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

Staffing

Hours and turnover

RN hours / resident day

1.51

Registered nurse staffing

LPN hours / resident day

0.96

Licensed practical nurse staffing

Aide hours / resident day

3.07

Nurse aide staffing

Weekend hours

5.05

Weekend nurse staffing

RN turnover

17%

Annual RN turnover

Total nurse turnover

17%

Annual nurse turnover

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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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

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