Crystal Cove Post Acute
Crystal Cove Post Acute in LACEY, WA — inspection on February 6, 2025.
Found 23 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
F-F550-Resident Rights/Exercise of Rights.
Previous survey deficiency dated 02/2019 (D), 08/2021 (E), 05/2023 (D) & 03/2024 (D) & 02/2025 (D).
Refer to
F-F561-Self-Determination.
Previous survey deficiency dated 08/2021 (D), 05/2023 (D), 03/2024 (C) & 02/2025 (E).
Refer to
F-F578-Request/Refuse/Discontinue Treatment; Formulate Adv Dir.
Previous survey deficiency dated 02/2019 (E), 08/2021 (E), 05/2023 (E) & 03/2024 (D).
Refer to
F-F585 Grievances
The governing body failed to ensure action or response was given to the resident council member concerns and to have a formal Grievance system in place.
Refer to
F-F604 Right to be Free from Restraints
The governing body failed to ensure assessments, orders, consent and care plans were in place for residents with bed rails.
Refer to
Findings included .
The facility policy titled, Transfer and Discharge, dated 2023, documented the facility's transfer/discharge notice would be provided to the resident and the resident's representative in a language and manner in which they could understand.
The notice would include all of the following at the time it is provided that facility would maintain evidence that the notice was sent to the Ombudsman.
<Transfer/discharge notice>
Resident 4 was admitted to the facility on [DATE]. Resident 4 was transferred to the hospital on 11/23/2024.
The electronic health record (EHR) documented no Transfer/Discharge notification was provided to Resident 4.
Resident 11 was admitted to the facility on [DATE]. Resident 11 was transferred to the hospital on 01/16/2025.
The EHR documented no Transfer/Discharge notification was provided to Resident 11
Resident 42 was admitted to the facility on [DATE]. Resident 42 was transferred to the hospital on 10/01/2024.
The EHR documented no Transfer/Discharge notification was provided to Resident 42.
Resident 57 was admitted to the facility on [DATE]. Resident 57 was transferred to the hospital on 01/17/2025.
The EHR documented no Transfer/Discharge notification was provided to Resident 57.
Resident 58 was admitted to the facility on [DATE]. Resident 58 was transferred to the hospital on 11/15/2024.
The EHR documented no Transfer/Discharge notification was provided to Resident 58.
<Ombudsman Notification>
Resident 3 was admitted to the facility on [DATE]. Resident 3 was transferred to the hospital on 10/04/2024.
The EHR documented no Ombudsman notification was provided.
Resident 4 was admitted to the facility on [DATE]. Resident 4 was transferred to the hospital on 11/23/2024.
The EHR documented no Ombudsman notification was provided.
Resident 11 was admitted to the facility on [DATE]. Resident 11 was transferred to the hospital on 01/16/2025.
The EHR documented no Ombudsman notification was provided.
505254
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 505254 B.
Wing 02/06/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Roo Lan Health & Rehab 1505 Carpenter Road SE Lacey, WA 98503
Findings included .
1) Resident 69 was admitted to the facility on [DATE].
The Admission Minimum Data Set (MDS, an assessment tool), dated 11/26/2024, documented Resident 69 had a Brief Mental Interview score of 00. Resident 69 does not speak English but was able to understand some English.
Resident 69's communication and activities care plan documented Resident does not use call light, ask for assistant, but is able to make hand gestures and point to items to communicate. Resident 69 will need to be assisted to and from activities. Resident 69 enjoys music, watching TV, one on one visits from staff and being outdoors.
An order, dated 01/14/2025, documented, Daily Skilled note required.
Please enter detailed chart note on services provided i.e. PT [physical therapy]/OT [occupational therapy] participation, ADLs [activities of daily living], transfer status, new orders, and any concerns. everyday shift. No documentation found in electronic health record (EHR) related to the listed tasks above.
An activities assessment, dated 11/30/2024, documented Resident 69 likes watching tv, scrolling online, listening to Christian & Marshallese music. Resident 69 also likes Bingo and Painting.
The question Activities should be modified to address communication deficit? was marked yes.
The question Does resident like independent activities (i.e. reading, puzzles etc.)? was marked yes.
The EHR marked no documentation of activities provided to Resident 69.
The Activities task documented Resident 69:
Listened to music on 12/31/2024 and 01/20/2025.
Watched TV on 12/31/2024, 01/01/2025, 01/04/2025, 01/06/2025, 01/11/2025, 01/20/2025 & 01/21/2025.
