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.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
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.