Walter B Crook Nursing Facility

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, record review, and facility policy review, the facility failed to accurately code a quarterly Minimum Data Set (MDS) assessment for one (1) of 16 MDS assessments reviewed. (Resident #6) Findings Include: Review of the facility policy titled, Comprehensive Assessments and the Care Delivery Process with revised date 12/2016, revealed, Comprehensive assessments will be conducted to .Define current treatments and services . Record review of Resident #6's quarterly MDS assessment, with an Assessment Reference Date (ARD) date of 10/14/25, noted that Section N - Medications, N0350 revealed the resident had received insulin injections for one (1) day during the last seven (7) days. Record review of Resident #6's Medication Administration Record (MAR) dated 10/1/2025-10/31/2025, revealed Resident #6 did not have an order for insulin, nor did she receive an insulin injection. Record review of Resident #6's Immunizations revealed Resident #6 received an influenza vaccination on 10/8/25. An…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, record reviews, and facility policy review, the facility failed to develop a plan of care that included nail care for Activities of Daily Living (ADLs) for two (2) of 16 sampled residents, (Resident #8 and #46); and failed to implement comprehensive care plans for two (2) of 16 sampled residents. (Resident #2 and #7) Findings Include: Review of the facility policy titled, Care Plans, Comprehensive Person-Centered with a revision date of December 2016, revealed under Policy Statement .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . Resident #2 and Resident #7 Record review of Resident #2's Care Plans revealed under, Focus: I am at risk for adverse effects r/t (related to) use of psychotropic medications for a dx (diagnosis) of Major Depressive d/o (disorder) and anxiety d/o (disorder). Also revealed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, record review, and facility policy review, the facility failed to provide proper nail care for two (2) of sixteen 16 sampled residents. (Resident #8 and #46) Findings Include: Record review of the facility policy titled Activities of Daily Living, Supporting revised March 2018, revealed .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Review of the facility policy titled Activities of Daily Living revealed under Fingernails/Toenails, Care of with a revision date of February 2018 states, The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. Resident #8 During an observation and interview with Resident #8 on 11/11/2025 at 11:46 AM and again on 11/12/25 at 10:15 AM, revealed the resident had approximately three-fourths (3/4) inch long, jagged fingernails with brown substance…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews and record review, the facility failed to provide bowel and bladder training services to reduce incontinence for one (1) of 16 sampled residents. (Resident #10)Findings include: Review of Facility Statement Regarding Bowel and Bladder Policy with no date revealed the facility did not have a policy for Bowel and Bladder. Record review of Resident #10's Bowel/Bladder Screenings dated 8/15/24 and 11/8/24 revealed Resident #10 was a good candidate for retraining. The Bowel/Bladder Screenings dated 2/3/25, 4/29/25, and 7/23/25, revealed Resident #10 was a candidate for schedule toileting. An interview on 11/12/2025 at 4:00 PM, with the Administrator and Director of Nursing (DON), revealed the facility did not currently have a bowel/bladder (B/B) toileting program. They stated that after the screenings are completed that a Registered Nurse (RN) reviews the screening and makes a decision or recommendation accordingly. Record review of Resident #10's plan of care, I sometimes have trouble…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interview, record review, and facility policy review, the facility failed to monitor for side effects of psychotropic medications for two (2) of five (5) residents reviewed for unnecessary medications. Resident #2 and #7 Findings Include: Review of the facility policy titled Antipsychotic Medication Use revised 12/16, revealed under, Policy Statement: Antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed. Also revealed under, Policy Interpretation and Implementation: . 17. Nursing staff shall monitor for and report any of the following side effects and adverse consequences of antipsychotic medications to the attending physician . Record review of Resident #2's Medication Administration Record (MAR) revealed an order dated 9/11/25, Quetiapine Fumarate (antipsychotic) Tab (tablet) 25 milligrams (MG) give one (1) tablet orally three times a day related to Major Depressive Disorder.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review and facility policy review, the facility failed to ensure infection control practices were maintained for two (1) of three (3) care opportunities. (Resident #13) Findings include:A review of the policy titled, ENHANCED BARRIER PRECAUTIONS (EBP) effective 4/1/24 revealed, For residents whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities: Device care of use: Central line, urinary catheter, feeding tube, etc.During an observation of medication administration on 11/12/2025 at 9:08 AM for Resident #13 with Licensed Practical Nurse (LPN) #3, it was observed that the nurse failed to use EBP while administering Percutaneous Endoscopic Gastrostomy (PEG) medications. During an interview on 11/12/25 at 9:25 AM with LPN #3, she confirmed that EBP should have been used during medication administration for residents with PEG tubes. She further stated that EBP was ordered to help prevent the spread of infection and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff and resident interviews, facility policy review and record review, the facility failed to keep residents free from physical restraints for one (1) of 20 residents reviewed during the survey. Resident #2 Findings include: Review of the facility policy titled, Restraints - Definitions, dated 12/1/14, revealed: 1. Physical restraints Any manual method or physical or mechanical device material or equipment attached or adjacent to the resident's body that the resident cannot remove easily which restricts freedom of movement for normal access to one's body. 2. Side Rails a. Side rail use is addressed in the same manner as any other restraint. b. side rails used as an enabler must be supported by documentation. c. The use of side rails as restraints is prohibited unless they are necessary to treat a resident's medical symptoms. d. Residents who attempt to exit a bed through between over or around side rails are at risk of injury or death. e. The potential for serious injury is more likely…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, staff interviews, and facility policy review, the facility failed to complete a Quarterly Minimum Data Set (MDS) Assessment, within 120 days, for 1 of 20 residents reviewed in the sample for MDS Assessments. Resident #38 FACILITY Resident Assessment Review of the facility policy titled, Resident Assessments, revised November 2019, revealed Policy Statement, A comprehensive assessment of every resident's needs is made at intervals designated by OBRA and PPS requirements. 2. Quarterly Assessment - Conducted not less frequently than three (3) months following the most recent OBRA assessment of any type. An interview on 12/07/22 at 01:30 PM with the Minimum Data Set (MDS) Nurse revealed she neglected to open the Quarterly MDS Assessment for the Assessment Reference Date (ARD) 10/18/22 for Resident #38. She revealed she had Resident #38's name written in on the MDS calendar, on 10/18/22, to remind her to open the Quarterly MDS Assessment for completion. She also revealed there was documentation entered in the Departmental Notes in the electronic health record…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, record review, and facility policy review, the facility failed to implement care plans for the use of side rails for one (1) of six (6) residents reviewed for side rails. Resident #17 Findings include: Review of the facility care plan policy with a revision date of December 2016, titled, Care Plans, Comprehensive Person-Centered revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The comprehensive, person-centered care plan will reflect currently recognized standards of practice for problem areas and conditions. An observation, on 12/05/22 at 02:47 PM revealed Resident #17 in bed with all four side rails up. An observation, on 12/06/22 at 02:30 PM revealed Resident #17 in bed with all four…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.