Cycle 1
Health 2023-11-29 · Fire 2023-11-29
2 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Tempe, AZ
Mirabella At Asu
5-star overall rating with 4-star inspections with 2 recent health deficiencies
65 East University Avenue, Tempe, AZ
(602) 777-7701
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
21
Certified beds
Average residents
18
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Pacific Retirement Services
Operator or chain grouping
Approved since
2021-09-09
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
10 facilities
Chain averages 5 overall / 4 health / 4 staffing / 5 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.40
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.99
Licensed practical nurse staffing · state 1.04 · national 0.87
Aide hours / resident day
3.52
Nurse aide staffing · state 2.36 · national 2.35
Total nurse hours
5.91
All reported nurse hours · state 4.12 · national 3.89
Licensed hours
2.39
RN + LPN hours · state 1.76 · national 1.54
Weekend hours
5.80
Weekend nurse staffing · state 3.62 · national 3.43
Weekend RN hours
1.08
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.29
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.50
CMS adjusted RN staffing hours
Adjusted total hours
6.31
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
60%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
61%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,913
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
38.11
Composite VBP score used to determine payment impact.
Payment multiplier
0.9912
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.61
Baseline 18.65% · Performance 19.76% · Measure score 3.61 · Achievement 3.61 · Improvement 0
Healthcare-associated infections
4.02
Baseline 6.14% · Performance 6.63% · Measure score 4.02 · Achievement 4.02 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.06% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 172 · Observed rate 7.56% · Lower 95% interval 6.68% |
| Discharge to community | 63.41% |
50.57%
12.8 pts better
|
Better than the National Rate · Eligible stays 169 · Observed rate 63.91% · Lower 95% interval 57.09% |
| Medicare spending per beneficiary | 0.89 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 95 · Denominator 95 |
| Falls with major injury | 4.21% |
0.77%
3.4 pts worse
|
Numerator 4 · Denominator 95 |
| Discharge self-care score | 64.29% |
53.69%
10.6 pts better
|
Numerator 36 · Denominator 56 |
| Discharge mobility score | 53.57% |
50.94%
2.6 pts better
|
Numerator 30 · Denominator 56 |
| Pressure ulcers or injuries, new or worsened | 3.19% |
2.29%
0.9 pts worse
|
Numerator 3 · Denominator 94 · Adjusted rate 3.34% |
| Healthcare-associated infections requiring hospitalization | 6.63% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 104 · Observed rate 5.77% · Lower 95% interval 3.47% |
| Staff COVID-19 vaccination coverage | 25% |
8.2%
16.8 pts better
|
Numerator 8 · Denominator 32 |
| Staff flu vaccination coverage | 27.91% |
42%
14.1 pts worse
|
Numerator 12 · Denominator 43 |
| Discharge function score | 67.86% |
56.45%
11.4 pts better
|
Numerator 38 · Denominator 56 |
| Transfer of health information to provider | 92.31% |
95.95%
3.6 pts worse
|
Numerator 72 · Denominator 78 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 13.51% |
25.2%
11.7 pts worse
|
Numerator 5 · Denominator 37 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 75.4% |
91.1%
15.7 pts worse
|
81.7%
6.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 95.4% · Q2 86.5% · Q3 70.1% · Q4 50.9% · 4Q avg 75.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.0% |
10.7%
0.3 pts worse
|
12.0%
1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.0% · Observed 11.3% · Expected 11.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.1%
1.1 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 65.3% |
87.3%
22 pts worse
|
79.7%
14.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 65.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.6% |
24.6%
1 pts worse
|
23.9%
1.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.6% · Observed 25.4% · Expected 23.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-10-13 · Fire 2022-10-13
3 health deficiencies
Top issue: Resident Rights (2 deficiencies)
1 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Cycle 3
Health 2021-08-24 · Fire 2021-08-24
1 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2022-10-13
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-11-21
D · Potential for more than minimal harm
2021-08-24
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2021-09-13
D · Potential for more than minimal harm
2021-08-24
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2021-09-13
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-14
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2026-01-19
E · Potential for more than minimal harm
2023-11-29
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-01-05
E · Potential for more than minimal harm
2022-10-13
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-11-21
D · Potential for more than minimal harm
2022-10-13
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2022-11-21
D · Potential for more than minimal harm
2022-10-13
F622 · Resident Rights Deficiencies
Health
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.
Corrected 2022-11-21
E · Potential for more than minimal harm
2021-08-24
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2021-09-09
Penalties and ownership
What sits behind the stars
Ownership
Desanto, Virginia
Corporate Officer · Individual
Dillon, Daniel
Corporate Officer · Individual
Dorough, Thomas
W-2 Managing Employee · Individual
Jolly, Edward
Corporate Officer · Individual
Mayers, Robert
Corporate Officer · Individual
Pacific Retirement Services Inc
Operational/Managerial Control · Organization
Sholty, Eric
Corporate Officer · Individual
Washington Federal
5% Or Greater Security Interest · Organization
Wilson, Doug
Corporate Officer · Individual
Nearby options
Other facilities in reach
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Plaza Healthcare
Scottsdale, AZ
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Tempe Post Acute
Tempe, AZ
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Rehab At Scottsdale Village Square
Scottsdale, AZ
2-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $199,344 in total fines with 16 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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