Crystal Cove Post Acute: Nutrition Supplement Failures - WA
The facility had simply run out.
Federal inspectors visited Crystal Cove, a post-acute care facility at 1505 Carpenter Road SE in Lacey, and documented that on August 22 alone, four residents went without their prescribed Magic Cup supplements and 12 residents went without their prescribed Mighty Shakes — for both breakfast and lunch. The Director of Nursing acknowledged both numbers when inspectors asked.
The resident with the pressure ulcer, identified in inspection records as Resident 1, had been admitted with multiple sclerosis, a skin infection, and an open wound to his left buttock. His physician ordered Mighty Shakes specifically for wound healing, starting June 30. High-calorie, high-protein supplements are a standard tool for supporting wound recovery, which demands more from the body than ordinary nutrition can easily provide.
What inspectors found when they watched him eat was something else entirely.
On the morning of August 6, his meal ticket said breakfast should include two hardboiled eggs, sausage, a biscuit, and milk. His tray arrived with one egg, a waffle, rice cereal, and a drink. No condiments. No sausage. No biscuit. That evening, his ticket listed baked ham. His tray had chicken, macaroni and cheese, vegetables, cornbread, and fruit. He was agitated. "I'm not eating that," he said.
A nursing assistant offered him the alternative meal. He refused it. "I'm not special," he said. "I don't need a special meal. I want what everybody else is having."
The Interim Dietary Manager, identified as Staff E, told inspectors that the facility had run out of ham about four trays before the end of the meal run, so she substituted chicken. Nobody had told the resident that was coming, or apparently asked whether he'd accept it.
The next morning, August 7, his ticket listed coffee cake. No coffee cake appeared on his tray. He told inspectors he was always missing something.
The second resident whose supplements were tracked by inspectors, Resident 5, had Alzheimer's disease and dementia, and required staff assistance to eat. A physician had ordered Magic Cup supplements three times per day in July. That order was discontinued and replaced on August 21 with Mighty Shakes three times per day. The following afternoon, at 1:49 PM on August 21, inspectors observed Resident 5's lunch tray. No Magic Cup. No Mighty Shake.
The consulting dietitian, reached by phone on August 21, told inspectors she had specifically ordered Magic Cup for residents and that the previous dietary manager had kept it in stock. She said she didn't know why the facility no longer had any.
The person now running dietary operations had been in the position for seven days. The new Dietary Manager, Staff F, told inspectors she had received little training, had been handed the facility's policies only recently, and had not yet had any interaction with the consulting dietitian. When inspectors asked on August 22 why Resident 5 hadn't received a supplement at lunch, she said they had run out of both Magic Cups and Mighty Shakes the day before. No residents had received them at breakfast or lunch.
The dietitian who ordered the supplements didn't know the supply was gone. The new dietary manager had never spoken with the dietitian. The residents whose physicians had ordered the supplements for wound healing and nutritional support went without, meal after meal, while the facility waited for stock to arrive.
Resident 1's wound was still there. He had been admitted months earlier, and his physician had decided in late June that standard meals weren't enough, that he needed something more. The order had been in place for nearly six weeks when inspectors arrived and found it wasn't being followed.
He sat with a tray that had the wrong meat on it, refused the substitute, and told the staff he just wanted what everyone else was having. What he actually needed, and what his doctor had ordered, wasn't on anyone's tray that day.
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 6, 2026 · Our methodology
Crystal Cove Post Acute in LACEY, WA was cited for violations during a health inspection on August 22, 2025.
The facility had simply run out.
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.