Crystal Cove Post Acute, Lacey, Washington
- 138
- Citations from health inspectionsWashington average: 50 a home
- 7
- Residents harmed or put in dangerWashington average: 2.0 a home
- $235,475
- Fines from the federal governmentWashington average: $52,633 a home
- No rating given
- Overall rating in starsWashington average: 3.3
The figures come from Medicare Care Compare files released October 8, 2026 by CMS, the federal Medicare agency. The citations span each home's three most recent inspection cycles plus their complaint visits, going back to March 2017 at the earliest; the fines span about three years, beginning September 2023. Browse the CMS files
22 inspection visits produced 138 citations. Residents were in immediate danger in two findings. Residents were found hurt in five cases. Federal fines came to $235,475 (four fines). Two times, Medicare stopped paying for new admissions.
This home is a Special Focus Facility. Homes that have done poorly on past inspections are put on this list by CMS, and they get extra attention.
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- The home's overall star rating
- No rating is given while the home stays on the Special Focus list
- Rating for health inspections
- No rating is given while the home stays on the Special Focus list
- Rating for staffing
- No rating is given while the home stays on the Special Focus list
- Rating for quality of care
- No rating is given while the home stays on the Special Focus list
- Nurse time for each resident
- 3.77 hours each dayThe Washington average is 4.36 hours
- Time from registered nurses
- 0.65 hours each dayThe Washington average is 0.94 hours
- Nursing staff who left during one year
- 69.7%against the Washington average of 45.1%
- Beds that are certified
- 96
- Ownership
- Limited Liability company (for profit)
- Chain
- This home is not part of a chain
- Street address
- 1505 Carpenter Road Se, Lacey, Washington 98503
- County
- Thurston
Each inspection's citations
Every citation marks a federal rule inspectors found broken, along with its seriousness and the number of residents affected.
One citation dated July 17, 2026
- F812 Food Storage and Kitchen Safety: risk of harm, no one found hurt, a pattern, several residents, found on a complaint visit.
Three citations dated June 22, 2026
- F812 Food Storage and Kitchen Safety: risk of harm, no one found hurt, a pattern, several residents, found on a complaint visit.
- F689 Accident Hazards and Supervision: risk of harm, no one found hurt, a pattern, several residents, found on a complaint visit.
- F584 A Safe, Clean, Homelike Room: risk of harm, no one found hurt, a pattern, several residents, found on a complaint visit.
One citation dated June 10, 2026
- F851 Submit Accurate Staffing Data to Federal Government: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
One citation dated June 2, 2026
- F684 Quality of Care: residents were harmed, one or a few residents, found on a complaint visit.
Two citations dated March 12, 2026
- F688 Range of Motion and Mobility: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
- F628 Required Transfer Paperwork and Notices: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
28 citations dated Jan. 13, 2026
- F947 Nurse Aide Skills, Dementia, and Abuse Training: risk of harm, no one found hurt, one or a few residents.
- F887 Coronavirus Vaccine Education, Offering, and Records: risk of harm, no one found hurt, a pattern, several residents.
- F881 Antibiotic Use Monitoring Program: risk of harm, no one found hurt, one or a few residents.
- F880 Infection Prevention and Control: risk of harm, no one found hurt, one or a few residents.
- F849 Arrange Hospice Care When Needed: risk of harm, no one found hurt, one or a few residents.
- F847 Right to Refuse Binding Arbitration: risk of harm, no one found hurt, one or a few residents.
- F812 Food Storage and Kitchen Safety: risk of harm, no one found hurt, one or a few residents.
- F809 Meals and Snacks at Preferred Times: risk of harm, no one found hurt, a pattern, several residents, found on a complaint visit.
- F806 Food That Meets Allergies and Preferences: risk of harm, no one found hurt, one or a few residents.
- F791 Dental Services for Residents: risk of harm, no one found hurt, one or a few residents.
- F761 Labeling and Locking Up Medicines: risk of harm, no one found hurt, a pattern, several residents.
