Nursing Care Index

Crystal Cove Post Acute

Lacey, Thurston County, Washington · CCN 505254 · For-profit (LLC) · not part of a chain

CMS rates Crystal Cove Post Acute unrated overall as of August 2026. 96 certified beds, 88 residents a day on average. 137 citations on record from the current inspection cycles, 2 at immediate jeopardy; 4 fines totalling $235,475 and 2 payment denials.

On record

CMS’s ratings

The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead.

OverallDid not submit staffing data, or submitted data that did not meet the criteria for a staffing rating (CMS footnote 18)
Health inspectionsDid not submit staffing data, or submitted data that did not meet the criteria for a staffing rating (CMS footnote 18)
StaffingDid not submit staffing data, or submitted data that did not meet the criteria for a staffing rating (CMS footnote 18)
Quality measuresDid not submit staffing data, or submitted data that did not meet the criteria for a staffing rating (CMS footnote 18)

Staffing

Total nurse staffing3.77444 hours per resident per day
Registered nurses0.65007 hours per resident per day
Weekend total3.21418 hours per resident per day
Nursing staff turnover69.7% (registered nurses 87.5%)

Citations from health inspections

Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.

SurveyFindingSeverityStatus
2026-06-22
complaint survey
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.
Resident Rights Deficiencies · tag F0584
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2026-06-26
2026-06-22
complaint survey
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2026-06-26
2026-06-22
complaint survey
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies · tag F0812
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2026-06-26
2026-06-10
complaint survey
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Administration Deficiencies · tag F0851
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-06-18
2026-06-02
complaint survey
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · tag F0684
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2026-06-17
2026-03-12
complaint survey
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Resident Rights Deficiencies · tag F0628
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-04-10
2026-03-12
complaint survey
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.
Quality of Life and Care Deficiencies · tag F0688
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-04-10
2026-01-13 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.
Resident Rights Deficiencies · tag F0584
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2026-03-06
2026-01-13 Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0605
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2026-03-06
2026-01-13 Develop 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 Planning Deficiencies · tag F0656
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2026-03-06
2026-01-13 Ensure each resident’s drug regimen must be free from unnecessary drugs.
Pharmacy Service Deficiencies · tag F0757
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2026-03-06
2026-01-13 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.
Pharmacy Service Deficiencies · tag F0761
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2026-03-06
2026-01-13
complaint survey
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 Dietary Deficiencies · tag F0809
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2026-03-06
2026-01-13 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.
Infection Control Deficiencies · tag F0887
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2026-03-06
2026-01-13 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies · tag F0550
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-03-06
2026-01-13 Honor the resident's right to organize and participate in resident/family groups in the facility.
Resident Rights Deficiencies · tag F0565
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-03-06
2026-01-13 Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Resident Rights Deficiencies · tag F0569
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-03-06
2026-01-13 Respond appropriately to all alleged violations.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0610
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-03-06
2026-01-13 Ensure each resident receives an accurate assessment.
Resident Assessment and Care Planning Deficiencies · tag F0641
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-03-06
2026-01-13 Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning Deficiencies · tag F0658
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-03-06
2026-01-13 Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies · tag F0686
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-03-06
2026-01-13
complaint survey
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-03-06
2026-01-13 Provide enough food/fluids to maintain a resident's health.
Quality of Life and Care Deficiencies · tag F0692
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-03-06
2026-01-13 Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Quality of Life and Care Deficiencies · tag F0694
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-03-06
2026-01-13 Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies · tag F0695
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-03-06
2026-01-13 Provide safe, appropriate dialysis care/services for a resident who requires such services.
Quality of Life and Care Deficiencies · tag F0698
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-03-06
2026-01-13 Observe each nurse aide's job performance and give regular training.
Nursing and Physician Services Deficiencies · tag F0730
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-03-06
2026-01-13 Provide or obtain dental services for each resident.
Quality of Life and Care Deficiencies · tag F0791
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-03-06
2026-01-13 Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Nutrition and Dietary Deficiencies · tag F0806
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-03-06
2026-01-13 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies · tag F0812
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-03-06
2026-01-13 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Administration Deficiencies · tag F0847
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-03-06
2026-01-13 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.
Administration Deficiencies · tag F0849
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-03-06
2026-01-13 Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-03-06
2026-01-13 Implement a program that monitors antibiotic use.
Infection Control Deficiencies · tag F0881
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-03-06
2026-01-13 Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Nursing and Physician Services Deficiencies · tag F0947
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-03-06
2026-01-02
complaint survey
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2026-01-22
2025-12-05
complaint survey
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.
Resident Rights Deficiencies · tag F0584
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-12-24
2025-12-05
complaint survey
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · tag F0684
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-12-24
2025-08-22
complaint survey
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Nutrition and Dietary Deficiencies · tag F0802
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2025-10-06
2025-08-22
complaint survey
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies · tag F0812
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2025-10-06
2025-08-22
complaint survey