Did I socialize during the 1:1 visit? On 12/31/2024, 01/01/2025 & 01/20/2025.
Observations on 01/27/2025 at 8:39 AM until 10:54 AM, showed Resident 69 laid in bed in the dark, with no music, no TV, no games or individual activities.
During this time, fifteen staff members entered the room and no one offered any activities to Resident 69.
At 10:54 AM Staff CC, Certified Nursing Assistant (CNA) and Staff Y, CNA, entered the room and closed the door behind them.
At 11: 02 AM Staff Y, CNA, brought in the hoyer (mechanical lift) and told Resident 69, they were getting her up for lunch.
505254
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 505254 B.
Wing 02/06/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Roo Lan Health & Rehab 1505 Carpenter Road SE Lacey, WA 98503
F-F677-ADL Care Provided for Dependent Residents
Refer to
F-F684 Quality of Care (H).
Refer to
F-F687 Foot Care
The governing body failed to ensure systems were in place and staffing was adequate to provide residents with ADLs such as oral care, shaving, assistance with meals, grooming and nail care.
Previously cited 02/2019, 08/2021, 05/2023, 03/2024 & 02/2025.
Refer to
F-F688 Increase/prevent Decrease In ROM (range of motion)/mobility
The governing body failed to ensure staffing levels were appropriate to be able to provide restorative nursing and to ensure the program had sufficient oversight.
Documentation provided showed Restorative Nursing Assistants (RNA) were pulled to provide resident care on the floor on 12/03/2024, 12/26/2024, 12/17/2024, 12/18/2024, 12/23/2024, 01/02/2025, 01/03/2025, 01/04/2025, 01/09/2025, 01/10/2025, 01/12/2025, 01/14/2025, 01/19/2025, 01/26/2025, 01/29/2025, 01/30/2025, 01/31/2025, & 02/04/2025.
Refer to
F-F692 Nutrition/hydration status maintenance
The governing body failed to ensure systems were in place to monitor residents for weight loss and obtain and implement timely interventions that resulted in harm to two residents (Resident 71 and Resident 65).
The governing body also failed to ensure systems were in place for monitoring and implementing fluid restrictions.
Refer to
Review of facility records showed the Infection Preventionist (IP) and Resident Care Managers (RCM)'s were pulled from job duties to provide resident care on 01/03/2025, 01/08/2025, 01/13/2025, 01/17/2025, 01/27/2025 & 02/04/2025.
Staff B acknowledged the dates.
Staff B said it made it challenging to get their job done because of oversight to the floor.
When asked how this would affect resident care, Staff B said it could potentially cause delays in care, untimely assessments/evaluation, it could have a [NAME] effect on resident care.
Staff B acknowledged staffing has been a concern.
Refer to
F-F726 Competent Nursing Staff
The governing body failed to ensure the licensed nurses and nursing aides had the appropriate competencies/skill sets to provide nursing services that included appropriate infection control procedures.
The facility also failed to implement policies for orientation of agency/contracted staff, provide updated trainings to ensure licensed staff were trained and competent in the management and monitoring of central venous catheters (centrally inserted access to veins), and to provide oversight of the Restorative Nursing Program (RNP).
Refer to
Findings included .
On 01/28/2025 at 9:16 AM, when asked if there was documentation of staffs COVID-19 vaccination status, Staff L, Infection Preventionist (IP) and Registered Nurse said it's was not a requirement, it was not part their hiring process and it was not being done.
On 01/29/2025 at 2:07 PM, when clarifying that keeping documentation of staff COVID-19 vaccination was a requirement Staff L, IP, said, I was told that it was not a requirement, that it is not mandated. I was keeping a record when it was a mandated requirement.
Staff L said, I don't yet have a staff list of vaccination status.
No associated WAC
505254
F-F758-Free from Unnecessary Psychotropic Meds/PRN Use
Refer to
F-F804-Nutritive Value/Appear, Palatable/Prefer Temp.
Previous survey deficiency dated 02/2019 (D), 08/2021 (E), 05/2023 (E) & 03/2024 (E).
505254
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 505254 B.
Wing 02/06/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Roo Lan Health & Rehab 1505 Carpenter Road SE Lacey, WA 98503
F-F812 Food procurement, store, prepare, serve (E). potential for actual harm Refer to
Findings included .
Review of the facility policy titled, Standard Precautions Infection Control, undated, described standard precautions as practices applied to all residents, to prevent the spread of infection to residents, staff, and visitors.
