Walter B Crook Nursing Facility

In the surveyor’s words

From the most serious findings on record at Walter B Crook Nursing Facility, in the surveyor’s own words.

• Actual harm, isolatedF686Nov 13, 2025

  Based 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. […]

• Actual harm, isolatedF686Feb 28, 2024

  Based 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). […]

• Actual harm, isolatedF880Feb 28, 2024

  Based 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. […]

• No harm, potential for more than minimal, isolatedF641Nov 13, 2025

  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. […]

• No harm, potential for more than minimal, isolatedF656Nov 13, 2025

  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 . […]