Crystal Cove Post Acute

During an observation and interview on 08/21/2025 at 12:51 PM, Staff K, Dietary Aid 1, was asked if he could demonstrate the chemical testing for the dishwasher and the sanitary bucket.

Staff K was unable to demonstrate how to complete the testing.

Staff K said not sure if I did strips.

Staff K was unable to show documentation of current dishwasher temperatures and chemical testing documentation for the dishwasher, 3 compartment sink or sanitary bucket.

During an interview on 08/20/2025 at 10:50 AM, Staff F, stated she started this position seven prior.

Staff F said she has had little training.

Staff F said she was given the facility policies the other day and had no interaction with the consultant Dietician.During an interview on 08/21/2025 at 1:00 PM, with Staff F, Dietary Manager 2, she said the cook walked out so she had to take over cooking and had a new cook that she was responsible for training.During a telephone interview on 08/21/2025 at 1:14 PM, with Staff I, Dietician Consultant, she said she works at the facility one day per week.

She said she is a consultant and does not have any kitchen involvement and does not oversee the kitchen.

Staff I said she has clinical duties only.During an interview on 08/22/2025 at 4:40 PM, Staff A, Administrator, acknowledged the facility has had staff turnover with kitchen staff and Dietary Managers within the last several months. He acknowledged staff were new to the facility and were still in training.

The Administrator acknowledged he is responsible for ensuring oversight in the kitchen.See F812

Reference WAC 388-97-1160

505254 08/22/2025

Crystal Cove Post Acute 1505 Carpenter Road SE Lacey, WA 98503

Findings included.Resident 1Resident 1 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis (neurological condition), cellulitis (skin infection) and a pressure ulcer to the left buttocks.

The admission Minimum Data Set (MDS), an assessment dated [DATE], documented Resident 1 was cognitively intact and required supervision to eat.

Review of Resident 1's physician's order, dated 06/25/2025, showed an order for regular diet, regular texture and thin consistency.Review of Resident 1's physician's order, dated 06/30/2025, showed an order for mighty shakes (high calorie, high protein nutritional supplement) for wounds with lunch and dinner.During observation on 08/06/2025 at 9:10 AM, showed Resident 1 with his breakfast tray.

The meal ticket on the tray showed breakfast should include two hardboiled eggs, sausage, biscuit, and milk.

The breakfast tray had one egg, a waffle, rice cereal and a drink with no condiments.During observation on 08/06/2025 at 6:20 PM, showed Resident 1's dinner tray with chicken, macaroni and cheese, vegetables, corn bread and fruit.

The menu indicated the resident would receive baked ham for the meat.

Resident was agitated and said, I'm not eating that! An unidentified nursing assistant offered Resident 1 the alternative meal and resident refused and stated, I'm not special, I don't need a special meal, I want what everybody else is having.

During an interview on 08/06/2025 at 6:00 PM with Staff E, Interim Dietary Manager, she stated we ran out of the ham about four trays before the end of the run so I gave the resident the alternative meat (chicken).During observation on 08/07/2025 at 10:15 AM, showed Resident 1's breakfast tray which included scrambled eggs, yogurt, and a fruit cup.

The menu indicated the resident was to receive coffee cake and no coffee cake was provided.During observation and interview on 08/07/2025 at 10:15 AM, Resident 1's breakfast meal showed the meal ticket indicated the resident was to have coffee cake with his breakfast. Resident 1 did not have coffee cake or any cake or pastry on the breakfast tray. Resident 1 said he was always missing something off of his tray.Resident 5Resident 5 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease and Dementia.

The significant change MDS, dated [DATE], documented Resident 1 was cognitively impaired, and required staff assistance for eating.Resident 5's physicians' orders showed the following:01/10/2024 - Regular diet, regular texture, thin consistency07/08/2025 - Magic Cup (nutritional supplement) three times per day.

Order discontinued08/21/2025 - Mighty shakes three times per day.During observation on 8/21/2025 at 1:49 PM, Resident 5's lunch meal showed no magic cup or mighty shake on the lunch tray.

During an interview on 08/20/2025 at 10:50 AM, Staff F, Dietary Manager 2, stated she started this position seven days prior.

Staff F said she has had little training.

She said she was given the facility policies the other day and has had no interaction with the consultant Dietician.During a telephone interview on 08/21/2025 at 1:26 PM, Staff I, Dietician said magic cup was a high protein and high calorie supplement that she specifically will order for residents.

