Fir Lane Care
2430 North 13th Street · Shelton, WA · 98584 · 3604261651
135 certified beds For profit - Limited Liability company Chain: Caldera Care
Why this verdict
- Inspection record is far worse than the national median (deficiency count and severity).
- Federal penalties on record: $121,488 in fines in the last 24 months.
- 3 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
1 immediate-jeopardy citation in prior inspection cycles
Serious past findings — check whether the underlying problems were fixed and stayed fixed.
Cited under the freedom-from-abuse rule
Cited 1 time under F600 (freedom from abuse/neglect) below the actual-harm level — worth asking about on a tour.
$121,488 in federal fines in the last 24 months
2 fines — CMS fines are reserved for verified, serious non-compliance.
66% of nursing staff left within a year
High turnover disrupts continuity of care; the national median is 45%.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 1 of 5 Staffing: 3 of 5 Quality measures: 3 of 5
| Total nurse hours / resident-day | 4.32 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.62 | 0.55–0.75 |
| Weekend hours / resident-day | 3.90 | ≈ weekday level |
| Nursing turnover / year | 66% | median 45% |
| Fines (3-yr window) | 2 · $121,488 |
Inspection citations (79 in the current record)
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Potential for harm · D April 30, 2026 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected May 21, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D February 24, 2026 · found via complaint
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Corrected March 10, 2026 · Resident Rights
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Potential for harm · D February 24, 2026 · found via complaint
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected March 10, 2026 · Resident Rights
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Potential for harm · D February 10, 2026 · found via complaint
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected March 5, 2026 · Resident Rights
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Potential for harm · D February 10, 2026 · found via complaint
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected March 5, 2026 · Resident Assessment and Care Planning
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Potential for harm · D February 10, 2026 · found via complaint
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected March 5, 2026 · Quality of Life and Care
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Potential for harm · D February 10, 2026 · found via complaint
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected March 5, 2026 · Resident Assessment and Care Planning
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Potential for harm · D August 21, 2025 · found via complaint
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected September 10, 2025 · Resident Rights
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Potential for harm · D August 21, 2025 · found via complaint
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected September 10, 2025 · Pharmacy Service
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Potential for harm · D August 21, 2025 · found via complaint
Provide and implement an infection prevention and control program.
Corrected September 10, 2025 · Infection Control
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Potential for harm · D June 9, 2025
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected July 10, 2025 · Resident Rights
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Potential for harm · D June 9, 2025
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected July 10, 2025 · Resident Rights
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Potential for harm · E June 9, 2025
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected July 10, 2025 · Resident Rights
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Potential for harm · E June 9, 2025
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected July 10, 2025 · Resident Rights
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Potential for harm · D June 9, 2025
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected July 10, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · E June 9, 2025
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected July 10, 2025 · Resident Rights
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Potential for harm · E June 9, 2025
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected July 10, 2025 · Resident Assessment and Care Planning
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Potential for harm · D June 9, 2025
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected July 10, 2025 · Resident Assessment and Care Planning
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Potential for harm · D June 9, 2025
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected July 10, 2025 · Resident Assessment and Care Planning
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Potential for harm · E June 9, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected July 10, 2025 · Quality of Life and Care
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Potential for harm · D June 9, 2025
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected July 10, 2025 · Quality of Life and Care
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Potential for harm · D June 9, 2025
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected July 10, 2025 · Quality of Life and Care
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Potential for harm · E June 9, 2025
Provide enough food/fluids to maintain a resident's health.
Corrected July 10, 2025 · Quality of Life and Care
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Potential for harm · E June 9, 2025
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected July 10, 2025 · Nursing and Physician Services
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Potential for harm · D June 9, 2025
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected July 10, 2025 · Pharmacy Service
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| February 21, 2025 | Fine | $75,361 |
| November 7, 2024 | Fine | $46,127 |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 505230 · certified since January 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.