The Lutheran Village At Miller's Grant

Based on observations and interviews, it was determined that the facility failed to: (1) discard expired food products, and (2) properly label food products with an expiration/use by date. This was evident during the initial tour of the kitchen and had the potential to affect all residents. The findings include: On 6/23/25 at 07:59 AM, a brief tour of the kitchen was conducted. The surveyor was accompanied by the facility's Chef, Staff #5. A brief interview with Staff #5 was conducted. When asked if food products should have an expiration date, he responded that it was the facility ' s expectation that all products have a use-by date. Additionally, Staff #5 stated that it's the facility ' s practice to discard expired items. A tour of the dry storage room revealed 3 bags of bread rolls that had an expiration date of 6/16/25. In each bag there were about 10 rolls. One bag was observed to have black-blue-greenish rolls. Additionally, the surveyor observed several fruit cocktail and artichoke hearts containers that had no expiration dates. There was a container with crushed peanuts…

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, observation and interviews, it was determined that the facility staff failed to provide nursing care within the standards of practice by (1) failed to implement fall prevention interventions, and (2) inaccurately documented an intervention that was not implemented. This was evident for 1 (Resident #5) of 2 residents reviewed for falls during the recertification survey. The findings include: On 6/23/25 at 10:00 AM, a review of Resident #5's medical records was conducted. The review revealed that the resident had sustained a fall in the facility. The resident had a care plan with interventions that included floor mats and hip protectors while in the wheelchair. Further review of records revealed an active order for Resident #5 to have hip protectors when sitting in a wheelchair at all times. On 6/23/25 at 10:28 AM, Resident #5 was observed sitting in a wheelchair with no hip protectors. On 6/23/25 at 12:40 AM, Resident #5 was observed sitting in a wheelchair in the living room area near the nurses' station. The resident had no hip protectors. On 6/23/25 at…

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 and interview, it was determined that the facility failed to ensure there was a system in place to ensure Geriatric Nursing Assistants (GNAs) completed 12 hours of in-service training annually. This was evident for 4 (GNA/Staff #6, GNA/Staff #7, GNA/Staff #8, and GNA/Staff #9) of 5 GNAs reviewed during the annual survey. The findings include: 1) On 06/24/25 at 09:53 AM, review of GNA/Staff #6's annual 12 hour GNA training provided by the facility revealed 0.5 hours completed in 2024. 2) On 06/24/25 at 09:53 AM, review of GNA/Staff #7's annual 12 hour GNA training provided by the facility revealed 0 hours completed in 2024. 3) On 06/24/25 at 09:53 AM, review of GNA/Staff #8's annual 12 hour GNA training provided by the facility revealed 0 hours completed in 2024. 4) On 06/24/25 at 09:53 AM, review of GNA/Staff #9's annual 12 hour GNA training provided by the facility revealed 0 hours completed in 2024. On 06/25/25 at 01:11 PM, the surveyor reviewed the concern with the Nursing Home Administrator. She agreed the facility was not in compliance for the 4 GNAs…

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 review of the facility's Pharmacy Recommendation/Review policy, the facility failed to develop policies and procedures related to time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. All residents have the potential to be affected. The findings include: Medication Regimen Review (MRR) or Drug Regimen Review is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. The MRR includes review of the medical record in order to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities. A copy of the facility's MRR policy was requested from the Nursing Home Administrator (NHA). On 8/31/22 at 12:05 PM, the facility's Pharmacy Recommendation/Review policy was reviewed. Review of the policy issued on 7/13/15 and revised on 9/9/21 revealed that there were no time frames for…

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 observations of the facility's kitchen food services, review of Dishwashing Machine temperature logs and staff interview it was determined that the facility failed to maintain food service equipment in a manner that ensures sanitary food service operations. This deficient practice has the potential to affect all the residents in the facility. The findings include: An initial environmental kitchen food services inspection was conducted in the facility's main kitchen on 8/30/22 at 8:50 AM. At the time of the kitchen tour the dishwashing machine was not observed in operation. The Dishwashing/Warewashing Machine Temperature log for August 2022 was reviewed. The document shown to have blank (no documentation) areas that could have been filled to show what are the minimum sanitation temperature requirements. The document instructed; Refer to machine data plate for temperature requirements. Review of the data plate on the dishwashing machine indicated a minimal wash temperature of 160 degrees Fahrenheit (F.) and a minimal final rinse temperature of 180 degrees F. The document…

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 and staff interview, it was determined that the facility failed to report allegations of abuse within 2 hours of the allegation to the regulatory agency, the Office of Health Care Quality (OHCQ). This was evident for 2 (Resident #163 and #164) of 2 residents reviewed for abuse during the annual survey. The findings include: 1) A review of facility self-report #MD00182656 on 8/30/22 at 11:46 AM revealed Resident #164 reported that a Geriatric Nursing Assistant (GNA) yelled at him/her for not using a cane and did not want to help the resident. On 8/30/22 at 11:46 AM, this surveyor reviewed the facility's investigations regarding this incident. A written statement by GNA #13 revealed that the incident occurred on 8/21/22 around 11 AM. However, the facility's initial self-report form was submitted to the OHCQ on 8/22/22 at 9:57 AM, and there was no documentation for a case number and officer's name. During an interview with the Nursing Home Administrator (NHA) on 8/31/22 at 11:05 AM, the NHA stated since right after the incident, the GNA was removed from Resident…

