Map showing the location of Crystal Cove Post Acute in LACEY, Washington
1505 CARPENTER ROAD SE, LACEY, WA, 98503

Overall Score

CMS Five-Star Quality Rating
1/5Much below averageCMS Five-Star overall rating

Where it ranks

  • WashingtonLowest tier among peers192 rated homes · average 3.2★
  • Thurston CountyLowest tier among peers7 rated homes · average 3.6★
  • United StatesLowest tier among peers14,574 rated homes · average 3.0★

How the rating is built

  • Health inspectionsStarting point1★−1.8 vs WA avg
  • StaffingCan add or remove a star1★−2.4 vs WA avg
  • Quality measuresCan add or remove a star2★−2.0 vs WA avg

CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.

  • Special Focus Facility candidateThis facility is on the CMS candidate list for the Special Focus Facility program, meaning it is among the poorest-performing facilities in its state on recent inspections.

Ratings & measures

Tap a row to see what it means
Health inspection ratingCMS stars from the last three on-site inspection cycles1★Lowest tier among peersWA avg2.8★U.S. avg2.8★
What is health inspection rating?

Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.

Why it matters

It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.

Staffing ratingCMS stars from payroll-reported hours and turnover1★Lowest tier among peersWA avg3.4★U.S. avg2.9★
What is staffing rating?

Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.

Why it matters

More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.

Quality measures ratingCMS stars from clinical outcomes and resident assessments2★Above only 1% of peersWA avg4.0★U.S. avg3.6★
What is quality measures rating?

Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.

Why it matters

It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.

Total nurse hoursPer resident per day, all nursing staff3.42hrsAbove only 1% of peersWA avg4.38Benchmark4.10
What is total nurse hours?

All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.

Why it matters

Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.

RN hoursPer resident per day, registered nurses only0.42hrsAbove only 4% of peersWA avg0.88Benchmark0.75
What is rn hours?

Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.

Why it matters

RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.

Nursing staff turnoverShare of nursing staff who left within a year · lower is better71%Above only 3% of peersWA avg47%RN turnover86%
What is nursing staff turnover?

The share of nursing staff who left within the past year, from the same payroll data.

Why it matters

High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.

Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$202,635Above only 5% of peersWA avg$53,236Fines · denials2 · 2
What is fines in the last three years?

Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.

Why it matters

Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.

Inspection history

Last three inspection cycles
122citations
19inspection dates
4actual harm (G–I)
2immediate jeopardy (J–L)
Jan 2, 2026most recent

Citations by monthFeb 2023 – Jan 2026

  • No actual harm (D–F)
  • Actual harm (G–I)
  • Immediate jeopardy (J–L)
  • $Fine or payment denial

Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.

