Lacey, WA

Lacey Post Acute & Rehabilitation

5-star overall rating with 4-star inspections with $7,443 in total fines with 14 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle

4524 Intelco Loop Se, Lacey, WA

(360) 491-9890

Compare this facility

Overall

5 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

120

Certified beds

Average residents

115

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Hill Valley Healthcare

Operator or chain grouping

Approved since

2012-07-25

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

40 facilities

Chain averages 2 overall / 2 health / 2 staffing / 4 quality stars

Changed ownership

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

0.63

Registered nurse staffing · state 0.88 · national 0.68

LPN hours / resident day

1.14

Licensed practical nurse staffing · state 0.81 · national 0.87

Aide hours / resident day

2.16

Nurse aide staffing · state 2.69 · national 2.35

Total nurse hours

3.93

All reported nurse hours · state 4.39 · national 3.89

Licensed hours

1.78

RN + LPN hours · state 1.70 · national 1.54

Weekend hours

3.55

Weekend nurse staffing · state 3.79 · national 3.43

Weekend RN hours

0.39

Weekend registered nurse coverage · state 0.63 · national 0.47

Physical therapist

0.08

Reported PT staffing · state 0.09 · national 0.07

Adjusted RN hours

0.61

CMS adjusted RN staffing hours

Adjusted total hours

3.79

CMS adjusted total nurse staffing hours

Case-mix index

1.42

Higher values indicate more complex resident acuity

RN turnover

52%

Annual RN turnover · state 47% · national 45%

Total nurse turnover

54%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

4,287

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

Performance score

40.56

Composite VBP score used to determine payment impact.

Payment multiplier

0.9935

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

7.11

Baseline 16.22% · Performance 18.14% · Measure score 7.11 · Achievement 7.11 · Improvement 0

Healthcare-associated infections

5.69

Baseline 3.91% · Performance 6.13% · Measure score 5.69 · Achievement 5.69 · Improvement 0

Total nurse turnover

2.20

Baseline 53.33% · Performance 54.70% · Measure score 2.20 · Achievement 2.20 · Improvement 0

Adjusted total nurse staffing

1.22

Baseline 3.70 hours · Performance 3.43 hours · Measure score 1.22 · Achievement 1.22 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	9.12%	10.72% 1.6 pts better	No Different than the National Rate · Eligible stays 350 · Observed rate 8% · Lower 95% interval 7.12%
Discharge to community	60.73%	50.57% 10.2 pts better	Better than the National Rate · Eligible stays 371 · Observed rate 55.53% · Lower 95% interval 55.55%
Medicare spending per beneficiary	0.81	1.02 0.2 pts better
Drug regimen review with follow-up	94.78%	95.27% 0.5 pts worse	Numerator 218 · Denominator 230
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 230
Discharge self-care score	45.95%	53.69% 7.7 pts worse	Numerator 85 · Denominator 185
Discharge mobility score	45.95%	50.94% 5 pts worse	Numerator 85 · Denominator 185
Pressure ulcers or injuries, new or worsened	2.17%	2.29% 0.1 pts better	Numerator 5 · Denominator 230 · Adjusted rate 2.79%
Healthcare-associated infections requiring hospitalization	6.14%	7.12% 1 pts better	No Different than the National Rate · Eligible stays 246 · Observed rate 5.28% · Lower 95% interval 4.29%
Staff COVID-19 vaccination coverage	1.38%	8.2% 6.8 pts worse	Numerator 3 · Denominator 218
Staff flu vaccination coverage	16.38%	42% 25.6 pts worse	Numerator 47 · Denominator 287
Discharge function score	55.14%	56.45% 1.3 pts worse	Numerator 102 · Denominator 185
Transfer of health information to provider	86.59%	95.95% 9.4 pts worse	Numerator 71 · Denominator 82
Transfer of health information to patient	92.54%	96.28% 3.7 pts worse	Numerator 124 · Denominator 134
Resident COVID-19 vaccinations up to date	35.56%	25.2% 10.4 pts better	Numerator 48 · Denominator 135