She stated the previous Dietary Manager kept them in stock and was unsure why the facility did not have any in stock.

During an interview on 08/22/2025 at 1:58 PM, with Staff F, Dietary Manager 2 she was asked why Resident 5 did not have a magic cup on their lunch tray.

She stated they ran out of the magic cups and mighty shakes yesterday and no residents received them with their breakfast and lunch.

During an interview on 08/22/2025 at 4:55 PM with Staff B, Director of Nursing, he acknowledged four residents did not receive the prescribed supplements of magic cup and 12 residents did not receive their might shakes on 8/22/2025 for breakfast and lunch meals.

Reference WAC 388-97-1160 (1)(a)(b)

505254 08/22/2025

Crystal Cove Post Acute 1505 Carpenter Road SE Lacey, WA 98503

Dietician.Hand washingDuring an observation in the kitchen on 08/05/2025, Staff L opened a bag of

new gloves without sanitizing the hands.During an observation in the kitchen on 08/18/2025 at 12:25

and onion with the gloved hands, picked up a hamburger bun with the same gloved hands, picked up a cooked hamburger patty and placed it on the bun, removed the gloves and donned new gloves and did not sanitize the hands.At 12:30 PM Staff O, Dietary Aid 4, came from the other side of the kitchen to the food prep station with gloved hands picked up lettuce and sliced onion and placed it on bread, finished making the sandwich, removed the gloves and left the kitchen without sanitizing the hands.Sanitary Kitchen Review of a Cooks Daily Cleaning Schedule dated 07/24/2025 showed no documentation tasks were completed.Review of a Dietary Aide Daily Cleaning/Prep Schedule, undated showed no documentation tasks were completed.During an observation of the kitchen and interview on 08/07/2025 at 12:35 PM, with Staff N, Dietary Aid 3, the stove and oven was observed with caked on brown debris, a thick brown substance on the floor under the stove and grill doors, black liquid on the outside of the grill beneath the grease trap, and the walk in refrigerator with wet blankets soaking up water on the floor of the refrigerator.

Staff N was asked how long the walk-in refrigerator had been leaking? He said it has been leaking as long as he had worked there, approximately 2 weeks.

During an interview on 08/21/2025 at 1:00 PM, with Staff F, Dietary Manager 2, she said the cook walked out so she had to take over cooking and had a new cook that she was responsible for training.

Staff F acknowledged the kitchen cleaning tasks have not been completed regularly.During a telephone interview on 08/21/2025 at 1:14 PM, with Staff I, Dietician Consultant, she said she works at the facility one day per week.

She said she is a consultant and does not have any kitchen involvement and does not oversee the kitchen.

Staff I said she has clinical duties only.

During an interview on 08/22/2025 at 4:40 PM, Staff A, Administrator, acknowledged the facility has had staff turnover with kitchen staff and Dietary Managers within the last several months. He acknowledged staff are new to the facility and are still in training.

The Administrator acknowledged he is responsible for ensuring oversight in the kitchen.

Reference WAC 388-97-1100 (3)

505254 08/22/2025

Crystal Cove Post Acute 1505 Carpenter Road SE Lacey, WA 98503

Findings included .Review of a facility document titled Mock Survey, dated 07/28/2025 and 07/29/2025 included the following:

The facility failed to ensure a resident receives care consistent with professional standards of practice, to prevent pressure injuries and does not does not develop pressure injuries.skin checks not completed every 7 days.no measurements of this wound were taken other than the measurements taken upon admission.Infection Prevention/Control.follow enhanced barrier precautions for residents.standing/pooled water on the floor between the walk-in fridge and freezer.Towels on the floor under food racks.[Staff L, Dietary Aid 2] observed performing chemical testing of water to ensure product disbursement.

Recommend staff training on proper chemical testing procedures.Kitchen hood dirty with dust and debris.During complaint investigation observation, interview and record review showed the facility was aware and had not taken actions to correct the above findings.Refer to F 686 - Pressure Ulcers.

The Administration failed to ensure a system was in place to ensure skin assessments and wound treatments were completed to treat and prevent pressure injuries for Resident 1 and Resident 5.Refer to F 802 - Sufficient Dietary Personnel.

The Administration failed to ensure sufficient dietary staff were trained and competent in recognizing and documenting appropriate food temperatures, appropriate chemical sanitation of the dishwasher, sanitizer bucket and three compartment sink, and providing meals at the established mealtimes for 1 of 1 kitchen.

This failure placed residents at risk of food born illness and decreased quality of life.Refer to F 812 - Food Safety Requirements.

