Mirabella At Asu

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, observation and the facility policy and procedures, the facility failed to ensure that an adequate supervision and environmental safeguards were provided to prevent elopement for a resident (#105). The deficient practice placed the resident at risk for serious injury, exposure to traffic injury, abduction and death.Findings Include:Resident #105 was admitted to the facility on [DATE], and discharged on October 29, 2025 with diagnosis that included seizures, depression, anxiety, unspecified dementia without behavioral disturbance, and difficulty in walking.The progress note dated October 17, 2025 at 11:28 pm stated under Mood and Behavior that it was unknown if resident slept through the night and also stated that the resident wandered at night.Another progress note dated October 18, 2025 at 1:14 pm stated that the resident was impulsive and is wandering.A quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed that Resident #105 had a Brief Interview for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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 resuscitation) and no artificial means of nutrition desired.The hospital discharge summary report dated [DATE] revealed the resident had an advance directive, had no preexisting DNR/DNI (Do Not Intubate) directives and a copy…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. The resident's care plan initiated on July 24, 2025 revealed the resident was at risk for falls, high risk medications were in use and anticoagulants prescribed. On July 29, 2025 Amiodarone HCL 200 Milligram, 2 tablets two times…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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. Staff #21 confirmed the information and stated the items would be discarded immediately.During the follow up observation of the nourishment refrigerator at 2:12p.m. on August 7, 2025 a tan grocery bag with unidentified food items was discovered. No labels or dates were visible on the bag or food items. When the bag was removed from the refrigerator Registered Nurse (RN) /staff # 47 stated that the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. The clinical admission note dated June 26, 2025 revealed the resident had an intact, patent catheter in place due to urinary retention. The physician order dated June 26, 2025 included to provide urinary catheter care every shift…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Number of residents sampled: 5Number of residents cited: 1 Based on clinical record review, staff interviews and review of facility policy and procedures, the facility failed to ensure there was adequate indication for the use of an antipsychotic for one of 5 sampled residents (#31). The deficient practice could result in resident receiving an unnecessary antipsychotic medication. Findings include: Resident #31 was admitted on [DATE] with diagnoses of displaced intertrochanteric fracture of the right femur, Parkinson's disease without dyskinesia, hypertensive chronic kidney disease, stage 3 chronic kidney disease and depression.The hospital Discharge summary dated [DATE] revealed the resident had depressive disorder and insomnia. Medications included Quetiapine (antipsychotic) 50 mg (milligrams) by mouth at bedtime and Quetiapine 25 mg by mouth at bedtime as needed to be combined with 50 mg dose if no success with sleeping.Further review of hospital discharge documentation revealed no evidence that resident #31…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, and policy review, the facility failed to ensure that the medication error rate was not 5% or greater for two of three residents (#37, #10). The deficient practice could result in further medication administration error.Findings include:Two medication administration errors were identified out of thirty-five opportunities during medication administration observation. The medication error rate was 5.71%.-Regarding Resident #37Resident #37 was admitted to the facility on [DATE] with diagnoses that included Parkinson's Disease without dyskinesia, essential hypertension, and unspecified dementia.A medication administration observation was conducted on August 6, 2025 at 8:56 PM with Licensed Practical Nurse (LPN/Staff #11). During medication administration for Resident #37, the LPN was observed placing one Docusate 100 milligram capsule into a medicine cup. Resident was administered the medication from the cup.Review of Medication Administration Records (MAR)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. with a social services worker (staff #1) who said that he had walked into the room to ask the resident's daughter some questions and that he saw the resident's private caregiver standing next to her. This staff said that the therapist walking into the room, and that he saw the caregiver lean in and yells in the resident's face that therapy was here and when she did not respond the caregivers'…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record reviews, facility documentation, resident and staff interviews, and policies and procedures, the facility failed to ensure that three residents (#108, #159 and #6) received the necessary services to maintain good grooming and personal hygiene. The sample size was 3. The deficient practice could result in poor hygiene for residents. Findings include: -Resident #108 was admitted to the facility on [DATE] with diagnoses that included aphasia, convulsions, fall, and weakness. Review of a Nursing Assistant admission Checklist dated October 3, 2022, revealed the resident preferred showers to be provided at 9:00 AM. The signature lines were blank with no evidence of a nurse signature or date. Upon obtaining a copy of the form, the RN signature had been completed and dated October 3, 2022 by staff #200. Review of a care plan dated October 5, 2022 for functional status with goal personal hygiene revealed the resident required bathing assistance of one-person assistance and preferred…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and policy review, the facility failed to ensure the advance directive process was complete for one resident (#158), by failing to obtain a physician order for DNR (Do Not Resuscitate). The sample size was 3. The deficient practice could lead to medical treatment inconsistent with the resident's wishes. The findings include: Resident #158 was admitted to the facility on [DATE] with diagnoses that included dislocation and pain to the left hip. Upon initial review of the resident's clinical record, including the physician order summary, on October 11, 2022 at 10:09 a.m., the resident did not have a code status/advance directive, nor was there a physician order that reflected the resident's wishes in the event of cardiac or respiratory arrest. On October 12, 2022 at 9:15 a.m. a written request was made for a copy of the resident's (#158) advance directive. On October 12, 2022 at 11:04 a.m. in response to the request for the resident's advance directive, the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and review of facility policies and procedures, the facility failed to ensure one sampled resident's (#8) clinical record included the required information for transfer/discharge. The deficient practice could result in residents not having a safe and effective transition of care. Findings include: Resident #8 was admitted on [DATE] with diagnoses that included ST elevation myocardial infarction, morbid obesity and diabetes mellitus. Review of a nursing Transfer to Hospital note dated August 15, 2022 at 2:41 PM revealed a radiology technician performed an arterial and venous ultrasound on the resident's right upper extremity as ordered. The radiology technician reported to the nurse that the resident's entire right arm was occluded. The note included the physician assistant and medical director were notified and an order was given to transfer the resident to the hospital. The note also revealed the resident agreed to the transfer and the bed hold form was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.