Phoenix, AZ

Acacia Health Center

5-star overall rating with 5-star inspections with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle

4555 East Mayo Blvd, Phoenix, AZ

(480) 384-5600

Compare this facility

Overall

5 / 5

CMS overall stars

Health inspections

5 / 5

Survey and complaint cycles

Staffing

5 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

78

Certified beds

Average residents

70

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Life Care Services

Operator or chain grouping

Approved since

2011-03-03

CMS approved date

Coverage

Medicare

Participation flags

Chain footprint

20 facilities

Chain averages 4 overall / 4 health / 4 staffing / 4 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

1.51

Registered nurse staffing · state 0.72 · national 0.68

LPN hours / resident day

0.96

Licensed practical nurse staffing · state 1.04 · national 0.87

Aide hours / resident day

3.07

Nurse aide staffing · state 2.36 · national 2.35

Total nurse hours

5.54

All reported nurse hours · state 4.12 · national 3.89

Licensed hours

2.47

RN + LPN hours · state 1.76 · national 1.54

Weekend hours

5.05

Weekend nurse staffing · state 3.62 · national 3.43

Weekend RN hours

1.21

Weekend registered nurse coverage · state 0.51 · national 0.47

Physical therapist

0.17

Reported PT staffing · state 0.10 · national 0.07

Adjusted RN hours

1.49

CMS adjusted RN staffing hours

Adjusted total hours

5.47

CMS adjusted total nurse staffing hours

Case-mix index

1.39

Higher values indicate more complex resident acuity

RN turnover

17%

Annual RN turnover · state 45% · national 45%

Total nurse turnover

17%

Annual nurse turnover · state 48% · national 46%

SNF VBP

Value-based purchasing

Program rank

37

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

94.59

Composite VBP score used to determine payment impact.

Payment multiplier

1.0276

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

10

Baseline 16.95% · Performance 14.74% · Measure score 10 · Achievement 10 · Improvement 9

Healthcare-associated infections

10

Baseline 5.92% · Performance 4.79% · Measure score 10 · Achievement 10 · Improvement 9

Total nurse turnover

10

Baseline 21.80% · Performance 14.82% · Measure score 10 · Achievement 10 · Improvement 9

Adjusted total nurse staffing

7.83

Baseline 5.75 hours · Performance 5.31 hours · Measure score 7.83 · Achievement 7.83 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	8.95%	10.72% 1.8 pts better	No Different than the National Rate · Eligible stays 998 · Observed rate 6.61% · Lower 95% interval 7.4%
Discharge to community	73.75%	50.57% 23.2 pts better	Better than the National Rate · Eligible stays 982 · Observed rate 76.99% · Lower 95% interval 71.67%
Medicare spending per beneficiary	0.85	1.02 0.2 pts better
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 689 · Denominator 689
Falls with major injury	1.16%	0.77% 0.4 pts worse	Numerator 8 · Denominator 689
Discharge self-care score	59.81%	53.69% 6.1 pts better	Numerator 314 · Denominator 525
Discharge mobility score	62.86%	50.94% 11.9 pts better	Numerator 330 · Denominator 525
Pressure ulcers or injuries, new or worsened	1.89%	2.29% 0.4 pts better	Numerator 13 · Denominator 689 · Adjusted rate 2.39%
Healthcare-associated infections requiring hospitalization	4.79%	7.12% 2.3 pts better	Better than the National Rate · Eligible stays 625 · Observed rate 2.88% · Lower 95% interval 3.51%
Staff COVID-19 vaccination coverage	4.93%	8.2% 3.3 pts worse	Numerator 11 · Denominator 223
Staff flu vaccination coverage	94.3%	42% 52.3 pts better	Numerator 215 · Denominator 228
Discharge function score	67.62%	56.45% 11.2 pts better	Numerator 355 · Denominator 525
Transfer of health information to provider	97.84%	95.95% 1.9 pts better	Numerator 590 · Denominator 603
Transfer of health information to patient	95.56%	96.28% 0.7 pts worse	Numerator 43 · Denominator 45
Resident COVID-19 vaccinations up to date	39.04%	25.2% 13.8 pts better	Numerator 130 · Denominator 333