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Administration Deficiencies · tag F0835
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-10-06
2025-08-22
complaint survey
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies · tag F0686
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-10-06
2025-08-22
complaint survey
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.
Nutrition and Dietary Deficiencies · tag F0803
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-10-06
2025-08-22
complaint survey
Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-10-06
2025-07-16
complaint survey
Provide enough food/fluids to maintain a resident's health.
Quality of Life and Care Deficiencies · tag F0692
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-08-18
2025-06-27
complaint survey
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies · tag F0755
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-08-15
2025-03-12
complaint survey
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 Care Deficiencies · tag F0678
J Immediate jeopardy to resident health or safety; isolated Deficient, Provider has date of correction
2025-03-31
2025-02-07
complaint survey
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies · tag F0686
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2025-03-31
2025-02-07
complaint survey
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Quality of Life and Care Deficiencies · tag F0693
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-03-31
2025-02-06 Provide enough food/fluids to maintain a resident's health.
Quality of Life and Care Deficiencies · tag F0692
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2025-03-31
2025-02-06 Provide 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 Services Deficiencies · tag F0725
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2025-03-31
2025-02-06 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.
Nursing and Physician Services Deficiencies · tag F0726
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2025-03-31
2025-02-06 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.
Administration Deficiencies · tag F0837
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2025-03-31
2025-02-06 Have a plan that describes the process for conducting QAPI and QAA activities.
Administration Deficiencies · tag F0865
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2025-03-31
2025-02-06 Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2025-03-31
2025-02-06 Honor the resident's right to organize and participate in resident/family groups in the facility.
Resident Rights Deficiencies · tag F0565
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-03-31
2025-02-06 Honor the resident's right to manage his or her financial affairs.
Resident Rights Deficiencies · tag F0567
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-03-31
2025-02-06 Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Resident Rights Deficiencies · tag F0568
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-03-31
2025-02-06 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.
Resident Rights Deficiencies · tag F0584
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-03-31
2025-02-06 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.
Resident Rights Deficiencies · tag F0585
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-03-31
2025-02-06 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0604
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-03-31
2025-02-06 Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Resident Rights Deficiencies · tag F0623
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-03-31
2025-02-06 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 Rights Deficiencies · tag F0625
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-03-31
2025-02-06 Ensure each resident receives an accurate assessment.
Resident Assessment and Care Planning Deficiencies · tag F0641
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-03-31
2025-02-06 Develop 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 Planning Deficiencies · tag F0656
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-03-31
2025-02-06 Develop 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 Planning Deficiencies · tag F0657
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-03-31
2025-02-06 Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning Deficiencies · tag F0658
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-03-31
2025-02-06 Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies · tag F0677
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-03-31
2025-02-06 Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · tag F0684
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-03-31
2025-02-06 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.
Quality of Life and Care Deficiencies · tag F0688
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-03-31
2025-02-06 Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Quality of Life and Care Deficiencies · tag F0694
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-03-31
2025-02-06 Ensure each resident’s drug regimen must be free from unnecessary drugs.
Pharmacy Service Deficiencies · tag F0757
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-03-31
2025-02-06 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.
Pharmacy Service Deficiencies · tag F0758
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-03-31
2025-02-06 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.
Pharmacy Service Deficiencies · tag F0761
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-03-31
2025-02-06 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.
Nutrition and Dietary Deficiencies · tag F0808
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-03-31
2025-02-06 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Administration Deficiencies · tag F0847
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-03-31
2025-02-06 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Administration Deficiencies · tag F0868
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-03-31
2025-02-06 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies · tag F0550
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-03-31
2025-02-06 Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Resident Rights Deficiencies · tag F0561
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-03-31
2025-02-06 Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Resident Rights Deficiencies · tag F0569
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-03-31
2025-02-06 Keep residents' personal and medical records private and confidential.
Resident Rights Deficiencies · tag F0583
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-03-31
2025-02-06 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.
Resident Rights Deficiencies · tag F0622
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-03-31
2025-02-06 PASARR screening for Mental disorders or Intellectual Disabilities
Resident Assessment and Care Planning Deficiencies · tag F0645
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-03-31
2025-02-06 Provide activities to meet all resident's needs.
Quality of Life and Care Deficiencies · tag F0679
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-03-31
2025-02-06 Provide appropriate foot care.
Quality of Life and Care Deficiencies · tag F0687
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-03-31
2025-02-06 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-03-31
2025-02-06 Provide 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 Care Deficiencies · tag F0690
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-03-31
2025-02-06 Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies · tag F0695
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-03-31
