaza Healthcare | 3.7 mi | ★★★★★ | 4 | 0 |
| Tempe Post Acute | 3.8 mi | ★★★★★ | 6 | 0 |
| Rehab At Scottsdale Village Square | 3.9 mi | — | 20 | 0 |
| Friendship Village Of Tempe | 4 mi | ★★★★★ | 2 | 0 |
| Haven Of Scottsdale | 4.5 mi | ★★★★★ | 13 | 0 |
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