Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
LACEY POST ACUTE & REHABILITATION
LACEY, WA · 120 certified beds · Last Life Safety survey June 6, 2025
CMS Certification Number 505525 · first certified July 2012
Ownership
Operated by HILL VALLEY HEALTHCARE · For profit - Limited Liability company
- Ownership changed April 1, 2023 (change of ownership)from MANOR CARE OF LACEY WA, ASSOCIATION
Position within WA
10 citations — more than 3% of the 193 certified nursing homes in WA. Compared within WA rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 1 citation; the earlier surveys in the window averaged 4.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (May 2026 to August 2026), and past the point by which nine in ten WA facilities have been surveyed. This facility’s last Life Safety survey was June 2025. Facilities in WA are typically surveyed 12–15 months after the last one (median 13), measured over 320 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
2 of the 10 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
4 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 10 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in WA, and nationally. Surveyors differ markedly between states, so the WA figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 10 |
| Median facility in WA | 31 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| September 7, 2023 | 7 |
| August 23, 2024 | 2 |
| June 6, 2025 | 1 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2025-06-06 |
| E-0039 | Conduct testing and exercise requirements. | 1 | 2023-09-07 |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | 1 | 2024-08-23 |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | 1 | 2023-09-07 |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | 1 | 2023-09-07 |
| E-0023 | Establish policies and procedures for medical documentation. | 1 | 2023-09-07 |
| K-0920 | Ensure proper usage of power strips and extension cords. | 1 | 2023-09-07 |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 1 | 2023-09-07 |
What the citations cover
- Smoke Deficiencies 4
- Gas, Vacuum, and Electrical Systems Deficiencies 3
- Emergency Preparedness Deficiencies 2
- Miscellaneous Deficiencies 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 4 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 3 |
| Emergency Preparedness Deficiencies | 2 |
| Miscellaneous Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
June 6, 2025 — 1 citation
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (July 8, 2025) |
August 23, 2024 — 2 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (September 5, 2024) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (September 5, 2024) |
September 7, 2023 — 7 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0023 | Establish policies and procedures for medical documentation. | Deficient, Provider has date of correction (October 13, 2023) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (October 13, 2023) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (October 17, 2023) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (October 9, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (October 13, 2023) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (October 9, 2023) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (October 17, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.