The Administration failed to ensure food temperatures were taken and documented, failed to ensure foods were cooked and served at the appropriate temperatures, failed to ensure food was stored and prepared in a sanitary manner, failed to ensure chemical solutions and water temperatures in the kitchen were maintained and documented and failed to ensure staff utilized proper handwashing during meal preparation and serving.

This failure placed all residents at risk for food borne illness.Refer to F 880 - Infection Control.

The Administration failed to ensure staff were properly trained in transmission based precautions for a antibiotic resistant bacteria.

During an interview on 08/22/2025 at 4:40 PM, Staff A, Administrator, acknowledged the facility had staff turnover with kitchen staff and Dietary Managers within the previous several months.

Staff A acknowledged staff were new to the facility and still in training.

The Administrator acknowledged the facility had an internal audit with findings.

Staff A acknowledged he was responsible for ensuring oversight in the kitchen.

Staff A said the facility has a Dietician Consultant that comes to the facility weekly and he was aware the Dietician Consultant did not oversee the kitchen.

Reference WAC 388-97-1620.

505254 08/22/2025

Crystal Cove Post Acute 1505 Carpenter Road SE Lacey, WA 98503

Findings included .Facility Policy

Review of the facility policy, titled Transmission-based Precautions undated showed, Signage that includes instructions for use of specific PPE [personal protective equipment] will be placed in a conspicuous location outside the resident's room, wing, or facility-wide.

Additionally, either the CDC category of transmission-based precautions (e.g., contact, droplet, or airborne) or instructions to see the nurse before entering will be included in the signage.

Contact Precautions: The facility will have PPE readily available near the entrance of the resident's room and will don appropriate PPE before or upon entry into the environment of a resident on transmission-based precautions.

Intended to prevent transmission of pathogens that are spread by direct or indirect contact with the resident or the resident's environment.

Healthcare personnel caring for residents on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment.

Donning personal protective equipment (PPE) upon room entry and discarding before exiting the room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination.

Review of facility policy, titled Infection Reporting, undated, showed, Transmission-based precautions will be noted with a sign on the resident's door for the duration the resident is on transmission-based precautions.

Review of the Center for Disease Control (CDC) website documented Carbapenem-resistant Acinetobacter baumannii (CRAB) is a species of bacteria that is an opportunistic pathogen. It can cause a variety of different types of infections.

Infections caused by (CRAB) are resistant to all available antibiotics.

CRAB spreads through direct and indirect contact with patients infected or colonized with CRAB or contaminated environmental surfaces.

Wear Gown & Gloves when caring for patients with CRAB.

Carbapenemases identified in U.S. CRAB.Less Common.OXA- 235-like.Resident 6 was admitted to the facility on [DATE] with diagnoses including quadriplegia (loss of motor and/or sensory function to trunk and limbs).

The quarterly Minimum Data Set (MDS), an assessment tool, dated 07/30/2025, documented Resident 6 was cognitively intact, and required staff assistance for activities of daily living.Resident 6's lab result (rectal swab) dated 07/31/2025 documented OXA-235 like detected.

Hand written note on lab result showed, Contact precautions.Resident 6's care plan, dated 7/29/2025, showed the resident was on enhanced barrier precautions related to a suprapubic catheter (flexible tube into bladder to drain urine).During an observation and interview on 08/20/2025 at 12:45 PM, Resident 6's room did not have signage on the resident's door to indicate the resident was on contact precautions.

Further observation showed Staff D, Certified Nursing Assistant (CNA) in the room at the bedside of Resident 6, assisting the resident with the tv remote.

Staff D did not wear a gown or gloves.

Staff D exited the resident's room.

Staff D was asked if they were aware Resident 6 was on contact precautions.

Staff D said they were aware but did not realize they needed to wear PPE.During an interview on 08/20/2025 at 4:19 PM, Staff B, Director of Nursing (DNS) said usually if a resident is on contact precautions they would just use PPE for the resident in the room who was on precautions but stated they contacted people today and they are going to use PPE for all residents in the room who are on contact precautions.

During an interview on 08/22/2025 at 3:00 PM, Staff C, Infection Preventionist, acknowledged Resident 6 had a positive wound culture and they implemented contact precautions.

Staff C said she was unsure why there was no signage on the resident's door.

Staff C acknowledged staff were to don a gown and gloves prior to entering a resident's room on contact precautions.

Reference WAC 388-97-1320 (2)(b)