Hearth Record

Crystal Cove Post Acute

A nursing home in Lacey, Washington 98503

1505 Carpenter Road SE, Lacey, Washington 98503. (360) 491-1765.

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The short answer

Record last released by CMS on Oct 28, 2026.

The last 24 months 135 citations in 17 months of the last 36. Last cited Jul 2026. Most serious: immediate jeopardy to health or safety (J). Every month

Each figure’s source sits beside it, in its section below.

What these words mean8
Star ratings
CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System.
Inspection (survey)
A visit by state inspectors, often unannounced, who check a place against the rules it must meet. For nursing homes and other places Medicare pays, CMS calls these visits surveys: a standard survey of a nursing home comes at least every 15 months, and a complaint survey whenever a complaint calls for one. Source: CMS; 42 CFR 488.308.
Deficiency, citation, violation
What inspectors write up when a place didn’t meet a rule: the rule, what they saw, and when. CMS calls it a deficiency; states may say citation or violation. It is the inspectors’ finding, not a court’s, and the place is usually asked for a plan to correct it. Source: CMS, statement of deficiencies (Form CMS-2567); each state’s licensing agency.
Scope and severity (A to L)
CMS grades each nursing home deficiency with a letter. A to C: no actual harm, with potential for minimal harm. D to F: no actual harm, but potential for more. G to I: actual harm. J to L: immediate jeopardy. Within each band, the letter rises as more residents were affected or could be: one or a few, a pattern, or widespread. Source: CMS, nursing home scope and severity grid (State Operations Manual, chapter 7).
Nurse staffing hours
The hours registered nurses, licensed practical nurses and nurse aides worked, per resident per day, from the payroll records each home sends CMS. Source: CMS, Payroll-Based Journal.
Fines and payment denials
A fine (civil money penalty) is money CMS makes a nursing home pay when it falls short of federal rules. A payment denial means Medicare and Medicaid stop paying for new admissions until the home meets the rules again. Source: CMS; 42 CFR 488.430 and 488.417.
Immediate jeopardy
CMS’s most serious finding: the place’s failure to meet a rule caused, or was likely to cause, serious injury, harm, impairment or death to someone in its care. Source: CMS; 42 CFR 489.3.
Capacity
The most people the licence or certification lets the place care for at once: residents, children, beds or apartments, as the state counts them. It isn’t how many are there now. Source: Each state’s licensing agency.

What did inspectors find?

38 health citations at the latest inspection cycle

The Washington average is 15.7.

Last standard inspection Jan 13, 2026.

Most serious in three years: immediate jeopardy to health or safety (J), at a complaint inspection on Mar 12, 2025

Source:

CMS, Provider Information, State and US Averages and Health Deficiencies. Released Oct 28, 2026. Updated monthly.

When those citations happened

135 citations in 17 months of the last 36. Last cited Jul 2026. Most serious: immediate jeopardy to health or safety (J). The last 3 years, to Nov 5, 2026.

135 citations by month over the last 3 years. Each cell is one month.
JanFebMarAprMayJunJulAugSepOctNovDec
2023 Dec
2024 JanFebMarAprMayJunJulAugSepOctNovDec
2025 JanFebMarAprMayJunJulAugSepOctNovDec
2026 JanFebMarAprMayJunJulAugSepOctNov

Hover or focus a month to read it.

No visit on record Visited, nothing cited A stronger orange is more serious, on its source’s own levels, read onto four bands: from the least serious it publishes to the most
Source:

Hearth Record drew this from the dates and levels in the source’s own records.

All 135 citations in the last three years

Grouped by inspection, newest first. Each carries , from A, the least serious, to L, the most. 35 came from complaint inspections.

Source:

CMS, Health Deficiencies. Released Oct 28, 2026. Updated monthly.

Jul 17, 2026: complaint inspection1 citation
  • Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

    Rule F0812. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jul 30, 2026.

Jun 22, 2026: complaint inspection3 citations
  • 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.

    Rule F0584. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jun 26, 2026.

  • Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

    Rule F0689. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jun 26, 2026.

  • Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

    Rule F0812. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jun 26, 2026.

Jun 10, 2026: complaint inspection1 citation
  • Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

    Rule F0851. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jun 18, 2026.

Jun 2, 2026: complaint inspection1 citation
  • Provide appropriate treatment and care according to orders, resident’s preferences and goals.

    Rule F0684. G: actual harm. From a complaint. Correction date, as CMS recorded it: Jun 17, 2026.

Mar 12, 2026: complaint inspection2 citations
  • Provide the required documentation or notification related to the resident’s needs, appeal rights, or bed-hold policies.

    Rule F0628. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Apr 10, 2026.

  • 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.

    Rule F0688. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Apr 10, 2026.

Jan 13, 2026: standard inspection26 citations
  • Honor the resident’s right to a dignified existence, self-determination, communication, and to exercise his or her rights.

    Rule F0550. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 6, 2026.

  • Honor the resident’s right to organize and participate in resident/family groups in the facility.

    Rule F0565. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 6, 2026.

  • Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.

    Rule F0569. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 6, 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.

    Rule F0584. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 6, 2026.

  • Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident’s ability to function.

    Rule F0605. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 6, 2026.

  • Respond appropriately to all alleged violations.

    Rule F0610. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 6, 2026.

  • Ensure each resident receives an accurate assessment.

    Rule F0641. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 6, 2026.

  • Develop and implement a complete care plan that meets all the resident’s needs, with timetables and actions that can be measured.

    Rule F0656. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 6, 2026.

  • Ensure services provided by the nursing facility meet professional standards of quality.

    Rule F0658. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 6, 2026.

  • Provide appropriate pressure ulcer care and prevent new ulcers from developing.

    Rule F0686. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 6, 2026.

  • Provide enough food/fluids to maintain a resident’s health.

    Rule F0692. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 6, 2026.

  • Provide for the safe, appropriate administration of IV fluids for a resident when needed.

    Rule F0694. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 6, 2026.

  • Provide safe and appropriate respiratory care for a resident when needed.

    Rule F0695. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 6, 2026.

  • Provide safe, appropriate dialysis care/services for a resident who requires such services.

    Rule F0698. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 6, 2026.

  • Observe each nurse aide’s job performance and give regular training.

    Rule F0730. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 6, 2026.

  • Ensure each resident’s drug regimen must be free from unnecessary drugs.

    Rule F0757. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 6, 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.

    Rule F0761. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 6, 2026.

  • Provide or obtain dental services for each resident.

    Rule F0791. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 6, 2026.

  • Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

    Rule F0806. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 6, 2026.

  • Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

    Rule F0812. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 6, 2026.

  • Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

    Rule F0847. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 6, 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.

    Rule F0849. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 6, 2026.

  • Provide and implement an infection prevention and control program.

    Rule F0880. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 6, 2026.

  • Implement a program that monitors antibiotic use.

    Rule F0881. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 6, 2026.

  • 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.

    Rule F0887. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 6, 2026.

  • Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

    Rule F0947. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 6, 2026.

Jan 13, 2026: standard and complaint inspection2 citations
  • Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

    Rule F0689. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Mar 6, 2026.

  • 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.

    Rule F0809. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Mar 6, 2026.

Jan 2, 2026: complaint inspection1 citation
  • Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

    Rule F0689. G: actual harm. From a complaint. Correction date, as CMS recorded it: Jan 22, 2026.

Dec 5, 2025: complaint inspection2 citations
  • 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.

    Rule F0584. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Dec 24, 2025.

  • Provide appropriate treatment and care according to orders, resident’s preferences and goals.

    Rule F0684. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Dec 24, 2025.

Aug 22, 2025: complaint inspection6 citations
  • Provide appropriate pressure ulcer care and prevent new ulcers from developing.

    Rule F0686. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Oct 6, 2025.

  • Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

    Rule F0802. F: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Oct 6, 2025.

  • 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.

    Rule F0803. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Oct 6, 2025.

  • Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

    Rule F0812. F: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Oct 6, 2025.

  • Administer the facility in a manner that enables it to use its resources effectively and efficiently.

