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Nursing HomeMedicaid

Crystal Cove Post Acute

On Medicare Special Focus status, a serious quality warning. Visit in person and ask tough questions before deciding.

1505 Carpenter Road Se, Lacey, WA 9850396 bedsLicensed & Active
Google rating
3.1/5

based on 48 Google reviews

5
4
3
2
1

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What this means for your family

While recent renovations and a rebrand have improved the facility's appearance, the persistent reports of neglect and medication errors are deeply concerning. We strongly advise families to conduct unannounced visits and speak directly with current residents' families before making a decision, as the quality of care appears highly inconsistent.

Google Reviews

Google Reviews

48 reviews on Google
Crystal Cove Post Acute, formerly known as Roo Lan, receives highly polarized reviews that suggest significant inconsistency in care quality. While some families praise the facility for its recent physical renovations, garden areas, and compassionate staff, a large number of reviewers report severe neglect, including issues with medication management, dehydration, and poor communication. Potential families should be aware of serious allegations regarding patient safety and administrative transparency that have persisted over several years.

Quality Themes

Tap a score for details
Food2.0Staff4.0Clean3.0Activities2.0Meds1.0Memory2.0Comms2.0Value1.0

Strengths

  • Well-maintained building and grounds
  • Pleasant outdoor garden and walking areas
  • Some staff noted as compassionate and attentive

Concerns

  • Neglect and poor basic care (dehydration, hygiene, feeding) (mentioned by 6 reviewers)
  • Medication management errors and delays (mentioned by 3 reviewers)
  • Lack of promised rehabilitation or memory care services (mentioned by 3 reviewers)
  • Poor communication and difficulty reaching staff (mentioned by 3 reviewers)

Rating Trends

Tap a year to see what changed

234'17(2)'19(2)'22(2)'24(4)'26(8)

Distribution · 49 analyzed

5
22
4
3
3
0
2
1
1
23

How They Respond to Reviews

3%response rate

This facility rarely responds to reviews.

Questions for Your Tour

  • 1Given the recent focus on staffing levels, could you walk me through your current process for ensuring residents receive consistent assistance with daily hygiene and hydration needs?
  • 2I noticed the facility has a beautiful outdoor garden area; how are residents encouraged to utilize these spaces, and what does a typical social or activity schedule look like for them?
  • 3Could you explain your current protocols for medication management and how you ensure accuracy and timeliness for residents who require daily assistance?
  • 4I see that you have responded to some feedback online; what is your preferred method for family members to communicate with the care team, and how do you ensure updates are shared promptly?
  • 5With the facility's current focus on rehabilitation and memory care, how do you tailor your support services to meet the specific needs of residents who require a higher level of daily supervision?
  • 6How does your nursing team coordinate with families during medical emergencies, and what steps do you take to ensure clear communication during those transitions?

Personalized based on this facility's data


Key Review Excerpts

If you want your family to die of neglect, send them here. They get their morning meds at noon. The might get fed. That is if staff decides to give them food.

Family member · 2025☆☆☆☆

My mom spent 5 awful months in this place. I'm not sure what memory care is there because none was ever done and rehab shouldn't be in the name because she never got any.

Family member · 2024☆☆☆☆

Clean, well run,friendly competent staff,this place is a great community asset,low key building with a nice paved and landscaped walking trail that weaves around the facility.

Community member · 2025★★★★★
Source: 48 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.57hrs
76%
Registered nurses for medical care
Total Nursing
3.39hrs
83%
All nurses + aides combined
Staff Turnover
69%
Lower is better (< 30% = good)
RN Turnover
86%
Lower is better (< 30% = good)

Both RN and total nursing hours are below national benchmarks. This can mean less clinical attention per resident, so ask about their staffing plan.

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 17 measures

Better Than Avg

8

measures

Worse Than Avg

8

measures

Mixed Results

1

measures

Long-Stay Residents
😔

Residents with depression symptoms

↓ Lower is better
This Facility3.1%
Better than Avg
Here
3.1%
US
12.1%
WA
17.2%
Thurston
16.6%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

🚶

Residents whose walking got worse

↓ Lower is better
This Facility28.4%
Worse than Avg
Here
28.4%
US
15.3%
WA
18.8%
Thurston
16.8%
💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility6.6%
Better than Avg
Here
6.6%
US
19.5%
WA
12.2%
Thurston
11.2%
🚿

Residents whose bladder or bowel control got worse

↓ Lower is better
This Facility12.3%
Better than Avg
Here
12.3%
US
19.4%
WA
23.0%
Thurston
22.4%
💊

