Crystal Cove Post Acute: Infection Control Failures - WA
The resident, identified in inspection records only as Resident 6, had a rectal swab come back positive on July 31, 2025 for OXA-235-like Carbapenem-resistant Acinetobacter baumannii, a strain of CRAB. Someone handwrote "Contact precautions" on the lab result. That was apparently as far as the information traveled.
CRAB is not a routine infection. The CDC describes it as an opportunistic pathogen resistant to all available antibiotics. It spreads through direct and indirect contact with infected patients and contaminated surfaces. Federal inspectors who arrived at Crystal Cove Post Acute on August 20, 2025, found no sign on Resident 6's door, no gown or gloves staged near the entrance, and a certified nursing assistant already inside the room, at the bedside, with no protective equipment on.
When inspectors asked the CNA, identified in records as Staff D, whether they knew Resident 6 was on contact precautions, the answer was yes. They just didn't know they needed to wear PPE.
Resident 6 was cognitively intact, according to a quarterly assessment completed July 30, 2025. The resident had quadriplegia and required staff assistance for daily activities, meaning staff were in that room regularly, touching the resident, touching the environment around them, and then moving on to other residents. The resident also had a suprapubic catheter, a tube inserted through the abdomen into the bladder to drain urine, which had already prompted a separate, enhanced barrier precaution on the care plan before the CRAB result even came back.
The facility's own infection control policy, though undated, was unambiguous. Signage was supposed to be posted in a conspicuous location outside the room. Gowns and gloves were required before entry. PPE was supposed to be staged near the room's entrance and discarded before leaving, specifically to prevent the kind of environmental spread CRAB is known for.
None of that was in place when inspectors arrived.
The Director of Nursing, Staff B, was interviewed later that afternoon. She acknowledged that staff on contact precautions should be wearing PPE, then added that she had contacted people that day and that going forward, staff would use PPE for all residents in rooms where a resident was on contact precautions. The timeline embedded in that statement is notable: the correction was announced the same afternoon inspectors found the problem.
Two days later, the facility's Infection Preventionist, Staff C, told inspectors she acknowledged Resident 6 had a positive culture and that contact precautions had been implemented. When asked about the missing door sign, she said she was unsure why it wasn't there.
The gap between what the lab result said on July 31 and what inspectors found on August 20 is three weeks. For three weeks, according to what inspectors observed and staff confirmed, a resident carrying a bacteria resistant to every antibiotic currently available was living in a room with no warning on the door and staff who didn't understand they needed to suit up before walking in.
Crystal Cove Post Acute's own policy exists because the logic behind contact precautions is straightforward: healthcare workers move between rooms, touch surfaces, touch residents, and carry pathogens with them when they leave. The gown and gloves go on before entry. They come off before exit. The sign on the door tells the next person who walks in what they're walking into. Remove any part of that chain and the precautions stop working.
Resident 6, who cannot move their trunk or limbs independently and relies entirely on staff for daily care, had no ability to enforce those protections themselves.
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: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: October 7, 2026 · Our methodology
Crystal Cove Post Acute in LACEY, WA was cited for violations during a health inspection on August 22, 2025.
Someone handwrote "Contact precautions" on the lab result.
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.