Crystal Cove Post Acute: Wound Care Skipped for Days - WA
Crystal Cove Post Acute failed to provide ordered wound treatments to multiple residents, leaving infections and surgical wounds untreated during a complaint investigation completed August 22.
The facility's electronic medication administration record showed no nurse signed off on completing wound care for Resident 1 on August 1 or August 2. The resident required daily treatment for four separate wounds, including a right foot abrasion that needed cleansing and oil emulsion, and infected toes requiring betadine antiseptic.
"They provided wound care sporadically," Resident 1 told inspectors during an August 5 interview. The resident confirmed no wound care occurred on Friday, August 1, or Saturday, August 2, though staff did provide treatment the following Sunday.
Resident 1 was admitted with multiple sclerosis, cellulitis skin infection, and the pressure ulcer. Their care plan required assistance with daily activities due to lower extremity impairment, but cognitive function remained intact.
The missed treatments affected complex wound care protocols. The left buttock surgical wound required cleansing with wound cleanser, treatment of surrounding skin with liquid protectant, and application of Dakins-soaked gauze covered with superabsorbent dressing. The right foot wounds needed different protocols, with eschar kept dry and betadine applied only to dead tissue areas.
Staff G, the facility's Resident Care Manager, acknowledged the treatment gaps during an August 21 interview. She confirmed nurses failed to sign documentation showing wound treatments were completed on those dates.
Another resident faced similar problems with wound assessment delays. Resident 4 was admitted to the facility but received no wound assessment until outside wound consultants evaluated them five days later on July 30.
"It's only done by the wound group every week," Resident 4 told inspectors on August 9, questioning whether they were receiving wound care according to their doctor's orders.
The Resident Care Manager acknowledged the facility should have completed wound assessments immediately upon Resident 4's admission, along with weekly follow-up assessments. She also admitted wound consultants recommended referring the resident to a vascular surgeon, but the facility never made that referral.
Documentation showed some wound treatments occurred sporadically. For Resident 1, nurses signed off on completing treatments August 3 and August 4, but gaps remained in the prescribed daily care schedule.
The facility's wound care protocols required multiple daily treatments for some residents. One order called for twice-daily treatment of the left buttock surgical wound, with morning treatments also going unsigned on August 2.
Different wounds demanded specific care approaches. The right foot toes needed to stay dry except during showers, when they required thorough patting dry afterward. Betadine application had to dry completely before loose wrapping with kerlix cling wrap.
Staff B, the Director of Nursing, confirmed during an August 22 interview that nursing staff or wound consultants should complete weekly wound and skin assessments. She acknowledged physician orders must be followed and documented in medical records.
The inspection revealed systemic problems with wound care documentation and completion. Multiple treatment orders went unsigned across different dates, affecting residents with complex medical conditions requiring consistent wound management.
Resident 4's case highlighted assessment delays that could affect treatment outcomes. The five-day gap between admission and initial wound assessment meant potential changes in wound condition went unmonitored during the critical early period of care.
The wound consultant recommendations for vascular surgery referral remained unfulfilled, potentially delaying specialized treatment that could improve healing outcomes for Resident 4.
Electronic medication administration records provided clear evidence of the treatment gaps, with unsigned entries showing when ordered wound care did not occur as prescribed by physicians.
The violations affected residents with serious underlying conditions. Multiple sclerosis patients like Resident 1 face increased infection risks and slower healing, making consistent wound care particularly critical for preventing complications.
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 electronic medication administration record showed no nurse signed off on completing wound care for Resident 1 on August 1 or August 2.
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.