Walter B Crook Nursing Facility

Inspectors wroteBased on observation, resident and staff interviews, record review, and facility policy review, the facility failed to identify, accurately assess, document, and implement treatment for a pressure injury for one (1) of 55 residents. This failure resulted in an avoidable full-thickness tissue loss wound not being treated after identification for ten (10) days because the physician order was not implemented for Resident #5. Findings Include:Review of the facility policy titled Wound Care Policy and Protocol dated 1/24/25, revealed under, 2. Policy Statement: Proper name of the facility is committed to 1. Proactive wound prevention through comprehensive assessments. 2. Prompt identification and treatment of wounds. 3. Use of advanced wound care techniques. 4. Minimizing infection risks through proper dressing techniques. 5. Educating staff and residents on wound prevention and care. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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)

Inspectors wroteBased 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 . [...]

Inspectors wroteBased 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)

Inspectors wroteBased on observation, staff interview, record review and facility policy review the facility failed to promote the healing of existing pressure injuries as evidenced by failure to perform hand hygiene during wound care. Resident #34 currently has a foul odor and purulent discharge to facility acquired pressure wounds of the right lower leg and right heel with a history of recent multiple pressure ulcer infections. Resident #42 has two (2) facility acquired pressure ulcers with a history of pressure ulcer infection. This is for two (2) of five (5) residents reviewed for pressure ulcers. (Resident #34 and Resident #42).

Inspectors wroteBased on observation, staff interview, record review and facility policy review the facility failed to perform hand hygiene during wound care, Foley and suprapubic catheter care, and Percutaneous Endoscopic Gastrostomy (PEG) tube care (Resident's #34 and #42) Resident #34 currently has a foul odor and purulent discharge from facility acquired pressure wounds of the right lower leg and right heel with a history of recent multiple pressure ulcer infections. Resident #42 has two (2) facility acquired pressure ulcers with a history of pressure ulcer infection. This is for two (2) of 10 residents observed during direct patient care. Resident's #34 and 42 Cross reference F686

Inspectors wroteBased on staff interview, record review and facility policy review the facility failed to complete and submit a Discharge Minimum Data Set (MDS) assessment timely in accordance with the current federal and state submission timeframes for one (1) of 18 resident's MDS assessments reviewed.

Inspectors wroteBased on staff interview, record review, and facility policy review the facility failed ensure the Minimum Data Set (MDS) accurately reflects the resident's status when the Discharge MDS was inaccurately coded for (1) one of 18 MDS assessments reviewed. (Resident #62)

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.