Crystal Cove Post Acute
1505 Carpenter Road Se · Lacey, WA · 98503 · 3604911765
96 certified beds For profit - Limited Liability company
Why this verdict
- On the federal Special Focus list of the most persistently poor performers.
- Inspection record is far worse than the national median (deficiency count and severity).
- Federal penalties on record: $221,750 in fines in the last 24 months.
- 4 citations involved actual harm to residents.
- Inspection results have improved across recent cycles.
Red flags
Special Focus Facility
CMS has designated this facility one of the most persistently poor performers in the country — it is under increased inspection and enforcement.
2 immediate-jeopardy citations in prior inspection cycles
Serious past findings — check whether the underlying problems were fixed and stayed fixed.
$221,750 in federal fines in the last 24 months
3 fines — CMS fines are reserved for verified, serious non-compliance.
69% of nursing staff left within a year
High turnover disrupts continuity of care; the national median is 45%.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: not rated Inspections: not rated Staffing: not rated Quality measures: not rated
| Total nurse hours / resident-day | 3.39 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.57 | 0.55–0.75 |
| Weekend hours / resident-day | 2.98 | ≈ weekday level |
| Nursing turnover / year | 69% | median 45% |
| Fines (3-yr window) | 3 · $221,750 |
Inspection citations (132 in the current record)
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Potential for harm · D March 12, 2026 · found via complaint
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected April 10, 2026 · Resident Rights
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Potential for harm · D March 12, 2026 · found via complaint
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected April 10, 2026 · Quality of Life and Care
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Potential for harm · D January 13, 2026
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected March 6, 2026 · Resident Rights
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Potential for harm · D January 13, 2026
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected March 6, 2026 · Resident Rights
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Potential for harm · D January 13, 2026
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected March 6, 2026 · Resident Rights
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Potential for harm · E January 13, 2026
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected March 6, 2026 · Resident Rights
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Potential for harm · E January 13, 2026
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected March 6, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D January 13, 2026
Respond appropriately to all alleged violations.
Corrected March 6, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D January 13, 2026
Ensure each resident receives an accurate assessment.
Corrected March 6, 2026 · Resident Assessment and Care Planning
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Potential for harm · E January 13, 2026
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected March 6, 2026 · Resident Assessment and Care Planning
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Potential for harm · D January 13, 2026
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected March 6, 2026 · Resident Assessment and Care Planning
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Potential for harm · D January 13, 2026
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected March 6, 2026 · Quality of Life and Care
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Potential for harm · D January 13, 2026
Provide enough food/fluids to maintain a resident's health.
Corrected March 6, 2026 · Quality of Life and Care
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Potential for harm · D January 13, 2026
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected March 6, 2026 · Quality of Life and Care
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Potential for harm · D January 13, 2026
Provide safe and appropriate respiratory care for a resident when needed.
Corrected March 6, 2026 · Quality of Life and Care
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Potential for harm · D January 13, 2026
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected March 6, 2026 · Quality of Life and Care
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Potential for harm · D January 13, 2026
Observe each nurse aide's job performance and give regular training.
Corrected March 6, 2026 · Nursing and Physician Services
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Potential for harm · E January 13, 2026
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected March 6, 2026 · Pharmacy Service
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Potential for harm · E January 13, 2026
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 March 6, 2026 · Pharmacy Service
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Potential for harm · D January 13, 2026
Provide or obtain dental services for each resident.
Corrected March 6, 2026 · Quality of Life and Care
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Potential for harm · D January 13, 2026
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected March 6, 2026 · Nutrition and Dietary
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Potential for harm · D January 13, 2026
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected March 6, 2026 · Nutrition and Dietary
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Potential for harm · D January 13, 2026
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected March 6, 2026 · Administration
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Potential for harm · D January 13, 2026
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 March 6, 2026 · Administration
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Potential for harm · D January 13, 2026
Provide and implement an infection prevention and control program.
Corrected March 6, 2026 · Infection Control
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| December 5, 2025 | Fine | $19,115 |
| June 27, 2025 | Payment Denial | 9 days |
| December 26, 2024 | Fine | $117,108 |
| December 26, 2024 | Payment Denial | 8 days |
| July 16, 2024 | Fine | $85,527 |
Family & resident reviews — a separate signal, never mixed into the score
No approved reviews yet. If your family has experience with this facility, yours could be the review that helps the next family decide.
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 505254 · certified since April 1, 1980. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.