Nursing home report card · Lacey, WA
Crystal Cove Post Acute
1505 Carpenter Road SE, Lacey, WA 98503
Call this home: (360) 491-1765
View this home on Medicare.gov ↗
Quick summary
This home is listed for extra oversight
Status: SFF. Special Focus Facility homes have a history of serious quality problems and get extra oversight.
Our summary of public Medicare records. It does not establish that this home harmed a particular resident. About this summary.
How recent is this information?
- Medicare file prepared
- Aug 1, 2026
- Our record last updated
- Oct 15, 2026
- Last routine health inspection
- Jan 13, 2026
These dates mean different things. A new file can include older inspections and staffing figures. Read about the dates.
Medicare ratings
One star is the lowest rating. Five stars is the highest. Ratings are a starting point—read the inspection findings too.
Combines inspection, staffing, and care measures.
No rating is available in our records
Based on problems found during health inspections.
No rating is available in our records
Based on staffing levels and related measures.
No rating is available in our records
Based on reported health and care results.
No rating is available in our records
What do the ratings and warnings mean?
- Medicare ratings
- One star is the lowest rating. Five stars is the highest. These are government ratings, not family reviews.
- Inspection problems
- Inspectors found that a home did not meet a care or safety rule. The official term is “deficiency.”
- Abuse warning
- Medicare has flagged the home because of abuse-related inspection findings. Read the findings and dates.
- Nursing staff time
- Average staff hours for each resident per day. This does not mean each resident gets that much one-to-one care.
At a glance
These numbers come from the records we have. Inspection problems are rules the home did not meet. The dates covered can differ.
Care, safety, and resident-rights issues on recent inspections
Building, alarms, exits, and related safety citations
Total fine amounts in the imported penalty records
Medicare home ID: 505254
Inspection findings to read first
Start with these past findings. We show the most serious first, then the most recent. They do not describe the home’s condition today.
Immediate danger to residents · isolated case
Mar 12, 2025 · Inspection rule 0678
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Immediate danger to residents · isolated case
Aug 19, 2024 · Inspection rule 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Caused actual harm · isolated case
Jun 2, 2026 · Inspection rule 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Nursing staff time
These are average staff hours for each resident per day. They are not one-to-one bedside care. The file does not give the reporting period for each figure.
about 39 minutes per resident per day
about 3 hr 46 min per resident per day
about 21 minutes per resident per day
Latest inspection summary
A summary of the most recent routine inspections. You can open the dated findings below.
We do not have a routine inspection summary for this home. Check the dated findings below and the Medicare.gov record.
How this home compares
Compared with state and national averages. The numbers may cover different periods.
- Registered nurse time per resident: 0.65 hours/day
- Total nurse time per resident: 3.77 hours/day
See the dates used for these averages
Medicare file dates: this home Aug 1, 2026; Washington averages Unavailable; U.S. averages Oct 1, 2026.
Other concerns in the records
These points may be worth asking about. They do not establish what happened to a particular resident. See our Terms of Use.
- Recent citations include infection-control problems
- Inspectors have listed an unusually high number of problems
- CMS has fined this home in the recent reporting period
How serious were the problems?
Inspectors rate each problem by how much harm it caused or could cause. We group the CMS letter codes into plain language.
- Immediate danger to residents2 citations
- Caused actual harm5 citations
- Could have caused harm130 citations
Why inspectors showed up
Routine checks happen on a schedule. Complaint visits happen when someone reports a concern.
- Complaints
- 0
- Routine
- 137
- Fire safety
- 0
- Other
- 0
Who owns it
Names CMS lists as owners or managers · reported as For profit - Limited Liability company.
- We do not have individual owner names for this home.
Inspection history
Open a date to read what inspectors found. The harm labels explain how serious the problem was at the time.
June 22, 20263 findings
- Quality of Life and Care problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0689 · code E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- Resident Rights problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0584 · code E
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.