2025-02-06 Provide safe, appropriate dialysis care/services for a resident who requires such services.
Quality of Life and Care Deficiencies · tag F0698
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-03-31
2025-02-06 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Pharmacy Service Deficiencies · tag F0756
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-03-31
2025-02-06 Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies · tag F0759
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-03-31
2025-02-06 Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Nutrition and Dietary Deficiencies · tag F0806
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-03-31
2025-02-06 Implement a program that monitors antibiotic use.
Infection Control Deficiencies · tag F0881
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-03-31
2025-02-06 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.
Infection Control Deficiencies · tag F0887
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-03-31
2024-12-26
complaint survey
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-03-31
2024-12-26
complaint survey
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies · tag F0812
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-03-31
2024-09-24
complaint survey
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies · tag F0755
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-10-09
2024-08-19
complaint survey
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · tag F0684
J Immediate jeopardy to resident health or safety; isolated Deficient, Provider has date of correction
2024-08-30
2024-08-19
complaint survey
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2024-08-30
2024-07-16
complaint survey
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Resident Rights Deficiencies · tag F0580
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-08-15
2024-07-16
complaint survey
Provide 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 Care Deficiencies · tag F0690
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-08-15
2024-05-14
complaint survey
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.
Resident Rights Deficiencies · tag F0622
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-05-25
2024-04-26
complaint survey
Have policies on smoking.
Environmental Deficiencies · tag F0926
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-05-08
2024-04-26
complaint survey
Respond appropriately to all alleged violations.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0610
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-05-08
2024-04-26
complaint survey
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Quality of Life and Care Deficiencies · tag F0744
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-05-08
2024-03-11 Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Resident Rights Deficiencies · tag F0561
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-04-25
2024-03-11 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.
Resident Rights Deficiencies · tag F0584
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-04-25
2024-03-11 Ensure each resident receives an accurate assessment.
Resident Assessment and Care Planning Deficiencies · tag F0641
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-04-25
2024-03-11 Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Resident Assessment and Care Planning Deficiencies · tag F0644
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-04-25
2024-03-11 Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Resident Assessment and Care Planning Deficiencies · tag F0655
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-04-25
2024-03-11 Develop 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 Planning Deficiencies · tag F0657
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-04-25
2024-03-11 Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning Deficiencies · tag F0658
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-04-25
2024-03-11 Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · tag F0684
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-04-25
2024-03-11 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies · tag F0755
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-04-25
2024-03-11 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.
Pharmacy Service Deficiencies · tag F0758
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-04-25
2024-03-11 Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies · tag F0759
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-04-25
2024-03-11 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.
Pharmacy Service Deficiencies · tag F0761
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-04-25
2024-03-11 Provide or obtain dental services for each resident.
Quality of Life and Care Deficiencies · tag F0791
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-04-25
2024-03-11 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Nutrition and Dietary Deficiencies · tag F0804
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-04-25
2024-03-11 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 Dietary Deficiencies · tag F0809
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-04-25
2024-03-11 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies · tag F0812
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-04-25
2024-03-11 Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-04-25
2024-03-11 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies · tag F0550
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-04-25
2024-03-11 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.
Resident Rights Deficiencies · tag F0578
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-04-25
2024-03-11 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Resident Rights Deficiencies · tag F0582
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-04-25
2024-03-11 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.
Resident Rights Deficiencies · tag F0585
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-04-25
2024-03-11 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 Rights Deficiencies · tag F0625
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-04-25
2024-03-11 PASARR screening for Mental disorders or Intellectual Disabilities
Resident Assessment and Care Planning Deficiencies · tag F0645
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-04-25
2024-03-11 Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies · tag F0677
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-04-25
2024-03-11 Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies · tag F0686
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-04-25
2024-03-11 Provide appropriate foot care.
Quality of Life and Care Deficiencies · tag F0687
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-04-25
2024-03-11 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-04-25
2024-03-11 Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies · tag F0695
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-04-25
2024-03-11 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.
Nursing and Physician Services Deficiencies · tag F0727
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-04-25
2023-10-18
complaint survey
Ensure that residents are fully informed and understand their health status, care and treatments.
Resident Rights Deficiencies · tag F0552
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-11-03
2023-10-18
complaint survey
Prepare residents for a safe transfer or discharge from the nursing home.
Resident Rights Deficiencies · tag F0624
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-11-03
2023-10-18
complaint survey
Develop 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 Planning Deficiencies · tag F0656
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-11-03