Jan 2, 20261 citationCycle 1worst G · actual harm
  1. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected Jan 22, 2026
Dec 5, 20252 citationsCycle 1worst D · no actual harm
  1. F584Honor 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.Resident RightsD · isolatedCorrected Dec 24, 2025
  2. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Dec 24, 2025
Aug 22, 20256 citationsCycle 1worst F · no actual harm
  1. F803Ensure 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.Nutrition and DietaryD · isolatedCorrected Oct 6, 2025
  2. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Oct 6, 2025
  3. F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Oct 6, 2025
  4. F835Administer the facility in a manner that enables it to use its resources effectively and efficiently.AdministrationE · patternCorrected Oct 6, 2025
  5. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Oct 6, 2025
  6. F802Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.Nutrition and DietaryF · widespreadCorrected Oct 6, 2025
Jul 16, 20251 citationCycle 1worst D · no actual harm
  1. F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareD · isolatedCorrected Aug 18, 2025
Jun 27, 20251 citationCycle 1worst D · no actual harmpayment denial
  1. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Aug 15, 2025
Mar 12, 20251 citationCycle 1worst J · immediate jeopardy
  1. Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.Quality of Life and CareJ · isolatedCorrected Mar 31, 2025
Feb 7, 20252 citationsCycle 1worst G · actual harm
  1. F693Ensure 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 CareD · isolatedCorrected Mar 31, 2025
  2. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareG · isolatedCorrected Mar 31, 2025
Feb 6, 202545 citationsCycle 1worst G · actual harm
  1. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Mar 31, 2025
  2. Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.Resident RightsE · patternCorrected Mar 31, 2025
  3. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareE · patternCorrected Mar 31, 2025
  4. Ensure each resident’s drug regimen must be free from unnecessary drugs.Pharmacy ServiceE · patternCorrected Mar 31, 2025
  5. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected Mar 31, 2025
  6. F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Resident RightsD · isolatedCorrected Mar 31, 2025
  7. F565Honor the resident's right to organize and participate in resident/family groups in the facility.Resident RightsE · patternCorrected Mar 31, 2025
  8. F567Honor the resident's right to manage his or her financial affairs.Resident RightsE · patternCorrected Mar 31, 2025
  9. F568Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.Resident RightsE · patternCorrected Mar 31, 2025
  10. F569Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.Resident RightsD · isolatedCorrected Mar 31, 2025
  11. F583Keep residents' personal and medical records private and confidential.Resident RightsD · isolatedCorrected Mar 31, 2025
  12. F584Honor 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.Resident RightsE · patternCorrected Mar 31, 2025
  13. F585Honor 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.Resident RightsE · patternCorrected Mar 31, 2025
  14. F604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.Freedom from Abuse, Neglect, and ExploitationE · patternCorrected Mar 31, 2025
  15. F622Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.Resident RightsD · isolatedCorrected Mar 31, 2025
  16. F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Resident RightsE · patternCorrected Mar 31, 2025
  17. F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningE · patternCorrected Mar 31, 2025
  18. F645PASARR screening for Mental disorders or Intellectual DisabilitiesResident Assessment and Care PlanningD · isolatedCorrected Mar 31, 2025
  19. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningE · patternCorrected Mar 31, 2025
  20. F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care PlanningE · patternCorrected Mar 31, 2025
  21. F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningE · patternCorrected Mar 31, 2025
  22. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareE · patternCorrected Mar 31, 2025
  23. F679Provide activities to meet all resident's needs.Quality of Life and CareD · isolatedCorrected Mar 31, 2025
  24. F687Provide appropriate foot care.Quality of Life and CareD · isolatedCorrected Mar 31, 2025
  25. F688Provide 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.Quality of Life and CareE · patternCorrected Mar 31, 2025
  26. F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Quality of Life and CareD · isolatedCorrected Mar 31, 2025
  27. F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareG · isolatedCorrected Mar 31, 2025
  28. F694Provide for the safe, appropriate administration of IV fluids for a resident when needed.Quality of Life and CareE · patternCorrected Mar 31, 2025
  29. F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected Mar 31, 2025
  30. F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Quality of Life and CareD · isolatedCorrected Mar 31, 2025
  31. F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Nursing and Physician ServicesF · widespreadCorrected Mar 31, 2025
  32. F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Nursing and Physician ServicesF · widespreadCorrected Mar 31, 2025
  33. F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Pharmacy ServiceD · isolatedCorrected Mar 31, 2025
  34. F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.Pharmacy ServiceE · patternCorrected Mar 31, 2025
  35. F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceD · isolatedCorrected Mar 31, 2025
  36. F761Ensure 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.Pharmacy ServiceE · patternCorrected Mar 31, 2025
  37. F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Nutrition and DietaryD · isolatedCorrected Mar 31, 2025
  38. F808Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.Nutrition and DietaryE · patternCorrected Mar 31, 2025
  39. F837Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.AdministrationF · widespreadCorrected Mar 31, 2025
  40. F847Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.AdministrationE · patternCorrected Mar 31, 2025
  41. F865Have a plan that describes the process for conducting QAPI and QAA activities.AdministrationF · widespreadCorrected Mar 31, 2025
  42. F868Have the Quality Assessment and Assurance group have the required members and meet at least quarterlyAdministrationE · patternCorrected Mar 31, 2025
  43. F880Provide and implement an infection prevention and control program.Infection ControlF · widespreadCorrected Mar 31, 2025
  44. F881Implement a program that monitors antibiotic use.Infection ControlD · isolatedCorrected Mar 31, 2025
  45. F887Educate 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.Infection ControlD · isolatedCorrected Mar 31, 2025
Dec 26, 20242 citationsCycle 2worst E · no actual harm$117,108, payment denial
