Cycle 1
Health 2024-10-15 · Fire 2024-10-15
8 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Lacey, WA
Panorama City Conv & Rehab Ctr
5-star overall rating with 4-star inspections with $11,190 in total fines with 8 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
1600 Sleater Kinney Road Se, Lacey, WA
(360) 456-0111
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
155
Certified beds
Average residents
119
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.85
Registered nurse staffing · state 0.88 · national 0.68
LPN hours / resident day
0.89
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
3.09
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
4.84
All reported nurse hours · state 4.39 · national 3.89
Licensed hours
1.75
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.97
Weekend nurse staffing · state 3.79 · national 3.43
Weekend RN hours
0.53
Weekend registered nurse coverage · state 0.63 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.76
CMS adjusted RN staffing hours
Adjusted total hours
4.31
CMS adjusted total nurse staffing hours
Case-mix index
1.54
Higher values indicate more complex resident acuity
RN turnover
13%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
27%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
521
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
68.36
Composite VBP score used to determine payment impact.
Payment multiplier
1.0215
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.42
Baseline 19.34% · Performance 17.99% · Measure score 7.42 · Achievement 7.42 · Improvement 5.33
Healthcare-associated infections
5.11
Baseline 6.37% · Performance 6.31% · Measure score 5.11 · Achievement 5.11 · Improvement 0
Total nurse turnover
8.44
Baseline 25.00% · Performance 29.20% · Measure score 8.44 · Achievement 8.44 · Improvement 0
Adjusted total nurse staffing
6.37
Baseline 3.83 hours · Performance 4.89 hours · Measure score 6.37 · Achievement 6.37 · Improvement 4.93
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.77% |
10.72%
2 pts better
|
No Different than the National Rate · Eligible stays 183 · Observed rate 4.92% · Lower 95% interval 5.77% |
| Discharge to community | 63.24% |
50.57%
12.7 pts better
|
Better than the National Rate · Eligible stays 176 · Observed rate 65.34% · Lower 95% interval 56.63% |
| Medicare spending per beneficiary | 0.98 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 97.78% |
95.27%
2.5 pts better
|
Numerator 176 · Denominator 180 |
| Falls with major injury | 2.22% |
0.77%
1.5 pts worse
|
Numerator 4 · Denominator 180 |
| Discharge self-care score | 62.71% |
53.69%
9 pts better
|
Numerator 74 · Denominator 118 |
| Discharge mobility score | 54.24% |
50.94%
3.3 pts better
|
Numerator 64 · Denominator 118 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 180 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.31% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 121 · Observed rate 4.13% · Lower 95% interval 3.67% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 231 |
| Staff flu vaccination coverage | 54.55% |
42%
12.5 pts better
|
Numerator 126 · Denominator 231 |
| Discharge function score | 55.93% |
56.45%
0.5 pts worse
|
Numerator 66 · Denominator 118 |
| Transfer of health information to provider | 93.1% |
95.95%
2.9 pts worse
|
Numerator 27 · Denominator 29 |
| Transfer of health information to patient | 99.23% |
96.28%
3 pts better
|
Numerator 129 · Denominator 130 |
| Resident COVID-19 vaccinations up to date | 64% |
25.2%
38.8 pts better
|
Numerator 64 · Denominator 100 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.7 |
1.4
0.7 pts better
|
1.9
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.5 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
1.5
0.9 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.5 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.2% |
96.0%
2.2 pts better
|
93.4%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.8% · Q2 97.9% · Q3 97.0% · Q4 100.0% · 4Q avg 98.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.9% |
93.8%
3.1 pts better
|
95.5%
1.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.7% |
2.6%
3.1 pts worse
|
3.3%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 5.3% · Q3 6.0% · Q4 7.0% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 68.0% |
16.3%
51.7 pts worse
|
11.4%
56.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 70.3% · Q2 72.3% · Q3 62.9% · Q4 66.7% · 4Q avg 68.0% |
| Percentage of long-stay residents who lose too much weight | 5.8% |
5.8%
About the same
|
5.4%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 6.8% · Q3 4.2% · Q4 5.3% · 4Q avg 5.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.2% |
12.1%
3.9 pts better
|
19.6%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 7.7% · Q3 9.4% · Q4 7.4% · 4Q avg 8.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.8% |
15.9%
10.1 pts better
|
16.7%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 3.0% · Q3 4.2% · Q4 8.5% · 4Q avg 5.8% · 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 | 27.8% |
20.0%
7.8 pts worse
|
16.3%
11.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.6% · Q2 27.3% · Q3 18.0% · Q4 24.8% · 4Q avg 27.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.0% |
15.8%
1.2 pts worse
|
14.9%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.7% · Q2 26.9% · Q3 6.1% · Q4 12.3% · 4Q avg 17.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
1.2%
0.9 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.0% · 4Q avg 0.3% · 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 1.1% · Q2 1.1% · Q3 0.0% · Q4 1.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.7% |
