Crystal Cove Post Acute

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

documentation was found that treatments were completed on 08/02/2025 and 08/04/2025.During an

interview on 08/09/2025 at 9:30 AM, Resident 4 was inquiring about how often staff were to provide wound care to wounds and said they did not believe they were getting wound care being completed per provider order. Resident 4 stated, It's only done by the wound group every week.During an interview and review of documents on 08/18/2025 at 2:15 PM, Staff G, Resident Care Manager (RCM) acknowledged Resident 4 was admitted to the facility on [DATE REDACTED] and the facility did not complete a wound assessment to include wound measurements and wound description until the wound consultants completed a wound assessment

on 07/30/2025 (5 days) after admission. She acknowledged the wound assessments should be completed

on admission and weekly. The RCM acknowledged the wound consultants recommended the resident should be referred to the resident's vascular surgeon and the facility had not made the referral.Resident 1Resident 1 was admitted to the facility on [DATE REDACTED] with diagnoses including Multiple Sclerosis (neurological disorder), Cellulitis (skin infection) and a pressure ulcer to the left buttocks. The admission MDS, dated [DATE REDACTED], documented Resident 1 was cognitively intact, had impairment to their lower extremities and required staff assistance for activities of daily living.Review of Resident 1's EMAR, dated 08/2025, showed

the following: 06/27/2025 - Wound care right knee: 1. Skin prep (liquid skin protectant). daily one time a day for wound care. Not signed as completed 08/01/2025 and 08/02/2025. 06/27/2025 - Wound care left knee:

1. 1. Skin prep daily one time a day for wound care. Not signed as completed 08/01/2025 and 08/02/2025.

07/19/2025 - Wound 2 Right Foot Abrasion. Cleanse wound to patient tolerance with house wound cleanser and gauze. Normal Saline (NS) may be substituted if a wound cleanser is not available. Treat peri wound (around wound) with skin prep. Apply oil emulsion to the wound bed. Cover with rolled gauze. One time a day for wound care. Not signed as completed 08/01/2025 and 08/02/2025. 07/19/2025 - Wound 3: Left Buttock Surgical Treatment Recommendations: Cleanse wound to patient tolerance with house wound cleanser and gauze. NS may be substituted if a wound cleanser is not available. Treat peri wound with skin prep (liquid skin protectant). Apply 1/4 Dakins (topical antiseptic for wounds) soaked gauze to the wound bed. Cover with superabsorbent dressing one time a day for wound care. Not signed as completed 08/02/2025. 07/19/2025 - Wound 4: Right foot: for toes: 1. Keep eschar (hard black layer of dead tissue) as dry as possible. Ok to get in shower but pat dry thoroughly afterwards. 2. Apply betadine (antiseptic) daily to eschar only 3. Let dry completely and leave open to the air or wrap loosely with kerlix (cling wrap) one time

a day for wound care. Not signed as completed 08/01/2025 and 08/02/2025. 08/02/2025 - Wound 3: Left Buttock Surgical Treatment Recommendations: Cleanse wound to patient tolerance with house wound cleanser and gauze. NS may be substituted if a wound cleanser is not available. Treat peri wound with skin prep. Apply 1/4 th Dakins soaked gauze to the wound bed. Cover with superabsorbent dressing two times a day for wound care. Not signed as completed am on 08/02/2025.During an interview on 08/05/2025 at 2:10 PM, Resident 1 said they provided wound care sporadically and that it was not completed on 08/01/2025 (Friday) or 08/02/2025 (Saturday) but they did provide wound care on 08/03/2025 (Sunday).During an

interview on 08/21/2025 at 3:08 M, Staff G, Resident Care Manger (RCM) acknowledged Resident 1's wound treatments were not signed by the nurse as completed on 08/01/2025 and 08/02/2025.During an

interview on 08/22/2025 at 4:55 PM, Staff B, Director of Nursing, acknowledged resident's wound/skin assessments were to be completed weekly by nursing or by the wound consultants and physician orders were to be followed and documented in the medical record.Reference WAC 388-97-1060 (3)(b)

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Crystal Cove Post Acute

1505 Carpenter Road SE Lacey, WA 98503

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

with water and added the chemical. Staff F said the strip was 10 and should be 200 - 275. Staff F acknowledged they use the 3 compartments sink daily and there was no documentation of monitoring the temperature or chemical testing.During an interview on 08/20/2025 at 11:58 AM, with the Echo lab technician he stated he came to assess the dishwasher as requested by facility. He stated the dishwasher is testing at 100 ppm which is adequate. He stated the facility ran out of the correct sink and surface product to use so the facility hooked it up to a chorine-based product, so they were checking the chemical using the wrong chemical strips. He said they needed to use chlorine strips to check ppm. He said he counseled staff to increase the product until it comes up to an appropriate level and order the correct sanitizer. 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 F812Reference WAC 388-97-1160

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Crystal Cove Post Acute

1505 Carpenter Road SE Lacey, WA 98503

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803

their might shakes on 8/22/2025 for breakfast and lunch meals. Reference WAC 388-97-1160 (1)(a)(b)

Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Crystal Cove Post Acute

1505 Carpenter Road SE Lacey, WA 98503

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

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.Hand washingDuring an observation in

the kitchen on 08/05/2025, Staff L opened a bag of frozen chicken with gloved hands, placed the chicken

on a sheet pan with gloved hands, left the station and returned to the station with the same gloves on. Staff L removed the gloves and donned new gloves without sanitizing the hands.During an observation in the kitchen on 08/18/2025 at 12:25 PM, Staff M, [NAME] 2 with gloved hands plated food, left the station and picked up a slice of tomato 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)

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Crystal Cove Post Acute

1505 Carpenter Road SE Lacey, WA 98503

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Level of Harm - Minimal harm or potential for actual harm

Based on observation, interview and record review the facility Administration failed to ensure there was active and engaged oversight and a monitoring system in place to correct findings from an internal audit related to treatment and service to prevent/heal pressure ulcers, food procurement, sufficient dietary support personnel and a sanitary kitchen. This failure placed residents at risk for development or worsening pressure ulcers, food borne illness and a diminished quality of life. 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.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Crystal Cove Post Acute

1505 Carpenter Road SE Lacey, WA 98503

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

Federal health inspectors cited Crystal Cove Post Acute in LACEY, WA for a deficiency under regulatory tag F-F0880 during a complaint investigation conducted on 2025-08-22.

Category: Infection Control Deficiencies

The facility was found deficient in the following area: Provide and implement an infection prevention and control program.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 6 deficiencies cited during this inspection of Crystal Cove Post Acute.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-06.