Acacia Health Center

In the surveyor’s words

From the most serious findings on record at Acacia Health Center, in the surveyor’s own words.

• No harm, potential for more than minimal, isolatedF641Dec 24, 2025

  Based on clinical record review, staff interviews, and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure a minimum data set (MDS) assessment was completed accurately for one resident (#54) out of 68 sampled residents. The deficient practice could result in further incomplete MDS assessments.Findings include:Resident #54 was admitted on [DATE] with diagnoses that included displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing, pain in right hip, and type 2 diabetes mellitus.A review of the Admission/Medicare-5 day MDS assessment dated [DATE] revealed that Resident #54 had a brief interview for mental status (BIMS) score of 15, which meant the resident was cognitively intact. […]

• No harm, potential for more than minimal, isolatedF812Dec 24, 2025

  Based on observations, staff interviews, and facility policies, the facility failed to ensure food items were appropriately stored and labeled; and, failed to ensure that food was not expired. The deficient practice may result in the food items not kept according to professional standards for food service safety.Findings include:During initial observation of the kitchen conducted on December 22, 2025, at 8:23 am, with the Dietary Manager (Staff #215), items were found to be opened and not labeled. Observation revealed an open container of turkey base with an open date of November 27, and without a year or use by or expiration date. Two zested oranges unlabeled with a use by date. An open container of ketchup with an illegible open date behind an unopened container of ketchup. […]

• No harm, potential for more than minimal, isolatedF842Dec 4, 2025

  Based on clinical record review, interviews, and facility documentation and policy the facility failed to ensure that medical records accurately documented skin impairments identified for resident #024. The deficient practice could result in medical records that do not accurately and completely reflect the care and services provided. The sample size was 3, and the facility census was 75. Findings Include:Resident # 024 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease with acute exacerbation, hypertensive heart disease with heart failure, paroxysmal atrial fibrillation, and generalized muscle weakness. The resident was discharged from the facility on December 18, 2024. […]

• No harm, potential for more than minimal, isolatedF584Aug 25, 2022

  Based on observation, residents and staff interviews, a facility document, and policy review, the facility failed to ensure the wall was repaired in one resident's (#41) room. The deficient practice prevented the resident's room from having a homelike environment. Findings include: During an interview conducted on August 24, 2022 at 2:34 p.m. with the resident #41, there were deep cracks observed in the wall approximately 3 inches by 6 inches to the left of the bed behind the recliner. It was also observed that the area was not painted along with two other areas on the left wall adjacent to the wall where the bed was located. The resident stated that no one has come to the room to look at the cracks and missing paint on the wall. […]

• No harm, potential for more than minimal, isolatedF842Aug 25, 2022

  Based on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure advance directive information was accurate for one resident (#13). The sample size was 2. The deficient practice could result in residents' wishes not being honored. Findings include: Resident #13 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's care plan initiated on [DATE] revealed the resident was a full code. Review of the advanced directives with the date [DATE] revealed the resident was a Do Not Resuscitate (DNR). During an interview conducted with the resident on [DATE] at 9:30 am, the resident stated that their code status was full code. […]