  1. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Mar 31, 2025
  2. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareE · patternCorrected Mar 31, 2025
Sep 24, 20241 citationCycle 2worst E · no actual harm
  1. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceE · patternCorrected Oct 9, 2024
Aug 19, 20242 citationsCycle 2worst J · immediate jeopardy
  1. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareJ · isolatedCorrected Aug 30, 2024
  2. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected Aug 30, 2024
Jul 16, 20242 citationsCycle 2worst D · no actual harm$85,527
  1. F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected Aug 15, 2024
  2. F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Quality of Life and CareD · isolatedCorrected Aug 15, 2024
May 14, 20241 citationCycle 2worst D · no actual harm
  1. F622Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.Resident RightsD · isolatedCorrected May 25, 2024
Apr 26, 20243 citationsCycle 2worst E · no actual harm
  1. F926Have policies on smoking.EnvironmentalE · patternCorrected May 8, 2024
  2. F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected May 8, 2024
  3. F744Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.Quality of Life and CareD · isolatedCorrected May 8, 2024
Mar 11, 202429 citationsCycle 2worst E · no actual harm
  1. F584Honor 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.Resident RightsE · patternCorrected Apr 25, 2024
  2. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceE · patternCorrected Apr 25, 2024
  3. F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceE · patternCorrected Apr 25, 2024
  4. F761Ensure 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.Pharmacy ServiceE · patternCorrected Apr 25, 2024
  5. F791Provide or obtain dental services for each resident.Quality of Life and CareE · patternCorrected Apr 25, 2024
  6. F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Nutrition and DietaryE · patternCorrected Apr 25, 2024
  7. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Apr 25, 2024
  8. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Apr 25, 2024
  9. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected Apr 25, 2024
  10. F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Resident RightsE · patternCorrected Apr 25, 2024
  11. F578Honor 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.Resident RightsD · isolatedCorrected Apr 25, 2024
  12. F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Resident RightsD · isolatedCorrected Apr 25, 2024
  13. F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected Apr 25, 2024
  14. F727Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.Nursing and Physician ServicesD · isolatedCorrected Apr 25, 2024
  15. F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.Pharmacy ServiceE · patternCorrected Apr 25, 2024
  16. 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.Nutrition and DietaryE · patternCorrected Apr 25, 2024
  17. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareE · patternCorrected Apr 25, 2024
  18. Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.Resident RightsD · isolatedCorrected Apr 25, 2024
  19. F585Honor 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.Resident RightsD · isolatedCorrected Apr 25, 2024
  20. F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningE · patternCorrected Apr 25, 2024
  21. F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Resident Assessment and Care PlanningE · patternCorrected Apr 25, 2024
  22. F645PASARR screening for Mental disorders or Intellectual DisabilitiesResident Assessment and Care PlanningD · isolatedCorrected Apr 25, 2024
  23. F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedResident Assessment and Care PlanningE · patternCorrected Apr 25, 2024
  24. F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care PlanningE · patternCorrected Apr 25, 2024
  25. F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningE · patternCorrected Apr 25, 2024
  26. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Apr 25, 2024
  27. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Apr 25, 2024
  28. F687Provide appropriate foot care.Quality of Life and CareD · isolatedCorrected Apr 25, 2024
  29. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Apr 25, 2024
Oct 18, 20233 citationsCycle 3worst D · no actual harm
  1. F624Prepare residents for a safe transfer or discharge from the nursing home.Resident RightsD · isolatedCorrected Nov 3, 2023
  2. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Nov 3, 2023
  3. F552Ensure that residents are fully informed and understand their health status, care and treatments.Resident RightsD · isolatedCorrected Nov 3, 2023
May 25, 202316 citationsCycle 3worst F · no actual harm
  1. F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.Pharmacy ServiceD · isolatedCorrected Jul 6, 2023
  2. F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Jul 6, 2023
  3. F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Infection ControlD · isolatedCorrected Jul 6, 2023
  4. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected Jul 6, 2023
  5. F800Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.Nutrition and DietaryF · widespreadCorrected Jul 6, 2023
  6. F803Ensure 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.Nutrition and DietaryF · widespreadCorrected Jul 6, 2023
  7. F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Nutrition and DietaryE · patternCorrected Jul 6, 2023
  8. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Jul 6, 2023
  9. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Jul 6, 2023
  10. Assure that each resident’s assessment is updated at least once every 3 months.Resident Assessment and Care PlanningD · isolatedCorrected Jul 6, 2023
  11. F583Keep residents' personal and medical records private and confidential.Resident RightsD · isolatedCorrected Jul 6, 2023
  12. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Jul 6, 2023
  13. F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareD · isolatedCorrected Jul 6, 2023
  14. F826Provide specialized rehabilitative services by qualified personnel, when ordered for a resident by a doctor.Quality of Life and CareD · isolatedCorrected Jul 6, 2023
  15. F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Resident RightsD · isolatedCorrected Jul 6, 2023
  16. F578Honor 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.Resident RightsE · patternCorrected Jul 6, 2023
Mar 29, 20231 citationCycle 3worst D · no actual harm
  1. F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Quality of Life and CareD · isolatedCorrected Apr 10, 2023
Feb 15, 20233 citationsCycle 3worst D · no actual harm
  1. Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.Resident RightsD · isolatedCorrected Mar 3, 2023
  2. F626Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.Resident RightsD · isolatedCorrected Mar 3, 2023
  3. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Mar 3, 2023