    Rule F0835. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Oct 6, 2025.

  • Provide and implement an infection prevention and control program.

    Rule F0880. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Oct 6, 2025.

Jul 16, 2025: complaint inspection1 citation
  • Provide enough food/fluids to maintain a resident’s health.

    Rule F0692. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Aug 18, 2025.

Jun 27, 2025: complaint inspection1 citation
  • Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

    Rule F0755. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Aug 15, 2025.

Mar 12, 2025: complaint inspection1 citation
  • Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

    Rule F0678. J: immediate jeopardy to health or safety. From a complaint. Correction date, as CMS recorded it: Mar 31, 2025.

Feb 7, 2025: complaint inspection2 citations
  • Provide appropriate pressure ulcer care and prevent new ulcers from developing.

    Rule F0686. G: actual harm. From a complaint. Correction date, as CMS recorded it: Mar 31, 2025.

  • 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.

    Rule F0693. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Mar 31, 2025.

Feb 6, 2025: standard inspection45 citations
  • Provide enough food/fluids to maintain a resident’s health.

    Rule F0692. G: actual harm. Correction date, as CMS recorded it: Mar 31, 2025.

  • Honor the resident’s right to a dignified existence, self-determination, communication, and to exercise his or her rights.

    Rule F0550. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2025.

  • Honor the resident’s right to and the facility must promote and facilitate resident self-determination through support of resident choice.

    Rule F0561. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2025.

  • Honor the resident’s right to organize and participate in resident/family groups in the facility.

    Rule F0565. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2025.

  • Honor the resident’s right to manage his or her financial affairs.

    Rule F0567. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2025.

  • Properly hold, secure, and manage each resident’s personal money which is deposited with the nursing home.

    Rule F0568. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2025.

  • Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.

    Rule F0569. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2025.

  • Keep residents’ personal and medical records private and confidential.

    Rule F0583. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2025.

  • 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.

    Rule F0584. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 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.

    Rule F0585. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2025.

  • Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

    Rule F0604. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2025.

  • Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

    Rule F0622. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2025.

  • Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

    Rule F0623. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2025.

  • 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.

    Rule F0625. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2025.

  • Ensure each resident receives an accurate assessment.

    Rule F0641. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2025.

  • PASARR screening for Mental disorders or Intellectual Disabilities

    Rule F0645. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2025.

  • Develop and implement a complete care plan that meets all the resident’s needs, with timetables and actions that can be measured.

    Rule F0656. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2025.

  • Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

    Rule F0657. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2025.

  • Ensure services provided by the nursing facility meet professional standards of quality.

    Rule F0658. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2025.

  • Provide care and assistance to perform activities of daily living for any resident who is unable.

    Rule F0677. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2025.

  • Provide activities to meet all resident’s needs.

    Rule F0679. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2025.

  • Provide appropriate treatment and care according to orders, resident’s preferences and goals.

    Rule F0684. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2025.

  • Provide appropriate foot care.

    Rule F0687. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2025.

  • 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.

    Rule F0688. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2025.

  • Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

    Rule F0689. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 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.

    Rule F0690. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2025.

  • Provide for the safe, appropriate administration of IV fluids for a resident when needed.

    Rule F0694. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2025.

  • Provide safe and appropriate respiratory care for a resident when needed.

    Rule F0695. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2025.

  • Provide safe, appropriate dialysis care/services for a resident who requires such services.

    Rule F0698. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2025.

  • Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

    Rule F0725. F: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2025.

  • Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident’s well being.

    Rule F0726. F: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2025.

  • Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

    Rule F0756. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2025.

  • Ensure each resident’s drug regimen must be free from unnecessary drugs.

    Rule F0757. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2025.

  • Implement 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.

    Rule F0758. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2025.

  • Ensure medication error rates are not 5 percent or greater.

    Rule F0759. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2025.

  • 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.

    Rule F0761. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2025.

  • Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

    Rule F0806. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2025.

  • Ensure 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.

    Rule F0808. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2025.

  • Establish 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.

    Rule F0837. F: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2025.

  • Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

    Rule F0847. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2025.

  • Have a plan that describes the process for conducting QAPI and QAA activities.

    Rule F0865. F: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2025.

  • Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

    Rule F0868. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2025.

  • Provide and implement an infection prevention and control program.

    Rule F0880. F: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2025.

  • Implement a program that monitors antibiotic use.

    Rule F0881. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2025.

  • 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.

    Rule F0887. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2025.

Dec 26, 2024: complaint inspection2 citations
  • Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

    Rule F0689. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Mar 31, 2025.

  • Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

    Rule F0812. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Mar 31, 2025.

Sep 24, 2024: complaint inspection1 citation
  • Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

    Rule F0755. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Oct 9, 2024.

Aug 19, 2024: complaint inspection2 citations
  • Provide appropriate treatment and care according to orders, resident’s preferences and goals.

    Rule F0684. J: immediate jeopardy to health or safety. From a complaint. Correction date, as CMS recorded it: Aug 30, 2024.

  • Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

    Rule F0689. G: actual harm. From a complaint. Correction date, as CMS recorded it: Aug 30, 2024.

Jul 16, 2024: complaint inspection2 citations
  • Immediately tell the resident, the resident’s doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

    Rule F0580. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Aug 15, 2024.

  • Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

    Rule F0690. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Aug 15, 2024.

May 14, 2024: complaint inspection1 citation
  • Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

    Rule F0622. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: May 25, 2024.

Apr 26, 2024: complaint inspection3 citations
  • Respond appropriately to all alleged violations.

    Rule F0610. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: May 8, 2024.

  • Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

    Rule F0744. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: May 8, 2024.

  • Have policies on smoking.

    Rule F0926. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: May 8, 2024.

Mar 11, 2024: standard inspection29 citations
  • Honor the resident’s right to a dignified existence, self-determination, communication, and to exercise his or her rights.

    Rule F0550. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 25, 2024.

  • Honor the resident’s right to and the facility must promote and facilitate resident self-determination through support of resident choice.

    Rule F0561. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 25, 2024.

  • 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.

    Rule F0578. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 25, 2024.

  • Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

    Rule F0582. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 25, 2024.

  • 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.

    Rule F0584. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 25, 2024.

  • 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.

    Rule F0585. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 25, 2024.

  • 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.

    Rule F0625. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 25, 2024.

  • Ensure each resident receives an accurate assessment.

    Rule F0641. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 25, 2024.

  • Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

    Rule F0644. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 25, 2024.

  • PASARR screening for Mental disorders or Intellectual Disabilities

    Rule F0645. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 25, 2024.

  • Create and put into place a plan for meeting the resident’s most immediate needs within 48 hours of being admitted

    Rule F0655. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 25, 2024.

  • Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

    Rule F0657. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 25, 2024.

  • Ensure services provided by the nursing facility meet professional standards of quality.

    Rule F0658. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 25, 2024.

  • Provide care and assistance to perform activities of daily living for any resident who is unable.

    Rule F0677. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 25, 2024.

  • Provide appropriate treatment and care according to orders, resident’s preferences and goals.

    Rule F0684. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 25, 2024.

  • Provide appropriate pressure ulcer care and prevent new ulcers from developing.

    Rule F0686. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 25, 2024.

  • Provide appropriate foot care.

    Rule F0687. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 25, 2024.

  • Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

    Rule F0689. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 25, 2024.

  • Provide safe and appropriate respiratory care for a resident when needed.

    Rule F0695. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 25, 2024.

  • Have 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.

    Rule F0727. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 25, 2024.

  • Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

    Rule F0755. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 25, 2024.

  • Implement 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.

    Rule F0758. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 25, 2024.

  • Ensure medication error rates are not 5 percent or greater.

    Rule F0759. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 25, 2024.

  • 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.

    Rule F0761. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 25, 2024.

  • Provide or obtain dental services for each resident.

    Rule F0791. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 25, 2024.

  • Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

    Rule F0804. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 25, 2024.

  • 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.

    Rule F0809. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 25, 2024.

  • Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

    Rule F0812. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 25, 2024.