- F757 Unnecessary Drugs: risk of harm, no one found hurt, a pattern, several residents.
- F730 Review Nurse Aide Performance and Training: risk of harm, no one found hurt, one or a few residents.
- F698 Dialysis Care: risk of harm, no one found hurt, one or a few residents.
- F695 Breathing and Oxygen Care: risk of harm, no one found hurt, one or a few residents.
- F694 Safe Fluids Given Through a Vein: risk of harm, no one found hurt, one or a few residents.
- F692 Enough Food and Fluids: risk of harm, no one found hurt, one or a few residents.
- F689 Accident Hazards and Supervision: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
- F686 Pressure Ulcer (Bedsore) Care: risk of harm, no one found hurt, one or a few residents.
- F658 Care That Meets Professional Standards: risk of harm, no one found hurt, one or a few residents.
- F656 A Complete Care Plan: risk of harm, no one found hurt, a pattern, several residents.
- F641 Accurate Resident Assessments: risk of harm, no one found hurt, one or a few residents.
- F610 Investigating Abuse Allegations: risk of harm, no one found hurt, one or a few residents.
- F605 Avoid Unnecessary Sedating or Psychiatric Drugs: risk of harm, no one found hurt, a pattern, several residents.
- F584 A Safe, Clean, Homelike Room: risk of harm, no one found hurt, a pattern, several residents.
- F569 Return Resident Funds After Discharge or Death: risk of harm, no one found hurt, one or a few residents.
- F565 Right to Resident and Family Groups: risk of harm, no one found hurt, one or a few residents.
- F550 Dignity and Resident Rights: risk of harm, no one found hurt, one or a few residents.
One citation dated Jan. 2, 2026
- F689 Accident Hazards and Supervision: residents were harmed, one or a few residents, found on a complaint visit.
Two citations dated Dec. 5, 2025
Six citations dated Aug. 22, 2025
- F880 Infection Prevention and Control: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
- F835 Run the Facility Effectively: risk of harm, no one found hurt, a pattern, several residents, found on a complaint visit.
- F812 Food Storage and Kitchen Safety: risk of harm, no one found hurt, widespread, found on a complaint visit.
- F803 Menus That Meet Nutrition Needs: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
- F802 Enough Kitchen Support Staff: risk of harm, no one found hurt, widespread, found on a complaint visit.
- F686 Pressure Ulcer (Bedsore) Care: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
One citation dated July 16, 2025
- F692 Enough Food and Fluids: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
One citation dated June 27, 2025
- F755 Pharmacy Services: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
One citation dated March 12, 2025
- F678 CPR and Basic Life Support: immediate danger to residents, one or a few residents, found on a complaint visit.
Two citations dated Feb. 7, 2025
- F693 Feeding Tube Care: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
- F686 Pressure Ulcer (Bedsore) Care: residents were harmed, one or a few residents, found on a complaint visit.
45 citations dated Feb. 6, 2025
- F887 Coronavirus Vaccine Education, Offering, and Records: risk of harm, no one found hurt, one or a few residents.
- F881 Antibiotic Use Monitoring Program: risk of harm, no one found hurt, one or a few residents.
- F880 Infection Prevention and Control: risk of harm, no one found hurt, widespread.
- F868 Quality Group Membership and Quarterly Meetings: risk of harm, no one found hurt, a pattern, several residents.
- F865 Written Quality Improvement Plan: risk of harm, no one found hurt, widespread.
- F847 Right to Refuse Binding Arbitration: risk of harm, no one found hurt, a pattern, several residents.
- F837 Governing Body and Licensed Administrator: risk of harm, no one found hurt, widespread.
- F808 Doctor Ordered Special Diets: risk of harm, no one found hurt, a pattern, several residents.
- F806 Food That Meets Allergies and Preferences: risk of harm, no one found hurt, one or a few residents.
- F761 Labeling and Locking Up Medicines: risk of harm, no one found hurt, a pattern, several residents.
- F759 Medication Error Rate of 5 Percent or More: risk of harm, no one found hurt, one or a few residents.
