Mirabella at Asu
Tempe, Arizona · CCN 035300
5 surveys since 2021, and no finding has been recorded at harm level.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
- Citations on record
- 12
- Surveys
- 5
- Harm or worse
- 0
- Immediate jeopardy
- 0
No finding on record has been cited at harm level or above.
Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.
The facility
- Certified beds
- 21
- Ownership
- Non profit - Corporation
- Chain
- PACIFIC RETIREMENT SERVICES
- County
- Maricopa
- Medicare-certified since
- 2021
CMS ratings
- Overall
- 3
- Health inspection
- 3
- Staffing
- 4
- Quality measures
- 4
CMS’s own Five-Star ratings.
Compared with similar facilities
Not shown for this facility: too few citations in window (n=12, floor 20).
Last survey on record
Nov 14, 2025
360 days ago.
Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.
Staffing
| Measure | This facility | Peer median |
|---|---|---|
| Nurse hours per resident day | 7.02 | 5.20 |
| Registered-nurse hours per resident day | 2.07 | — |
| Annual nurse turnover | 61.5% | 53.2% |
As reported by the facility to CMS, beside the peer-group median.
Enforcement
No fines, payment denials or special-focus designation on the current CMS record.
Severity of recent findings
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J— | K— | L— |
| Actual harm | G— | H— | I— |
| No harm, potential for more than minimal | D545.5% | E654.5% | F— |
| No harm, potential for minimal | A— | B— | C— |
Most frequently cited here
In CMS’s current monthly file.
- F5782×
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
- F6051×
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
- F6091×
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- F6221×
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
- F6771×
Provide care and assistance to perform activities of daily living for any resident who is unable.
In the surveyor’s words
From the most serious findings on record at Mirabella at Asu, in the surveyor’s own words.
- No harm, potential for more than minimal, patternF578Aug 8, 2025
Number of residents sampled: 9Number of residents cited: 2Based on clinical record reviews, staff interviews, and review of facility policy, the facility failed to ensure that a current copy of the advance directives were in the clinical record for 2 of 9 sampled residents (#31 and #4) residents. The deficient practice could result in resident wishes not respected and followed. -Resident #31 was admitted on [DATE] with diagnoses of displaced intertrochanteric fracture of the right femur, subsequent encounter for closed fracture with routine healing, Parkinson's disease, hypertensive chronic kidney disease, Stage 3 chronic kidney disease and depression.The portable medical order signed by resident #31 and dated [DATE] included that the resident had a code status of no CPR (cardiopulmonary… […]
- No harm, potential for more than minimal, patternF756Aug 8, 2025
Based on clinical record review, staff interviews and review of facility policy and procedures, the facility failed to ensure that the attending physician documented acknowledgement of their monthly Medication Regimen Review recommendations for three of five sampled residents ( #8, #10 #15). The deficient practice could result in regulatory recommendations provided by a licensed pharmacy not being considered during treatment of the residents. Findings Include: - Regarding Resident #8 Resident # 8 was admitted on [DATE] with diagnoses to include repeated falls, acute embolism malnutrition, anxiety and depression. The residents MDS (Minimum Data Set) dated August, 2025 revealed a BIMS (Brief Interview for Mental Status of 12, indicating that the resident had moderate cognitive impairment. […]
- No harm, potential for more than minimal, patternF812Aug 8, 2025
Number of residents sampled: 16Number of residents cited: 0The facility failed to ensure that all food in the nourishment refrigerator was labeled according to facility policy. Findings include: During the initial observation of the nourishment refrigerator conducted on August 5, 2025 at 11:46 a.m., the following items were found to be stored with no resident name, room number and no open or received date.- 1 Yogurt Parfait- 1 cup containing an unidentified white liquid- 1 carton Protein drink- 1 pink thermos containing an unknown substanceAt the time of the observation certified nursing assistant (CNA) / staff #21 was asked to confirm that the names and dates were absent on these items. […]
- No harm, potential for more than minimal, patternF880Aug 8, 2025
Number of residents sampled: 5Number of residents cited:Based on observations, clinical record review, staff interviews and facility policy review, the facility failed to ensure that signs were posted related to enhanced barrier precautions (EBP) for two residents (#12 and #31) of 5 sampled residents. The deficient practice could result in transmission of infections to staff and other residents. Findings include: -Resident #4 was admitted on [DATE] with diagnoses of mechanical complications of other prosthetic devices, Parkinson's disease without dyskinesia and benign prostatic hyperplasia (BPH) without lower urinary tract symptoms. The alert charting dated June 26, 2025 included that the resident was alert and oriented x 3 and had a foley catheter 16Fr in place which was draining well. […]
- No harm, potential for more than minimal, patternF609Nov 29, 2023
Based on clinical record, facility documents, staff interviews and facility policy, the facility failed to ensure that an allegation of abuse was reported to the appropriate state agencies for 3 residents (#65, #164, and #167). Findings include: -Resident #65 was admitted on [DATE] with diagnoses of Aphasia following Cerebral Infarction, and need for assistance with personal care. A Minimum Data Set (MDS) dated [DATE] included that the staff had assessed the resident as severely impaired to make decisions regarding daily life and that the resident had a memory problem An interview was conducted on 11/29/23 at 10:58 a.m. […]
Every survey on record
FindingsAt actual harm or above
- Nov 14, 2025Complaint1 finding
- Aug 8, 2025Standard6 findings
- Nov 29, 2023Complaint1 finding
- Oct 13, 2022Standard3 findings
- Aug 24, 2021Standard1 finding
Surveys that found no deficiencies are not in CMS’s files and do not appear here.
Comparable facilities
The nearest facilities to this one in the same peer group, by weighted findings.
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