  • Provide and implement an infection prevention and control program.

    Rule F0880. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 25, 2024.

Is it certified, and in good standing?

  • Certified for Medicare and Medicaid since Apr 1, 1980.
  • On CMS’s special focus list, which CMS keeps for homes with a history of serious problems.
  • No abuse icon from CMS.
  • No change of ownership in the last 12 months.
  • CMS lists its ownership as for profit, limited liability company.
  • 96 certified beds.
Source:

CMS, Provider Information. Released Oct 28, 2026. Updated monthly.

Has it been fined or penalized?

  • 4 fines in the last three years, $235,672 in all.
  • 2 Medicare payment denials in the last three years.
  • 35 citations in the last three years came from complaint inspections.
Source:

CMS, Penalties and Health Deficiencies. Released Oct 28, 2026. Updated monthly.

Fines and payment denials, newest first
DateKindAmount
Jun 2, 2026Fine$20,415
Dec 5, 2025Fine$12,622
Jun 27, 2025Medicare payment denialNot given
Dec 26, 2024Medicare payment denialNot given
Dec 26, 2024Fine$117,108
Jul 16, 2024Fine$85,527

Who does the caring?

3.72 nurse hours per resident per day

The Washington average is 4.42.

CMS publishes staffing about four months after the fact.

Source:

CMS, Provider Information and State and US Averages. Released Oct 28, 2026. Updated monthly.

Staffing measures
MeasureThis homeWashington average
Nurse hours per resident per day3.724.42
Of which registered nurses0.670.99
At weekends3.213.82
Nursing staff turnover65.6%43.9%
Registered nurse turnover81.3%43.8%
Administrators who leftNot givenNot given

Who owns it?

  • Foundation Healthcare Services LLC owns 100% directly since Mar 1, 2020.
  • Foundation Resource Center LLC runs it.
  • 33 owners or officers are people: Scott Lindahl (owns 5% or more through other companies, 25%); Scott Lindahl (corporate officer, 25%); Steven Frost (owns 5% or more through other companies, 25%); Steven Frost (corporate officer, 25%); Kirkman Lindahl (owns 5% or more through other companies, 25%); Kirkman Lindahl (corporate officer, 25%); Jeffrey Lindahl (owns 5% or more through other companies, 25%); Achashman Berihun (runs it (operational or managerial control)); Achashman Berihun (additional disclosable party (controls, leases property to, or provides services to the home)); Scott Lindahl (runs it (operational or managerial control)); Scott Lindahl (additional disclosable party (controls, leases property to, or provides services to the home)); John Maina (runs it (operational or managerial control)); John Maina (additional disclosable party (controls, leases property to, or provides services to the home)); Chukwuemeka Nwankwo (runs it (operational or managerial control)); Chukwuemeka Nwankwo (additional disclosable party (controls, leases property to, or provides services to the home)); David Lindahl (additional disclosable party (controls, leases property to, or provides services to the home)); Brandt Anderson (runs it (operational or managerial control)); Brandt Anderson (additional disclosable party (controls, leases property to, or provides services to the home)); Steven Frost (runs it (operational or managerial control)); Steven Frost (additional disclosable party (controls, leases property to, or provides services to the home)); Kirkman Lindahl (runs it (operational or managerial control)); Kirkman Lindahl (additional disclosable party (controls, leases property to, or provides services to the home)); Brianna De Oro (runs it (operational or managerial control)); Brianna De Oro (additional disclosable party (controls, leases property to, or provides services to the home)); Jay Zwahlen (runs it (operational or managerial control)); Jay Zwahlen (additional disclosable party (controls, leases property to, or provides services to the home)); Jeffrey Lindahl (corporate officer); Jeffrey Lindahl (runs it (operational or managerial control)); Jeffrey Lindahl (additional disclosable party (controls, leases property to, or provides services to the home)); Mckennzie Bracy (runs it (operational or managerial control)); Mckennzie Bracy (additional disclosable party (controls, leases property to, or provides services to the home)); Chateau Johnson (runs it (operational or managerial control)); Chateau Johnson (additional disclosable party (controls, leases property to, or provides services to the home)).
  • No private-equity firm among the owners CMS lists.
  • No real-estate investment trust among the owners CMS lists.
Source:

CMS, All Owners. Checked Nov 5, 2026. Updated monthly.