- F758 Psychotropic Drugs and PRN Orders: risk of harm, no one found hurt, a pattern, several residents.
- F757 Unnecessary Drugs: risk of harm, no one found hurt, a pattern, several residents.
- F756 Monthly Drug Regimen Review: risk of harm, no one found hurt, one or a few residents.
- F726 Nurses and Aides Have Needed Skills: risk of harm, no one found hurt, widespread.
- F725 Enough Nursing Staff: risk of harm, no one found hurt, widespread.
- F698 Dialysis Care: risk of harm, no one found hurt, one or a few residents.
- F695 Breathing and Oxygen Care: risk of harm, no one found hurt, one or a few residents.
- F694 Safe Fluids Given Through a Vein: risk of harm, no one found hurt, a pattern, several residents.
- F692 Enough Food and Fluids: residents were harmed, one or a few residents.
- F690 Bladder, Bowel and Catheter Care: risk of harm, no one found hurt, one or a few residents.
- F689 Accident Hazards and Supervision: risk of harm, no one found hurt, one or a few residents.
- F688 Range of Motion and Mobility: risk of harm, no one found hurt, a pattern, several residents.
- F687 Proper Foot Care: risk of harm, no one found hurt, one or a few residents.
- F684 Quality of Care: risk of harm, no one found hurt, a pattern, several residents.
- F679 Activities That Meet Every Resident's Needs: risk of harm, no one found hurt, one or a few residents.
- F677 Help With Daily Living: risk of harm, no one found hurt, a pattern, several residents.
- F658 Care That Meets Professional Standards: risk of harm, no one found hurt, a pattern, several residents.
- F657 Updating the Care Plan on Time: risk of harm, no one found hurt, a pattern, several residents.
- F656 A Complete Care Plan: risk of harm, no one found hurt, a pattern, several residents.
- F645 Screening for Mental Illness or Intellectual Disability: risk of harm, no one found hurt, one or a few residents.
- F641 Accurate Resident Assessments: risk of harm, no one found hurt, a pattern, several residents.
- F625 Written Notice of Bed Hold Policy: risk of harm, no one found hurt, a pattern, several residents.
- F623 Notice Before Transfer or Discharge: risk of harm, no one found hurt, a pattern, several residents.
- F622 Valid Reasons and Paperwork for Transfer or Discharge: risk of harm, no one found hurt, one or a few residents.
- F604 Freedom From Physical Restraints: risk of harm, no one found hurt, a pattern, several residents.
- F585 Right to File Complaints Without Retaliation: risk of harm, no one found hurt, a pattern, several residents.
- F584 A Safe, Clean, Homelike Room: risk of harm, no one found hurt, a pattern, several residents.
- F583 Keep Resident Records Private: risk of harm, no one found hurt, one or a few residents.
- F569 Return Resident Funds After Discharge or Death: risk of harm, no one found hurt, one or a few residents.
- F568 Properly Manage Resident Money Held by Facility: risk of harm, no one found hurt, a pattern, several residents.
- F567 Right to Manage Own Finances: risk of harm, no one found hurt, a pattern, several residents.
- F565 Right to Resident and Family Groups: risk of harm, no one found hurt, a pattern, several residents.
- F561 Respect Resident Choices and Self Determination: risk of harm, no one found hurt, one or a few residents.
- F550 Dignity and Resident Rights: risk of harm, no one found hurt, one or a few residents.
Two citations dated Dec. 26, 2024
One citation dated Sept. 24, 2024
- F755 Pharmacy Services: risk of harm, no one found hurt, a pattern, several residents, found on a complaint visit.
Two citations dated Aug. 19, 2024
Two citations dated July 16, 2024
One citation dated May 14, 2024
- F622 Valid Reasons and Paperwork for Transfer or Discharge: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
Three citations dated April 26, 2024
- F926 Smoking Policies: risk of harm, no one found hurt, a pattern, several residents, found on a complaint visit.