These precautions included hand hygiene, selection and use of personal protective equipment (PPE) as was appropriate, safe injection practices with the proper disposal of injection equipment in the sharp's container, environmental cleaning and disinfection, and the reprocessing of reusable resident medical equipment.
Review of the Centers for Disease Control and Prevention (CDC) document titled, Clinical Safety: Hand Hygiene for Healthcare Workers, recommends hand hygiene be performed before touching a patient, before moving from a soiled body part to a clean body part on the same resident, after touching a resident or their surroundings, after any contact with blood, body fluids, or contaminated surfaces, and immediately after glove removal.
<Standard Precautions>
>Hall A<
Observation of Hall A for the lunch meal on 01/22/2025 showed the following:
At 12:21 PM, Staff PP, Certified Nursing Assistant (CNA), delivered a lunch tray to the resident in room [ROOM NUMBER]/Bed A.
Staff PP assisted the resident with positioning and moved the overbed table before exiting the room without performing hand hygiene.
505254
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 505254 B.
Wing 02/06/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Roo Lan Health & Rehab 1505 Carpenter Road SE Lacey, WA 98503
F-F868 QAA Committee
The governing body failed to maintain a Quality Assessment and Assurance (QAA) committee that included the Infection Preventionist (IP) and the Medical Director or his/her designee, to conduct required Quality Assurance and Performance Improvement (QAPI) and QAA activities.
On 02/06/2025 at 10:05 AM, in a joint interview with Staff A, Administrator and Staff B, Director of Nursing Services, Staff A reviewed the QAPI/QAA required attendees for the past year of QAPI/QAA meetings.
Staff A said she had not yet attended a QPAI meeting, only due to time frame.
Staff A acknowledged the missing required QAPI/QAA committee members.
QAPI meeting attendance sheet documented:
May 24th, 2024: No IP in attendance.
August 29th, 2024: No IP or Medical Director in attendance.
September 11th, 2024: No IP or Medical Director in attendance.
December 20th, 2024: No IP in attendance
Refer to
Findings included .
On 02/06/2025 at 10:05 AM, in a joint interview with Staff A, Administrator and Staff B, Director of Nursing Services, Staff A reviewed the QAPI/QAA required attendees for the past year of QAPI/QAA meetings. QAPI meeting attendance sheet documented:
May 24th, 2024: No IP in attendance.
August 29th, 2024: No IP or Medical Director in attendance.
September 11th, 2024: No IP or Medical Director in attendance.
December 20th, 2024: No IP in attendance.
Staff A, Administrator, said they had only been in the facility since January 13th, 2025, so was unable to speak to last year's QAPI/QAA attendees.
Staff A said she had not yet attended a QPAI meeting, only due to time frame.
Staff A acknowledged the missing required QAPI/QAA committee members.
Reference
F-F881 Antibiotic Stewardship Program
The governing body failed to ensure systems and staff were in place to implement an effective Antibiotic Stewardship Program (ASP) for three of three months (October 2024, November 2024 and December 2023) reviewed.
Refer to
Findings included .
The facility's blank Arbitration Agreement was reviewed on 01/27/2025 and found to be missing wording that:
1.
The resident or their representative had the right to communicate with federal, state, or local officials such as federal or state surveyors, other federal or state health department employees and representative of the State Long Term Care Ombudsman
2.
That a neutral arbitrator would be agreed upon by both parties
3.
That the selection of a venue would be convenient to both parties
During an interview on 01/27/2025 at 1:08 PM, Staff U, Human Resources/Payroll, was asked questions about the binding arbitration agreement and Staff A, Administrator, was present.
When asked where in the agreement that it said the resident/representative could communicate with federal, state, or local officials such as federal surveyors, other federal or state health department employees or the office of the state long term care ombudsman, Staff U said they had looked at the form and it did not show any contact numbers.
When asked how the resident would know their right on making a mutual neutral arbitrator, Staff U said they did not see in the document where it would say on how to select one.
When asked if there was any wording for the selection of venue that was convenient to both parties, Staff U said they did not see any wording.
At 01/27/2025 at 1:17 PM, Staff A, Administrator, when asked if the binding arbitration agreements were missing the wording just mentioned in the three above questions, said yes they should be listed.
1) Resident 53 was admitted to the facility on [DATE].
The Admission Minimum Data Set Assessment (MDS), dated [DATE], showed Resident 53 was cognitively intact, was able to make themself understood and was able to understand others.
505254
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 505254 B.
Wing 02/06/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Roo Lan Health & Rehab 1505 Carpenter Road SE Lacey, WA 98503