Crystal Cove Post Acute: Kitchen Safety Failures - WA
The facility's mock survey, conducted July 28 and 29, documented standing water pooled on the floor between the walk-in refrigerator and freezer, towels laid on the floor beneath food storage racks, a kitchen hood coated in dust and debris, and a dietary aide performing chemical testing of water incorrectly. The same audit flagged that skin assessments on residents with wounds were not being completed every seven days, and that wound measurements had not been taken since admission.
That was the internal audit. The facility's own findings, in its own document.
By August 22, when state inspectors arrived on a complaint investigation, none of it had been corrected.
The administrator, identified in the report as Staff A, did not dispute this. In an interview at 4:40 p.m. on the day of inspection, he acknowledged the kitchen audit findings, acknowledged the facility had experienced significant turnover among kitchen staff and dietary managers over the preceding several months, and acknowledged that current staff were new and still in training. He also acknowledged that the weekly dietician consultant who visited the facility did not oversee kitchen operations, and that he, the administrator, was responsible for that oversight.
What the report describes is not a facility that missed something. It is a facility that found something, documented it, and then watched it sit.
The kitchen failures were extensive. Inspectors found that food temperatures were not being taken or recorded, that food was not consistently cooked and served at required temperatures, that chemical solution concentrations and water temperatures in the dishwasher, sanitizer bucket, and three-compartment sink were not being maintained or documented, and that staff were not washing their hands properly during meal preparation and serving. Every resident in the building ate food prepared in that kitchen.
The wound care failures were more specific. Two residents, identified as Resident 1 and Resident 5, were not receiving skin assessments on the required schedule, and their wounds were not being measured to track healing or deterioration. The mock survey had noted that no wound measurements had been taken beyond those recorded at admission. For a resident developing or worsening a pressure injury, consistent measurement is how staff and clinicians know whether a treatment is working or a wound is getting worse.
The infection control finding added another layer. Staff were not properly trained in transmission-based precautions for a resident with an antibiotic-resistant bacteria. The report does not identify the organism or the resident, but the precaution type, enhanced barrier precautions, is used specifically when standard measures are not sufficient to contain spread.
The administrator's explanation, that the kitchen had gone through turnover and staff were still learning, does not account for the gap between the mock survey and the inspection. Turnover may explain how problems develop. It does not explain why a completed internal audit produced no corrective action over the weeks that followed.
The mock survey is the detail that sharpens everything else in this report. A facility that had never looked would face a different kind of accountability than a facility that looked, wrote it down, and let it stand. Crystal Cove did the audit. The findings were specific enough that inspectors could cite them directly in the complaint investigation. The administrator confirmed he knew. The kitchen hood was still dirty. The floor was still wet. The wounds were still going unmeasured.
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.
Download the official CMS inspection PDF from Medicare.gov
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: September 22, 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 own findings, in its own document.
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.