Lacey Post Acute & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Lacey Post Acute & Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF695Sep 13, 2023

  Based on interview and record review, the facility failed to ensure residents were administered oxygen according to the provider orders for 1 of 3 sample residents (1) reviewed for respiratory care. This failure resulted in harm to Resident 1 when their oxygen was not maintained at the ordered rate and the resident experienced hypoxia (low oxygen blood levels) and requried hospitalization . This failure placed residents at risk for shortness of breath, unmet care needs and a decreased quality of care. […]

• No harm, potential for more than minimal, widespreadF628Jul 22, 2026

  Based on interview and record review, the facility failed to notify the State Ombudsman of the transfer to hospital and/or discharge from the facility for 2 of 2 sampled residents (Residents 3 and 124) reviewed for discharge and hospitalization. This failure placed residents at risk of not knowing their rights during discharge and a diminished quality of life.Findings included. Record review of Resident 3's Electronic Health Record (EHR) showed Resident 3 was admitted to the facility on [DATE], and was cognitively intact. […]

• No harm, potential for more than minimal, widespreadF727Aug 5, 2022

  Based on interview and record review, the facility failed to provide at least eight hours of Registered Nurse (RN) supervision for one of 30 days (07/29/2022) reviewed for RN coverage. This failure placed residents at risk for not receiving needed care and supervision of care. Findings included . The Aging and Long-Term Support Administration (ALTSA) Staffing Pattern, the facility's Hours By Shift Report and the facility's Daily Nurse Staffing Forms showed the facility did not have an RN on duty for the three shifts (day, evening & night) on 07/29/2022. On 08/05/2022 at 12:10 PM, Staff A, Administrator, said they did not meet the eight hours RN requirement on 07/29/2022. Reference WAC 388-97-1080 (3)

• No harm, potential for more than minimal, widespreadF730Aug 5, 2022

  Based on interview and record review, the facility failed to ensure performance reviews were completed for one of two Certified Nursing Assistants (NA) Staff (J) reviewed for nurse aide performance reviews. This failure placed residents at risk of receiving care from unskilled NA staff. Finding included . The employee record for Staff J, NA, documented a hire date of 10/07/2020. No Annual Performance Evaluations were found in Staff J's personnel file. On 08/04/2022 at 3:09 PM, Staff A, Administrator, said their performance evaluations were not up-to-date. Reference WAC 388-97-1680 (2)(b)(i)

• No harm, potential for more than minimal, widespreadF725Apr 9, 2021

  Based on interview and record review, the facility failed to ensure sufficient staffing levels were met to provide nursing care to residents according to care planned needs for two of two facility floors (1st and 2nd) and three of four sampled residents (1, 2 & 3). This failure placed residents at risk for unmet physical, mental and psychosocial needs, a decline in health status and a diminished quality of life. Findings included . The Facility Assessment, dated 10/2020, documented nursing assistants were staffed based on state staffing requirements and documented 30 full time nursing assistants, three part time nursing assistants and three PRN (as needed) nursing assistants. […]