Staffing

From quarterly payroll reports

Hours per resident per day

  • All nursing staffRNs, LPNs and aides combined3.42hrsAbove only 1% of peers−0.96 vs WA avg
  • Registered nursesRN hours only0.42hrsAbove only 4% of peers−0.46 vs WA avg
  • Licensed practical nursesLPN hours0.74hrs
  • Nurse aidesCNA hours2.26hrs
  • Weekend nursingAll staff on Saturdays and Sundays3.07hrs
  • Washington average
  • Research benchmark (4.10 total, 0.75 RN)

Turnover & capacity

  • Nursing staff turnoverShare who left within a year · lower is better71%Above only 3% of peersWA avg 47%
  • RN turnoverRegistered nurses only86%Not ranked by CMS
  • Administrators who leftIn the past year—
  • Occupancy96 certified beds · ~88 residents a day92%Above 86% of peersWA avg 76%

Fines & penalties

Roughly the past three years

Enforcement summary

  • $202,635In fines
  • 2Fines
  • 2Payment denials
  • $53,236WA avg in fines
Above only 5% of peersFewer fines than 5% of rated homes in Washington

Actions on record

  1. Jun 27, 2025Denial of payment for new admissionsfrom Sep 27, 2025
  2. Dec 26, 2024Civil money penalty$117,108
  3. Dec 26, 2024Denial of payment for new admissionsfrom Mar 23, 2025
  4. Jul 16, 2024Civil money penalty$85,527

Ownership

As filed with CMS

Structure

Ownership type
For profit - Corporation
Chain
Independent
Certification
Medicare and Medicaid
Location type
Urban
Ownership change
None in the last 12 months

People and entities on file

Direct owners (5%+)
  • Foundation Healthcare Services LLC
Indirect owners (5%+)
  • Steven Frost
  • Jeffrey Lindahl
  • Kirkman Lindahl
  • Scott Lindahl
Operational or managerial control
  • Foundation Resource Center LLC
  • Brandt Anderson
  • Achashman Berihun
  • McKennzie Bracy
  • Brianna De Oro
  • Steven Frost
  • Chateau Johnson
  • Jeffrey Lindahl
  • +5 more
Corporate officers
  • Steven Frost
  • Jeffrey Lindahl
  • Kirkman Lindahl
  • Scott Lindahl

Person Organization

Sources & notes

Public data, updated quarterly

Data sources

  • CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
  • CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
  • CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.

Notes

  • CMS Certification Number 505254 · 1505 CARPENTER ROAD SE, LACEY, WA, 98503.
  • Percentiles compare this facility with every rated nursing home in Washington and Thurston County. Turnover and fines are inverted so a high percentile is always good.
  • This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.

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