Crystal Cove Post Acute: Failed Mock Survey Fixes - WA
The facility's mock survey on July 28 and 29 revealed that skin checks weren't being completed every seven days for residents at risk of developing bedsores. Wound measurements weren't being taken beyond the initial assessment when residents arrived. Staff weren't following enhanced barrier precautions for residents with antibiotic-resistant bacteria.
In the kitchen, the audit found standing water pooled on the floor between the walk-in refrigerator and freezer. Towels were scattered on the floor under food storage racks. The kitchen hood was caked with dust and debris. A dietary aide was performing chemical testing of dishwasher sanitizer incorrectly.
When complaint investigators arrived August 22, they found the facility had done nothing to address any of these findings from its own audit conducted nearly a month earlier.
Administrator Staff A acknowledged during an interview that the facility had experienced significant turnover among kitchen staff and dietary managers in recent months. He said new employees were still in training. He admitted he was responsible for oversight of the kitchen operations.
The administrator confirmed that a dietician consultant visited weekly but acknowledged this person did not oversee kitchen operations.
State inspectors found the administrative failures had put residents at risk across multiple areas of care. Two residents specifically suffered from inadequate pressure ulcer prevention and treatment. The facility failed to ensure proper skin assessments and wound care protocols were followed.
In the kitchen, inspectors documented that dietary staff weren't properly trained to recognize and document appropriate food temperatures. Chemical sanitation procedures for the dishwasher, sanitizer buckets, and three-compartment sink were inadequate. Meals weren't consistently served at established times.
Food safety violations extended beyond staff training. Inspectors found that food temperatures weren't being taken and documented properly. Foods weren't cooked and served at appropriate temperatures. Chemical solutions and water temperatures in the kitchen weren't maintained or documented according to safety standards. Staff weren't following proper handwashing procedures during meal preparation and serving.
These kitchen deficiencies placed all residents at risk of foodborne illness, according to the inspection report.
The infection control failures specifically involved staff training on transmission-based precautions for antibiotic-resistant bacteria. The facility's own audit had identified this problem in July, but staff were still improperly trained when state inspectors arrived.
The inspection revealed a pattern of administrative negligence. The facility had the tools to identify problems through its internal audit process. The mock survey had functioned exactly as intended, flagging serious deficiencies that could harm residents.
But having the information wasn't enough. The administration failed to create systems to ensure the identified problems were corrected. No monitoring system was in place to verify that skin assessments were completed on schedule. No oversight ensured kitchen staff received proper training on food safety protocols. No verification confirmed that infection control procedures were being followed.
The facility's dietician consultant visited weekly but wasn't assigned to oversee the kitchen operations where multiple food safety violations were occurring. This left a gap in professional oversight at a time when new, untrained staff were handling food preparation and safety procedures.
Standing water between kitchen appliances created conditions for bacterial growth. Towels on the floor under food storage areas violated basic sanitation principles. The dirty kitchen hood indicated poor maintenance of essential ventilation equipment.
For residents requiring wound care, the administrative failures had direct consequences. Without regular skin assessments, pressure ulcers could develop undetected. Without proper wound measurements, treatment progress couldn't be monitored effectively. The facility's own audit had identified these exact problems, yet they persisted.
The inspection found that some residents were affected by each category of administrative failure. The facility served a population that included people at risk for pressure ulcers, people requiring specialized infection control precautions, and people dependent on the facility for all their meals.
Crystal Cove Post Acute's internal audit process had worked correctly, identifying real problems that posed genuine risks to resident health and safety. The administration's failure was in the follow-through. They had documented what needed to be fixed but created no system to ensure the fixes actually happened.
The administrator's acknowledgment of responsibility for kitchen oversight highlighted the scope of the administrative failure. He knew about the problems, knew about the staff turnover, knew about the training needs, and knew about the audit findings. Yet the problems remained unaddressed when state inspectors arrived to investigate complaints about the facility.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Crystal Cove Post Acute from 2025-08-22 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Crystal Cove Post Acute in LACEY, WA was cited for violations during a health inspection on August 22, 2025.
The facility's mock survey on July 28 and 29 revealed that skin checks weren't being completed every seven days for residents at risk of developing bedsores.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.