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	96.5%	96.0% 0.5 pts better	93.4% 3.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 98.5% · Q2 95.8% · Q3 95.3% · Q4 96.3% · 4Q avg 96.5%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	90.0%	93.8% 3.8 pts worse	95.5% 5.5 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 90.0%
Percentage of long-stay residents experiencing one or more falls with major injury	0.8%	2.6% 1.8 pts better	3.3% 2.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	5.7%	16.3% 10.6 pts better	11.4% 5.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 9.2% · Q3 8.6% · Q4 0.0% · 4Q avg 5.7%
Percentage of long-stay residents who lose too much weight	9.2%	5.8% 3.4 pts worse	5.4% 3.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 10.3% · Q3 4.9% · Q4 7.8% · 4Q avg 9.2%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	13.9%	12.1% 1.8 pts worse	19.6% 5.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 17.4% · Q3 13.1% · Q4 11.8% · 4Q avg 13.9%
Percentage of long-stay residents who received an antipsychotic medication	16.2%	15.9% 0.3 pts worse	16.7% 0.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 16.1% · Q3 16.3% · Q4 18.6% · 4Q avg 16.2% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.1% 0.1 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	19.6%	20.0% 0.4 pts better	16.3% 3.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q2 10.4% · Q3 28.0% · Q4 33.6% · 4Q avg 19.6% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	8.9%	15.8% 6.9 pts better	14.9% 6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 7.5% · Q3 13.6% · Q4 10.2% · 4Q avg 8.9% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	1.1%	1.2% 0.1 pts better	1.0% 0.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.5% · Q3 1.6% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.8%	1.7% 0.9 pts better	1.7% 0.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.0% · Q3 0.0% · Q4 1.9% · 4Q avg 0.8% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	24.9%	23.5% 1.4 pts worse	19.8% 5.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 30.2% · Q3 30.7% · Q4 28.8% · 4Q avg 24.9%
Percentage of long-stay residents with pressure ulcers	5.3%	4.7% 0.6 pts worse	5.1% 0.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 9.2% · Q2 1.4% · Q3 6.1% · Q4 4.9% · 4Q avg 5.3% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	90.7%	87.7% 3 pts better	81.7% 9 pts better	Short Stay · 2024Q4-2025Q3 · Q1 92.7% · Q2 93.9% · Q3 92.1% · Q4 85.2% · 4Q avg 90.7%
Percentage of short-stay residents who had an outpatient emergency department visit	10.3%	13.2% 2.9 pts better	12.0% 1.7 pts better	Short Stay · 20240701-20250630 · Adjusted 10.3% · Observed 9.8% · Expected 10.7% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.9%	1.4% 0.5 pts better	1.6% 0.7 pts better	Short Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.4% · Q3 0.9% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	86.5%	82.0% 4.5 pts better	79.7% 6.8 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 86.5%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	16.6%	19.9% 3.3 pts better	23.9% 7.3 pts better	Short Stay · 20240701-20250630 · Adjusted 16.6% · Observed 15.9% · Expected 22.8% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-06-06 · Fire 2025-06-06

14 health deficiencies

Top issue: Resident Rights (5 deficiencies)

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Cycle 2 Health 2024-08-23 · Fire 2024-08-23

15 health deficiencies

Top issue: Resident Assessment and Care Planning (5 deficiencies)

2 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 3 Health 2023-09-07 · Fire 2023-09-07

7 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

7 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-06-06

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-07-08

F · Potential for more than minimal harm 2024-08-23

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2024-09-05

E · Potential for more than minimal harm 2024-08-23

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-09-05

F · Potential for more than minimal harm 2023-09-07

E23 · Emergency Preparedness Deficiencies

Fire Safety

Establish policies and procedures for medical documentation.

Corrected 2023-10-13

F · Potential for more than minimal harm 2023-09-07

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2023-10-13

F · Potential for more than minimal harm 2023-09-07

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2023-10-09

F · Potential for more than minimal harm 2023-09-07

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-10-13

F · Potential for more than minimal harm 2023-09-07

K921 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that testing and maintenance of electrical equipment is performed.

Corrected 2023-10-17

D · Potential for more than minimal harm 2023-09-07

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2023-10-17

D · Potential for more than minimal harm 2023-09-07

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2023-10-09

Inspection history

Recent health citations

D · Potential for more than minimal harm 2026-01-05

F627 · Resident Rights Deficiencies

Health

Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.

Corrected 2026-01-21

D · Potential for more than minimal harm 2025-12-08

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2026-01-09

D · Potential for more than minimal harm 2025-12-08

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2026-01-09

E · Potential for more than minimal harm 2025-06-06

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2025-07-18

E · Potential for more than minimal harm 2025-06-06

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-07-18

D · Potential for more than minimal harm 2025-06-06

F552 · Resident Rights Deficiencies

Health

Ensure that residents are fully informed and understand their health status, care and treatments.

Corrected 2025-07-18

D · Potential for more than minimal harm 2025-06-06

F569 · Resident Rights Deficiencies

Health

Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.

Corrected 2025-07-18

D · Potential for more than minimal harm 2025-06-06

F578 · Resident Rights Deficiencies

Health

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Corrected 2025-07-18

D · Potential for more than minimal harm 2025-06-06

F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Corrected 2025-07-18

D · Potential for more than minimal harm 2025-06-06

F645 · Resident Assessment and Care Planning Deficiencies

Health

PASARR screening for Mental disorders or Intellectual Disabilities

Corrected 2025-07-18

D · Potential for more than minimal harm 2025-06-06

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2025-07-18

D · Potential for more than minimal harm 2025-06-06

F761 · Pharmacy Service Deficiencies

Health

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected 2025-07-18

D · Potential for more than minimal harm 2025-05-23

F627 · Resident Rights Deficiencies

Health

Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.

Corrected 2025-06-23

D · Potential for more than minimal harm 2025-05-16

F678 · Quality of Life and Care Deficiencies

Health

Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

Corrected 2025-07-28

D · Potential for more than minimal harm 2025-01-30

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2025-02-25