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 medical record review, facility documentation, and staff interviews it was determined that the facility: 1) failed to ensure accurate MDS assessment related to urinary and bowel toileting programs, and 2) failed to provide an accurate assessment for a resident with an indwelling foley catheter. This is exemplified for 2 (resident #3, #164) of 8 residents that were coded on their most recent MDS assessments to be on a urinary and/or bowel toileting program, and 1 (Resident # 2) of 3 residents reviewed for urinary catheter or incontinence during the facility's Annual Medicare/Medicaid survey. The findings include. The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing homes to gather information on each resident's strengths and needs. Information obtained, drives the resident care planning decisions. The MDS assessments need to be accurate to ensure that each resident receives the care they need. From the mds-3.0-rai-manual-v1.17.1_october_2019 related to coding H0200 A to C =…

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 medical record review and staff interview, it was determined the facility failed to provide the resident or resident representative with a summary of their baseline care plan on admission. This was evident for 1 (Resident #164) of 2 residents reviewed during the annual survey. The findings include: A baseline care plan must be prepared for all residents within 48 hours of a resident's admission. Its purpose is to provide the minimum healthcare information necessary to properly care for a resident until a comprehensive care plan can be completed for the resident. The baseline care plan, along with a copy of their medications, is to be given to the resident and/or resident representative and details a variety of components of the care that the facility intends to provide to that resident. This allows residents and their representatives to be more informed about the care that they receive. On 08/31/22 at 11:00 AM, a review of Resident #164's electronic and paper medical records revealed the resident was…

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 reviews, observation, and staff interview, it was determined that the facility failed to develop and implement comprehensive person-centered care that was resident-specific with measurable objectives and goals. This was evident for 2 (residents #3, and #12) of 12 residents reviewed during the recertification survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. 1) On 8/31/22 at 9:30 AM Resident #3's medical record was reviewed and revealed a diagnosis of unspecified dementia with behavioral disturbances. Review of Resident #3's care plan, has mood and behavior issues such as putting staff out of room and a goal that the resident will have decreased/minimal mood and behavior through the next review date. The goal was not measurable. A care plan focus area for Resident #3 was written as [name of resident] plans to remain in this facility for long-term care. The goal was [name of resident] and family will verbalize/communicate 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.

Based on a review of resident medical records and interviews with facility staff, it was determined that the facility failed to: 1) review and revise resident care plans after each assessment or as resident care needs became apparent or changed over time. This was evident but not limited to 3 (#2, #3, #12) of 12 residents reviewed during the annual survey. The findings include: Care plans are developed for residents to guide the care that residents receive in the facility. They are required to be developed within 7 days of completion of a resident's admission comprehensive Minimum Data Set (MDS) assessment and revised at least every quarter (or more often as needed). The facility is required to have care plans developed and revised by an interdisciplinary team including: the attending physician, a registered nurse, a nursing aide, a representative from dietary services, the resident, and the resident's representative (as practicable). 1) Resident #3's medical record was reviewed on 8/31/22. Review of the MDS assessments revealed that the last quarterly assessment reverence date was…

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 observations and staff interviews, it was determined that the facility failed to remove expired drugs and medical supplies from the med cart and storage room. This was found to be evident in 1of 1 medication cart and medication storage room observed during the annual survey The findings include: On 08/31/22 at 09:30 AM, an exploration of the medication storage cart and Medication storage room of the facility with a Registered Nurse (RN #6) was conducted. It was observed that some of the medications and medical supplies had expiration dates on them. These were kept and currently being used for the residents. 08/31/22 09:35 AM: The Medication storage room and med cart review was done in the company of the Charge Nurse (Staff #6) and findings includes: 1. A 1/2 Empty bottle of Multivitamin Centrum silver with expiration date of 10/21 belonging to Resident (#164) 2. Vitamin A& D ointment with expiration date of 7/2022 3. Providine Iodine swab stick with an expiration date of 7/2021 4. BD Vacutainer Eclipse (2 Boxes) a blood collection needle device with an expiration date of…

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 medical record review and staff interview, it was determined the facility failed to maintain staff documentation of education regarding the benefits, risks, and potential side effects of receiving the Coronavirus Disease 2019 (COVID-19) vaccine to Resident #11 and Staff #7. This was evident when the COVID- 19 vaccination for residents and staff was reviewed during the facility's annual Medicare/ Medicaid survey. The findings include: On 8/30/22 and 8/31/22 the facility's COVID-19 vaccination for residents and staff was reviewed. Upon review of Resident #11's COVID-19 status it revealed the resident received both the first and second dose of COVID-19 vaccine and one booster vaccine. The second booster vaccine was declined by Resident #11. Staff # 7 was reviewed and received a medical exemption for the COVID-19 vaccine. On 9/1/22 at 2:00 PM the Director of Nursing (DON) had a discussion with the survey team regarding COVID-19 education that is provided to residents and staff. The DON stated that staff and residents are given handouts about COVID-19 updates. The survey team…

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 a review of employees' training records and interviews, it was determined that the facility failed to have a process to ensure that all Geriatric Nursing Assistants (GNAs) have no less than 12 hours of education per year and that the education includes annual dementia management training. This is evident for 1 (GNA #9) of 3 GNA training records reviewed during an annual survey. The findings include: On 9/2/22 at 9:03 AM, the Nursing Home Administrator (NHA) provided a requested list of the facility's all nursing staff with hire dates. Out of a list of 11 full-time GNAs, 3 employees were selected at random. The surveyor reviewed 3 GNAs education records on 9/2/22 at 10:09 AM. On 9/2/22 at 10:20 AM, the Director of Nursing (DON) confirmed that GNA #9 was hired in May 2016, resigned in May 2021, and re-hired in February 2022. The DON submitted staff education documentation, including GNA #9's online training record on 5/25/2016, competency records for 9/13/2018 and 10/9/2020, and all-day nursing in-service sign-in sheet on 2/18/2021. However, there was no evidence to prove…

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.