Deficiencies (last 4 years)
Deficiencies (over 4 years)
2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
46% better than Arizona average
Arizona average: 3.7 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Annual Inspection
Census: 75
Capacity: 75
Deficiencies: 1
Date: Dec 4, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory standards, focusing on safeguarding resident-identifiable information and accurate medical record documentation.
Findings
The facility failed to ensure accurate documentation of skin impairments for resident #024, resulting in inconsistencies between clinical records and discharge summaries. The nursing home provided education to staff after identifying documentation omissions and communication issues related to wound care.
Deficiencies (1)
Failure to safeguard resident-identifiable information and maintain accurate medical records on skin impairments for resident #024.
Report Facts
Facility census: 75
Sample size: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #21 | Certified Nursing Assistant (CNA) | Interviewed regarding documentation and communication of skin integrity changes |
| Staff #01 | Wound Care Nurse and Director of Nursing (DON) | Interviewed about wound care classification, reporting, and discharge summary preparation |
| Staff #44 | Registered Nurse (RN) | Interviewed about importance of accurate documentation in resident records |
Inspection Report
Complaint Investigation
Census: 75
Capacity: 75
Deficiencies: 1
Date: Dec 4, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding concerns about inaccurate documentation of skin impairments and wound care for resident #024, including issues with discharge wound care instructions.
Complaint Details
The complaint investigation was substantiated with findings that the discharge summary instructions were inconsistent with the resident's clinical record due to omissions related to skin impairments. The resident's representative expressed concern about insufficient communication and inaccurate discharge paperwork.
Findings
The facility failed to ensure medical records accurately documented skin impairments for resident #024, resulting in discharge instructions that did not reflect active wounds. The facility provided education to nursing staff after identifying documentation omissions and communication issues.
Deficiencies (1)
Failed to safeguard resident-identifiable information and/or maintain medical records on each resident in accordance with accepted professional standards.
Report Facts
Sample size: 3
Facility census: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #01 | Wound Care Nurse and Director of Nursing (DON) | Provided information about wound care classification, reporting procedures, and discharge summary preparation. |
| Staff #21 | Certified Nursing Assistant (CNA) | Described procedures for reporting skin integrity changes and documentation responsibilities. |
| Staff #44 | Registered Nurse (RN) | Discussed importance of accurate documentation for wound care and treatment. |
Inspection Report
Deficiencies: 0
Date: Dec 6, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction related to a regulatory survey of Acacia Health Center conducted by the Department of Health & Human Services and Centers for Medicare & Medicaid Services.
Findings
No health deficiencies were found during the survey.
Inspection Report
Deficiencies: 0
Date: Dec 6, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction related to a facility survey conducted for regulatory compliance purposes.
Findings
No health deficiencies were found during the survey.
Inspection Report
Deficiencies: 0
Date: Oct 13, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for Acacia Health Center, summarizing the findings of a regulatory survey completed on 10/13/2023.
Findings
No health deficiencies were found during the survey.
Inspection Report
Deficiencies: 0
Date: Oct 13, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for Acacia Health Center, summarizing the findings of the inspection completed on 10/13/2023.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Deficiencies: 3
Date: Aug 25, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to facility maintenance, nurse staffing information posting, and accuracy of advance directive documentation.
Findings
The facility failed to ensure timely repair of wall damage in a resident's room, accurate posting of nurse staffing information including total staff numbers and actual hours worked, and consistent documentation of advance directives for a resident, potentially affecting resident safety and rights.
Deficiencies (3)
Failure to ensure the wall was repaired in one resident's room, preventing a homelike environment.
Failure to post nurse staffing information daily including total number of licensed and unlicensed staff and actual hours worked.
Failure to ensure advance directive information was accurate and consistent for one resident.
Report Facts
Work order completion timeframe: 3
Dates of Daily Staff Postings reviewed: August 6, 14, and 17, 2022
Sample size for advance directive review: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN/staff #131) | Interviewed regarding wall repair order submission | |
| Administrator (staff #200) | Interviewed about maintenance inspections and repair priorities | |
| Director of Nursing (DON/staff #18) | Present during interviews and provided statements on maintenance and advance directives | |
| Facility's Manager (staff #79) | Interviewed about facility inspections and wall damage | |
| Staffing and Transportation Coordinator (staff #116) | Interviewed about daily nurse staffing postings | |
| Director of Social Services (staff #159) | Interviewed about review and execution of advance directives | |
| Registered Nurse (RN/staff #97) | Interviewed about resident code status and advance directive documentation |
Inspection Report
Routine
Deficiencies: 3
Date: Aug 25, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to facility maintenance, nurse staffing information posting, and safeguarding resident-identifiable information including advance directives.
Findings
The facility failed to ensure timely repair of wall damage in a resident's room, accurate posting of nurse staffing information including total staff numbers and actual hours worked, and consistent documentation of advance directive information for one resident. These deficiencies posed minimal to potential harm and affected a few to some residents.
Deficiencies (3)
Failed to ensure the wall was repaired in one resident's room, preventing a homelike environment.
Failed to ensure nurse staffing information posted daily included total number of licensed and unlicensed staff and actual hours worked.
Failed to ensure advance directive information was accurate and consistent for one resident.
Report Facts
Work order completion timeframe: 3
Daily Staff Postings reviewed: 3
Sample size for advance directive review: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN/staff #131) | Interviewed regarding wall repair order submission process | |
| Administrator (staff #200) | Interviewed about maintenance inspection and repair priorities | |
| Director of Nursing (DON/staff #18) | Present during multiple interviews and provided statements on maintenance and advance directives | |
| Facility's Manager (staff #79) | Interviewed about facility inspections and wall damage | |
| Staffing and Transportation Coordinator (staff #116) | Interviewed about Daily Staff Posting responsibilities and content | |
| Director of Social Services (staff #159) | Interviewed about review and execution of advance directives | |
| Registered Nurse (RN/staff #97) | Interviewed regarding resident code status and advance directive documentation |
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