- F744 Proper Dementia Treatment and Services: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
- F610 Investigating Abuse Allegations: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
29 citations dated March 11, 2024
- F880 Infection Prevention and Control: risk of harm, no one found hurt, a pattern, several residents.
- F812 Food Storage and Kitchen Safety: risk of harm, no one found hurt, a pattern, several residents.
- F809 Meals and Snacks at Preferred Times: risk of harm, no one found hurt, a pattern, several residents.
- F804 Food Taste and Temperature: risk of harm, no one found hurt, a pattern, several residents.
- F791 Dental Services for Residents: risk of harm, no one found hurt, a pattern, several residents.
- F761 Labeling and Locking Up Medicines: risk of harm, no one found hurt, a pattern, several residents.
- F759 Medication Error Rate of 5 Percent or More: risk of harm, no one found hurt, a pattern, several residents.
- F758 Psychotropic Drugs and PRN Orders: risk of harm, no one found hurt, a pattern, several residents.
- F755 Pharmacy Services: risk of harm, no one found hurt, a pattern, several residents.
- F727 Required Registered Nurse and Nursing Director: risk of harm, no one found hurt, one or a few residents.
- F695 Breathing and Oxygen Care: risk of harm, no one found hurt, one or a few residents.
- F689 Accident Hazards and Supervision: risk of harm, no one found hurt, one or a few residents.
- F687 Proper Foot Care: risk of harm, no one found hurt, one or a few residents.
- F686 Pressure Ulcer (Bedsore) Care: risk of harm, no one found hurt, one or a few residents.
- F684 Quality of Care: risk of harm, no one found hurt, a pattern, several residents.
- F677 Help With Daily Living: risk of harm, no one found hurt, one or a few residents.
- F658 Care That Meets Professional Standards: risk of harm, no one found hurt, a pattern, several residents.
- F657 Updating the Care Plan on Time: risk of harm, no one found hurt, a pattern, several residents.
- F655 Baseline Care Plan at Admission: risk of harm, no one found hurt, a pattern, several residents.
- F645 Screening for Mental Illness or Intellectual Disability: risk of harm, no one found hurt, one or a few residents.
- F644 Coordinate Assessments With Mental Health Screening Program: risk of harm, no one found hurt, a pattern, several residents.
- F641 Accurate Resident Assessments: risk of harm, no one found hurt, a pattern, several residents.
- F625 Written Notice of Bed Hold Policy: risk of harm, no one found hurt, one or a few residents.
- F585 Right to File Complaints Without Retaliation: risk of harm, no one found hurt, one or a few residents.
- F584 A Safe, Clean, Homelike Room: risk of harm, no one found hurt, a pattern, several residents.
- F582 Notice of Medicare and Medicaid Coverage and Costs: risk of harm, no one found hurt, one or a few residents.
- F578 The Right to Refuse Treatment: risk of harm, no one found hurt, one or a few residents.
- F561 Respect Resident Choices and Self Determination: risk of harm, no one found hurt, a pattern, several residents.
- F550 Dignity and Resident Rights: risk of harm, no one found hurt, one or a few residents.
Three citations dated Oct. 18, 2023
- F656 A Complete Care Plan: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
- F624 Prepare Residents for Safe Transfer or Discharge: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
- F552 Keep Residents Informed About Health and Care: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
Payment Denials and Fines
| Date | Penalty | Amount |
|---|---|---|
| June 2, 2026 | Fine | $20,415 |
| Dec. 5, 2025 | Fine | $12,425 |
| June 27, 2025 | Payment denial for new admissions | nine days |
| Dec. 26, 2024 | Fine | $117,108 |
| Dec. 26, 2024 | Payment denial for new admissions | eight days |
| July 16, 2024 | Fine | $85,527 |
Ownership and Management of the Home
- The home is run by Foundation Resource Center LLC (operational or managerial control).
The CMS Care Compare files, updated every month, provide provider information, health deficiencies, penalties, and ownership. The CMS certification number is 505254. Other homes in Washington.