CMS, Provider Information. Released Oct 28, 2026. Updated monthly.

Organisations CMS lists
OrganisationRoleShareSince
Foundation Healthcare Services LLCOwns 5% or more directly100%Mar 1, 2020
Foundation Resource Center LLCRuns it (operational or managerial control)Feb 1, 2020
Foundation Resource Center LLCAdditional disclosable party (controls, leases property to, or provides services to the home)Feb 11, 2025
Wa1west LLCAdditional disclosable party (controls, leases property to, or provides services to the home)Feb 1, 2020
An organisation CMS lists without a nameAdditional disclosable party (controls, leases property to, or provides services to the home)Sep 9, 2025
An organisation CMS lists without a nameAdditional disclosable party (controls, leases property to, or provides services to the home)Sep 9, 2025
An organisation CMS lists without a nameAdditional disclosable party (controls, leases property to, or provides services to the home)Sep 9, 2025

How do residents fare?

  • CMS hasn’t rated this home’s quality measures.
Source:

CMS, Provider Information and State and US Averages. Released Oct 28, 2026. Updated monthly.

CMS’s star ratings, from 1 to 5
MeasureRating
Overall ratingNot rated
Health inspectionsNot rated
StaffingNot rated
Quality measuresNot rated

How does it compare nearby?

  • Among the 12 nearest homes, within 19.0 miles, this one had the 3rd most health citations at the latest inspection cycle (38; the middle value was 17.5).
Source:

CMS, Provider Information. Released Oct 28, 2026. Updated monthly.

What the record doesn’t say

  • Complaints that didn’t lead to a citation aren’t published.
  • Inspections reach CMS’s data about six weeks after they happen, and staffing about four months after.
  • CMS publishes the inspectors’ full written findings in a separate monthly file, which isn’t loaded yet.
  • Fines and Medicare payment denials are the only enforcement CMS publishes; state licence actions aren’t included.

Sources

  • Centers for Medicare & Medicaid Services, Provider Information (4pq5-n9py).

    Released Oct 28, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).

  • Centers for Medicare & Medicaid Services, Health Deficiencies (r5ix-sfxw).

    Released Oct 28, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).

  • Centers for Medicare & Medicaid Services, Penalties (g6vv-u9sr).

    Released Oct 28, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).

  • Centers for Medicare & Medicaid Services, All Owners (afe44b85-cc6d-40d7-b5df-00ae8910d1d2).

    Checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).

  • Centers for Medicare & Medicaid Services, State and US Averages (xcdc-v8bm).

    Released Oct 28, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).

If you believe something here is wrong, a correction starts with the agency whose record this copies: CMS. CMS’s own record is on Care Compare. If Hearth Record copied something wrongly, it will fix it and log the correction publicly, with its date: how corrections work.

Source:

This copy of the record was made on Nov 5, 2026.

From the home

The public record above comes first. Anything the home adds will appear here, below it, and say who wrote it.

Replies

None. Replies aren’t open yet. When they open, the home will be able to answer any finding for free, and the reply will show beside that finding, unedited and dated.

Paid listing

None. Paid listings aren’t open yet. When they open, anything paid for will say “Paid by the home”, and paying will never change a finding, a rating or the order of results.

How to read a record

Four things every record does, shown on an example record made up for this guide.

An example record, made up for this guide

An example nursing home

Made up for this guide: no real place is shown

Not fully inspected in over two years (CMS flag)

11 health citations at the latest inspection cycle

The state average is 14.3.

Source:

CMS, State and US Averages and Health Deficiencies. Released Oct 28, 2026. Updated monthly.

From the homeNone yet. Replies and paid listings aren’t open, and when they open they will sit here, below the record.

1 of 4

Every fact names its source.

Who published it, when, and how often it changes sit beside each fact, with a link to the agency’s own file.

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