Fines and payment denials

DatePenaltyAmount
2026-06-02Fine$20,415
2025-12-05Fine$12,425
2025-06-27Payment denial for 9 days from 2025-09-27
2024-12-26Payment denial for 8 days from 2025-03-23
2024-12-26Fine$117,108
2024-07-16Fine$85,527

Who owns and runs it

Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.

NameRoleShareSince
Foundation Resource Center LLC
Organization
adp of the snf2025-02-11
Wa1west LLC
Organization
adp of the snf2020-02-01
Foundation Resource Center LLC
Organization
operational/managerial control2020-02-01
Anderson, Brandt
Individual
adp of the snf2022-01-02
Berihun, Achashman
Individual
adp of the snf2020-02-01
Bracy, Mckennzie
Individual
adp of the snf2020-02-01
De Oro, Brianna
Individual
adp of the snf2025-02-24
Frost, Steven
Individual
adp of the snf2020-02-01
Johnson, Chateau
Individual
adp of the snf2024-12-30
Lindahl, David
Individual
adp of the snf2020-03-01
Lindahl, Jeffrey
Individual
adp of the snf2019-02-01
Lindahl, Kirkman
Individual
adp of the snf2020-03-01
Lindahl, Scott
Individual
adp of the snf2020-03-01
Maina, John
Individual
adp of the snf2025-03-27
Nwankwo, Chukwuemeka
Individual
adp of the snf2025-04-01
Zwahlen, Jay
Individual
adp of the snf2024-01-01
Frost, Steven
Individual
corporate officer2020-03-01
Lindahl, Jeffrey
Individual
corporate officer2020-03-01
Lindahl, Kirkman
Individual
corporate officer2020-03-01
Lindahl, Scott
Individual
corporate officer2020-03-01
Anderson, Brandt
Individual
operational/managerial control2022-01-02
Berihun, Achashman
Individual
operational/managerial control2020-02-01
Bracy, Mckennzie
Individual
operational/managerial control2020-02-01
De Oro, Brianna
Individual
operational/managerial control2025-02-24
Frost, Steven
Individual
operational/managerial control2020-02-01
Johnson, Chateau
Individual
operational/managerial control2024-12-30
Lindahl, Jeffrey
Individual
operational/managerial control2019-02-01
Lindahl, Kirkman
Individual
operational/managerial control2019-02-01
Lindahl, Scott
Individual
operational/managerial control2019-02-01
Maina, John
Individual
operational/managerial control2025-03-27
Nwankwo, Chukwuemeka
Individual
operational/managerial control2025-04-01
Zwahlen, Jay
Individual
operational/managerial control2024-01-01

What changed

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Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Every nursing home in Thurston County.