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.4	1.7 0.3 pts better	1.9 0.5 pts better	Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.3 · Expected 1.8 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.0	1.5 0.5 pts better	1.8 0.8 pts better	Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.9 · Expected 1.5 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	97.1% 2.9 pts better	93.4% 6.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	94.6% 5.4 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury	5.0%	2.1% 2.9 pts worse	3.3% 1.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 7.4% · Q3 0.0% · Q4 5.6% · 4Q avg 5.0% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	0.0%	4.2% 4.2 pts better	11.4% 11.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents who lose too much weight	1.2%	5.3% 4.1 pts better	5.4% 4.2 pts better	Long Stay · 2024Q4-2025Q3 · Q3 0.0% · Q4 0.0% · 4Q avg 1.2%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	9.2%	20.5% 11.3 pts better	19.6% 10.4 pts better	Long Stay · 2024Q4-2025Q3 · Q2 15.0% · Q3 8.3% · Q4 0.0% · 4Q avg 9.2%
Percentage of long-stay residents who received an antipsychotic medication	6.2%	11.8% 5.6 pts better	16.7% 10.5 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 6.2% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.3% 0.3 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	9.3%	14.5% 5.2 pts better	16.3% 7 pts better	Long Stay · 2024Q4-2025Q3 · Q4 14.0% · 4Q avg 9.3% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	11.5%	10.8% 0.7 pts worse	14.9% 3.4 pts better	Long Stay · 2024Q4-2025Q3 · Q2 5.0% · Q3 8.3% · Q4 25.0% · 4Q avg 11.5% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	0.9% 0.9 pts better	1.0% 1 pts better	Long 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 long-stay residents with a urinary tract infection	0.9%	1.2% 0.3 pts better	1.7% 0.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	25.1%	20.5% 4.6 pts worse	19.8% 5.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q2 26.6% · Q3 32.0% · Q4 17.0% · 4Q avg 25.1%
Percentage of long-stay residents with pressure ulcers	4.9%	4.8% 0.1 pts worse	5.1% 0.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 4.0% · Q3 8.5% · Q4 2.6% · 4Q avg 4.9% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	99.9%	91.1% 8.8 pts better	81.7% 18.2 pts better	Short Stay · 2024Q4-2025Q3 · Q1 99.7% · Q2 99.7% · Q3 100.0% · Q4 100.0% · 4Q avg 99.9%
Percentage of short-stay residents who had an outpatient emergency department visit	5.8%	10.7% 4.9 pts better	12.0% 6.2 pts better	Short Stay · 20240701-20250630 · Adjusted 5.8% · Observed 5.1% · Expected 9.9% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.4%	1.1% 0.7 pts better	1.6% 1.2 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.4% · Q2 0.4% · Q3 0.4% · Q4 0.5% · 4Q avg 0.4% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	99.5%	87.3% 12.2 pts better	79.7% 19.8 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 99.5%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	21.8%	24.6% 2.8 pts better	23.9% 2.1 pts better	Short Stay · 20240701-20250630 · Adjusted 21.8% · Observed 17.1% · Expected 18.7% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-12-06 · Fire 2024-12-06

1 health deficiencies

Top issue: Resident Assessment and Care Planning (1 deficiency)

2 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 2 Health 2023-10-13 · Fire 2023-10-13

0 health deficiencies

No concentrated health issue counts in this cycle.

1 fire-safety deficiencies

Top issue: Emergency Preparedness (1 deficiency)

Cycle 3 Health 2022-08-25 · Fire 2022-08-25

3 health deficiencies

Top issue: Nursing and Physician Services (1 deficiency)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2024-12-06

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2024-12-31

D · Potential for more than minimal harm 2024-12-06

K341 · Smoke Deficiencies

Fire Safety

Install a fire alarm system that can be heard throughout the facility.

Corrected 2024-12-31

E · Potential for more than minimal harm 2023-10-13

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2023-12-07

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-12-04

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2025-12-21

D · Potential for more than minimal harm 2022-08-25

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2022-10-07

D · Potential for more than minimal harm 2022-08-25

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2022-10-07

B · Minimal harm 2022-08-25

F732 · Nursing and Physician Services Deficiencies

Health

Post nurse staffing information every day.

Corrected 2022-10-07

Penalties and ownership

What sits behind the stars

Ownership

Lcs Desert Ridge Ii LLC

5% Or Greater Direct Ownership Interest · Organization

85% 1 facilities 2024-11-20

Lcs Desert Ridge LLC

5% Or Greater Direct Ownership Interest · Organization

15% 1 facilities 2010-07-28

Bird, John

Corporate Officer · Individual

0% 8 facilities 2024-02-15

Davis, James

5% Or Greater Indirect Ownership Interest · Individual

0% 6 facilities 2024-11-20

Lahey, Daniel

Corporate Officer · Individual

0% 7 facilities 2024-02-15

Lcs Holding Company LLC