23.5%
3.2 pts worse
|
19.8%
6.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.6% · Q2 32.1% · Q3 25.9% · Q4 20.2% · 4Q avg 26.7% |
| Percentage of long-stay residents with pressure ulcers | 1.7% |
4.7%
3 pts better
|
5.1%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 3.3% · Q3 0.0% · Q4 2.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.2% |
87.7%
3.5 pts better
|
81.7%
9.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 88.4% · Q2 92.0% · Q3 92.4% · Q4 92.1% · 4Q avg 91.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.5% |
13.2%
4.7 pts better
|
12.0%
3.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.5% · Observed 7.6% · Expected 10.0% · 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 0.0% · Q2 1.1% · Q3 1.2% · Q4 1.2% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 83.7% |
82.0%
1.7 pts better
|
79.7%
4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 83.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.8% |
19.9%
3.1 pts better
|
23.9%
7.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.8% · Observed 14.4% · Expected 20.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-13 · Fire 2023-11-13
12 health deficiencies
Top issue: Resident Assessment and Care Planning (5 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-10-10 · Fire 2022-10-10
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-15
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-11-08
D · Potential for more than minimal harm
2024-10-15
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-11-08
F · Potential for more than minimal harm
2023-11-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-12-05
F · Potential for more than minimal harm
2023-11-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-12-07
D · Potential for more than minimal harm
2023-11-13
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-12-11
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-07-18
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-08-14
D · Potential for more than minimal harm
2025-07-18
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-08-14
G · Actual harm
2025-05-12
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-01-17
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-02-14
D · Potential for more than minimal harm
2025-01-17
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 2025-02-14
E · Potential for more than minimal harm
2024-10-15
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-11-22
E · Potential for more than minimal harm
2024-10-15
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-11-22
D · Potential for more than minimal harm
2024-10-15
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-11-22
D · Potential for more than minimal harm
2024-10-15
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-11-22
D · Potential for more than minimal harm
2024-10-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-22
G · Actual harm
2024-06-11
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-05
E · Potential for more than minimal harm
2024-06-11
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-07-05
E · Potential for more than minimal harm
2023-11-13
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-12-22
E · Potential for more than minimal harm
2023-11-13
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2023-12-22
D · Potential for more than minimal harm
2023-11-13
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-12-22
D · Potential for more than minimal harm
2023-11-13
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-12-22
D · Potential for more than minimal harm
2023-11-13
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-12-22
D · Potential for more than minimal harm
2023-11-13
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-12-22
D · Potential for more than minimal harm
2023-11-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-12-22
D · Potential for more than minimal harm
2023-11-13
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-12-22
D · Potential for more than minimal harm
2022-10-10
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-11-11
Penalties and ownership
What sits behind the stars
$11,190
2025-05-12
Fine
Fine · fine $11,190
Fine
Ownership
Flemming, Stanley
Operational/Managerial Control · Individual
Gavin, William
Corporate Director · Individual
Goldberg, Frederick
Corporate Director · Individual
Hedden, Dale
Corporate Director · Individual
Jensen, Daryl
Corporate Director · Individual
Madden, Kathryn
Corporate Director · Individual
Mah, Douglas
Corporate Director · Individual
Mason, Nancy
Corporate Director · Individual
Murphy, Judy
Corporate Director · Individual
Murry, Matthew
Corporate Officer · Individual
Strader, Charles
Operational/Managerial Control · Individual
Strader, Charles
Corporate Officer · Individual
Wilkerson, Dennis
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Woodard Creek Health & Rehabilitation
Olympia, WA
1-star overall rating with 1-star inspections with 34 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Olympia Transitional Care And Rehabilitation
Olympia, WA
4-star overall rating with 3-star inspections with 11 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Crystal Cove Post Acute
Lacey, WA
1-star overall rating with 1-star inspections with Special Focus status with $202,635 in total fines with 59 recent health deficiencies with 19 fire-safety deficiencies in the latest cycle
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