Residents on antipsychotic medication

↓ Lower is better
This Facility11.7%
Better than Avg
Here
11.7%
US
15.5%
WA
15.2%
Thurston
21.5%
💉

Residents vaccinated for pneumonia

↑ Higher is better
This Facility88.8%
Worse than Avg
Here
88.8%
US
93.4%
WA
95.9%
Thurston
95.9%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility44.3%
Worse than Avg
Here
44.3%
US
81.8%
WA
87.8%
Thurston
84.8%
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility61.5%
Worse than Avg
Here
61.5%
US
79.8%
WA
82.0%
Thurston
80.2%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility0.8%
Better than Avg
Here
0.8%
US
1.6%
WA
1.3%
Thurston
1.6%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

40deficiencies
5penalties
Well above state avg (17.1)
36 complaint-triggered
$202,635 in fines

Crystal Cove Post Acute shows significant quality concerns with 40 complaint-triggered deficiencies indicating families have repeatedly filed reports about problems. The facility has persistent issues across resident safety, medication management, and nutrition services, with safety hazards and treatment failures recurring across multiple surveys. While most violations show correction dates, the pattern of ongoing complaints and repeat deficiencies suggests systemic problems that families should carefully consider.

Mar 12, 2026Complaint
2
0628Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

0688Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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.

Jan 13, 2026Routine
31
0039Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Conduct testing and exercise requirements.

0353Potential for harm · WidespreadCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0921Potential for harm · WidespreadCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure that testing and maintenance of electrical equipment is performed.

0584Potential for harm · PatternCorrected

Resident Rights Deficiencies

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.

0605Potential for harm · PatternCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

0656Potential for harm · PatternCorrected

Resident Assessment and Care Planning Deficiencies

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

0757Potential for harm · PatternCorrected

Pharmacy Service Deficiencies

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

0761Potential for harm · PatternCorrected

Pharmacy Service Deficiencies

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.

0887Potential for harm · PatternCorrected

Infection Control Deficiencies

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.

0222Potential for harm · PatternCorrected

Egress Deficiencies

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

0374Potential for harm · PatternCorrected

Smoke Deficiencies

Install smoke barrier doors that can resist smoke for at least 20 minutes.

0550Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

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

0565Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

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

0569Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

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

0610Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

0641Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

0658Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

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

0686Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

0692Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

0694Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

0695Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

0698Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

0730Potential for harm · IsolatedCorrected

Nursing and Physician Services Deficiencies

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

0791Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide or obtain dental services for each resident.

0806Potential for harm · IsolatedCorrected

Nutrition and Dietary Deficiencies

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

0812Potential for harm · IsolatedCorrected

Nutrition and Dietary Deficiencies

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

0847Potential for harm · IsolatedCorrected

Administration Deficiencies

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

0849Potential for harm · IsolatedCorrected

Administration Deficiencies

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.

0880Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0881Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Implement a program that monitors antibiotic use.

0947Potential for harm · IsolatedCorrected

Nursing and Physician Services Deficiencies

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

Jan 13, 2026Complaint
2
0809Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

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.

0689Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

Jan 2, 2026Complaint
1
0689Actual harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

Dec 5, 2025Complaint
2
0584Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

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.

0684Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

Aug 22, 2025Complaint
10
0802Potential for harm · WidespreadCorrected

Nutrition and Dietary Deficiencies

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

0812Potential for harm · WidespreadCorrected

Nutrition and Dietary Deficiencies

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

0324Potential for harm · WidespreadCorrected

Smoke Deficiencies

Provide properly protected cooking facilities.

0835Potential for harm · PatternCorrected

Administration Deficiencies

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

0686Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

0803Potential for harm · IsolatedCorrected

Nutrition and Dietary Deficiencies

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.

0880Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0353Potential for harm · IsolatedCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0355Potential for harm · IsolatedCorrected

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

0511Potential for harm · IsolatedCorrected

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Federal Penalties

Fine

Dec 5, 2025

$19,115

Payment Denial

Jun 27, 2025

9-day denial

Fine

Dec 26, 2024

$117,108

Payment Denial

Dec 26, 2024

8-day denial

Fine

Jul 16, 2024

$85,527

Ownership & Operations

Who Operates This Facility

Owner / Operator

Crystal Cove Post Acute

Organization Type

for profit

Ownership & Management

Key personnel

Frost, StevenOfficer / DirectorLindahl, JeffreyOfficer / DirectorLindahl, KirkmanOfficer / DirectorLindahl, ScottOfficer / DirectorFoundation Resource Center LLCManager
Source: Medicare provider data

Contact

Get in Touch

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References & Resources

EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.

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