- Nutrition and Dietary problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0812 · code E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
June 10, 20261 finding
- Administration problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0851 · code D
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
June 2, 20261 finding
- Quality of Life and Care problemsCaused actual harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0684 · code G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
March 12, 20262 findings
- Resident Rights problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0628 · code D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0688 · code D
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.
January 13, 202628 findings
- Nutrition and Dietary problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0809 · code E
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
- Infection Control problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0887 · code E
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
- Resident Assessment and Care Planning problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0641 · code D
Ensure each resident receives an accurate assessment.
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0692 · code D
Provide enough food/fluids to maintain a resident's health.
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0698 · code D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
- Resident Rights problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0584 · code E
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.
- Nursing and Physician Services problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0947 · code D
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
- Nursing and Physician Services problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0730 · code D
Observe each nurse aide's job performance and give regular training.
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0791 · code D
Provide or obtain dental services for each resident.
- Nutrition and Dietary problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0806 · code D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
- Nutrition and Dietary problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0812 · code D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- Administration problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0847 · code D
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
- Administration problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0849 · code D
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.
- Infection Control problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0881 · code D
Implement a program that monitors antibiotic use.
- Freedom from Abuse, Neglect, and Exploitation problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0605 · code E
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
- Resident Assessment and Care Planning problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0656 · code E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- Pharmacy Service problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0757 · code E
Ensure each resident’s drug regimen must be free from unnecessary drugs.
- Pharmacy Service problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0761 · code E
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.
- Resident Rights problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0550 · code D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- Resident Rights problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0565 · code D
Honor the resident's right to organize and participate in resident/family groups in the facility.
- Resident Rights problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0569 · code D
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
- Freedom from Abuse, Neglect, and Exploitation problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0610 · code D
Respond appropriately to all alleged violations.
- Resident Assessment and Care Planning problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0658 · code D
Ensure services provided by the nursing facility meet professional standards of quality.
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0686 · code D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0689 · code D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0694 · code D
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0695 · code D
Provide safe and appropriate respiratory care for a resident when needed.
- Infection Control problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0880 · code D
Provide and implement an infection prevention and control program.
January 2, 20261 finding
- Quality of Life and Care problemsCaused actual harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0689 · code G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
December 5, 20252 findings
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0684 · code D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- Resident Rights problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0584 · code D
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.
August 22, 20256 findings
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0686 · code D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- Infection Control problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0880 · code D
Provide and implement an infection prevention and control program.
- Nutrition and Dietary problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0803 · code D
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
- Administration problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0835 · code E
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
- Nutrition and Dietary problemsCould have caused harm · widespread case
Inspection type and official rule codes
Routine health inspection · CMS tag 0812 · code F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- Nutrition and Dietary problemsCould have caused harm · widespread case
Inspection type and official rule codes
Routine health inspection · CMS tag 0802 · code F
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
July 16, 20251 finding
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0692 · code D
Provide enough food/fluids to maintain a resident's health.
June 27, 20251 finding
- Pharmacy Service problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0755 · code D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
March 12, 20251 finding
- Quality of Life and Care problemsImmediate danger to residents · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0678 · code J
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
February 7, 20252 findings
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0693 · code D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
- Quality of Life and Care problemsCaused actual harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0686 · code G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Fines & penalties
These fines appear in Medicare’s records. A listed amount does not tell us whether it has been paid.
- Fine · Jun 2, 2026$20,415
- Fine · Dec 5, 2025$12,425
- Payment Denial · Jun 27, 2025Unavailable
- Fine · Dec 26, 2024$117,108
- Payment Denial · Dec 26, 2024Unavailable
- Fine · Jul 16, 2024$85,527
Related topics
Questions about Crystal Cove Post Acute
What is Crystal Cove Post Acute's Medicare star rating?
Has Crystal Cove Post Acute been fined?
Does Crystal Cove Post Acute have a Medicare abuse warning?
How does Crystal Cove Post Acute compare with other nursing homes in Washington?
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