Above average — CMS composite of the measures below.
The next survey window likely opens 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 Acacia Health Center during CMS and state inspections, most recent first.
A resident admitted with a hip fracture, pain, and a history of type 2 DM had an Admission/Medicare 5‑day MDS coded to show 2 days of insulin injections, despite having no care plan focus for diabetes and no diabetic medications listed. The cognitively intact resident reported not being diabetic, not receiving insulin or fingerstick glucose checks, and only receiving non‑diabetes injections. An LPN confirmed there were no orders for glucose monitoring or insulin, and MDS staff later verified that the two injections were a flu shot and a COVID vaccine, not insulin, indicating the MDS assessment was completed inaccurately.
Surveyors identified that dietary staff did not consistently follow facility policy and professional standards for food storage and datemarking, with multiple opened items in the kitchen lacking complete dates or labels, including turkey base, ketchup, maple syrup with visible buildup, zested oranges, and potato pancakes left open to air. Additional observations on the units found multiple single-serve cereal containers past their expiration dates in dry storage and refrigerators. The Dietary Manager and Administrator both acknowledged that facility practice requires opened items to be dated, used within a set timeframe, and expired foods discarded, and the written policy specifies first-in/first-out rotation and clear labeling and dating of leftovers, but these procedures were not followed for the items observed.
A resident with multiple chronic conditions and several skin wounds received wound care per provider orders, but the medical records and discharge summary did not accurately document the resident's skin impairments. Discharge instructions given to the resident's representative were inconsistent with the clinical record, and staff interviews revealed that documentation practices involving multiple nurses contributed to omissions in the record.
Inaccurate MDS Coding of Insulin Injections for Non‑Insulin‑Treated Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure an accurate Minimum Data Set (MDS) assessment for one resident. The resident was admitted with diagnoses including a displaced intertrochanteric fracture of the left femur, pain in the right hip, and type 2 diabetes mellitus. The Admission/Medicare 5-day MDS documented a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact, and recorded that the resident received injections on 2 days in the 7-day look-back period, including 2 days of insulin injections under Section N0350. The resident’s care plan contained no focus area for diabetes and no mention of insulin or other diabetic medications. During interview, the resident, who was cognitively intact, stated they were not diabetic, had not received insulin at the facility or in the hospital, and had not undergone fingerstick glucose monitoring, though they acknowledged receiving injections that were not for diabetes. Further interviews and record review showed that nursing staff and MDS staff confirmed there were no orders for blood glucose checks and no insulin orders or administration for this resident. An LPN stated there were no orders to check fingerstick glucose and no insulin was given. Two MDS coordinators, who did not complete the original assessment, reviewed the hospital records, medications, and treatments over the 7-day period and confirmed the resident received two injections, identified as a flu shot and a COVID vaccine, not insulin. They acknowledged that documenting insulin injections on the MDS was an error. The DON stated the expectation that resident assessments be completed thoroughly and accurately. The MDS coordinator job description and the facility’s resident assessment policy both assign responsibility to the MDS nurse/resident assessment coordinator to ensure accuracy and completeness of the MDS and medical record, and to ensure timely and appropriate resident assessments and reviews, which was not met in this case.
Improper Food Storage, Labeling, and Expired Items in Dietary and Unit Areas
Penalty
Summary
The deficiency involves the facility’s failure to store, label, and monitor food items in accordance with its own policies and professional food service standards. During an initial kitchen observation with the Dietary Manager, surveyors found multiple opened food items that were not properly labeled or datemarked, including an open container of turkey base with only “November 27” written and no year or use-by/expiration date, two unlabeled zested oranges, an open container of ketchup with an illegible open date stored behind an unopened ketchup container, an opened bottle of maple syrup dated “August 8” with no year and thick brown buildup on the inside walls above the remaining syrup, and a bag of potato pancakes open to air with no open date, use-by date, or expiration date. The Dietary Manager stated that standard practice was to use items within 30 days of opening, that oranges used for zesting should be discarded after use, that food items without a year marked should be discarded, and that food should be closed and labeled when returned to the freezer, but these practices were not followed for the items observed. A subsequent observation of unit refrigerators and dry storage snacks revealed multiple expired single-serve cereal containers, including several containers of Special K Original Toasted cereal and Cheerios Toasted Whole Grain cereal with expiration dates that had already passed. The Dietary Manager stated that staff were expected to check each dried cereal package and discard expired items, similar to the process for refrigerated and frozen foods. The Administrator stated that once items are opened they should be dated and discarded after seven days, and that the expectation was that any opened item be dated and expired foods be discarded. The facility’s written policy on Food Storage and Datemarking required use of the first-in, first-out method, proper stock rotation by trained staff, and that leftover food items be covered or wrapped, clearly labeled, dated, and used within seven days or discarded, but the observations showed that these requirements were not consistently implemented for the food items found in the kitchen and on the units.
Inaccurate Documentation of Skin Impairments in Medical Records
Penalty
Summary
The facility failed to ensure that medical records accurately documented skin impairments for a resident with multiple complex medical diagnoses, including chronic obstructive pulmonary disease, heart failure, atrial fibrillation, and generalized muscle weakness. The resident had several skin conditions, such as arterial ulcers and skin tears, which required specific wound care treatments as ordered by providers. However, a review of the clinical record, Minimum Data Set (MDS), and wound evaluations revealed inconsistencies and omissions in the documentation of these skin impairments, particularly in the discharge summary and instructions provided to the resident's representative. During the resident's stay, multiple provider orders directed staff to perform specific wound care interventions for various wounds on the resident's toes and knee. Despite these orders and ongoing wound care, the discharge summary and transition of care documents did not accurately reflect the resident's current skin conditions at the time of discharge. The resident's representative reported receiving written discharge instructions that did not match the actual status of the wounds, leading to concerns about insufficient communication and incomplete documentation regarding the resident's wound care needs. Interviews with facility staff, including CNAs, RNs, and the DON, confirmed that documentation practices relied on multiple staff members completing different sections of the electronic record, sometimes without re-verifying previously entered information. This process contributed to the omission of critical wound care information in the discharge summary. The facility's own investigation acknowledged that incorrect documentation was submitted on the discharge assessment, and staff interviews highlighted the importance of accurate recordkeeping for continuity of care.
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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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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Life Care Center Of Paradise Valley | 3 mi | ★★★★★ | 9 | 0 |
| Ridgecrest Post Acute | 3.2 mi | ★★★★★ | 2 | 0 |
| Vi At Grayhawk, A Vi And Plaza Companies Community | 5.3 mi | ★★★★★ | 0 | 0 |
| Vi At Silverstone, A Vi And Plaza Companies Commun | 5.3 mi | ★★★★★ | 0 | 0 |
| Phoenix Mountain Post Acute | 5.6 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.