Lutheran Social Ministries Cranes Mill

Based on observations, interviews, record review, and review of other facility documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure a.) stored narcotic medication was maintained with the safety tamper resistant seal (Resident #4), identified for 1 of 1 medication cart inspected, b.) ensure an accurate ordering and receiving of narcotic medications on the required Federal narcotic acquisition forms (DEA Form-222) were completed with sufficient detail to enable accurate reconciliation, identified for 7 of 9 provided DEA Form-222, and c.) medication was properly disposed after falling onto the bed, observed during medication pass observation. The deficient practice was evidenced by the following: 1.) On 3/11/25 at 9:29 AM, the surveyor and the Licensed Practical Nurse (LPN) began the narcotic medication inspection, which was stored in a mounted, double locked portion of the medication cart (narcotic box), assigned to the 2500 hall. At 9:32 AM, in the presence of LPN, the surveyor reviewed the…

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 observation, interview, and record review it was determined the facility failed to provide physical privacy during a pressure ulcer treatment for 1 (Resident #21) of 9 residents reviewed for privacy and dignity. The deficient practice was evidenced by the following. On 3/7/25 at 10:42 AM the surveyor observed Resident #21 awake and alert in bed. The resident had a private duty companion seated at the bedside. A review of the electronic medical record revealed the following information. The 1/27/25 admission Minimum Data Set (MDS) assessment tool indicated the resident had moderate cognitive impairment and was admitted with a full thickness sacral pressure ulcer. The Resident Medical Profile included a 2/14/25 physician's order for nursing to cleanse the right sacrum with normal saline solution, pack with Iodoform packing strips, cover with dry gauze and foam dressing once daily. The surveyor approached Resident #21's room on 3/11/25 at 1:08 PM to observe the resident's pressure ulcer treatment which had been prearranged with the Licensed Practical Nurse (LPN) who would…

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 observation, interview, and record review it was determined the facility failed to follow appropriate infection control practices to prevent or reduce the spread of infection during a pressure ulcer treatment for 1 (Resident #21) of 2 residents reviewed for pressure ulcers. The deficient practice was evidenced by the following. The surveyor observed Resident #21 awake and alert in bed on 3/7/25 at 10:42 AM . The resident had a private duty companion seated at the bedside. A review of the electronic medical record revealed the following information. The 1/27/25 admission Minimum Data Set (MDS) assessment tool indicated the resident had moderate cognitive impairment and was admitted with a full thickness sacral pressure ulcer. The Resident Medical Profile included a 2/14/25 physician's order for nursing to cleanse the right sacrum with normal saline solution, pack with Iodoform packing strips, cover with dry gauze and foam dressing once daily. The surveyor observed the resident's pressure ulcer treatment on 3/11/25 at 1:08 PM. The Licensed Practical Nurse (LPN) sanitized the…

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 interview, record review, facility policy review, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to revise their pneumococcal vaccine policy to reflect current pneumococcal vaccination guidelines. This failure increased the risk for residents to not be vaccinated per current guidelines and contract pneumonia. Findings include: During an interview on 08/22/23 at 12:28 PM, the Infection Control Preventionist (ICP) stated that the facility only offers the PCV13 and was not familiar with the most current CDC recommendations for the pneumococcal vaccines. During an interview on 08/22/23 at 2:37 PM, the Director of Nursing (DON) stated the facility does have access to the PCV20 [Pneumococcal conjugate vaccines]. During an interview on 08/22/23 at 2:58 PM, the Administrator stated the pneumococcal policies were a work in progress and needed to be updated as the regulations change. Review of a policy provided by the facility titled Pneumococcal (Pneumonia) Vaccination Program for Residents/Participants, dated 01/18/18, indicated…

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 observation, interview, and record review, it was determined that the facility failed to maintain oxygen supplies in a manner that was consistent with infection control protocols and professional standards of practice. This was found with 1 of 3 residents reviewed for respiratory care, Resident # 26. The deficient practice was evidenced by the following: On 1/23/23 at 9:23 AM, the surveyor observed Resident #26 in bed, awake. The resident was receiving oxygen through a nasal cannula (plastic prongs inserted into the nostrils to deliver oxygen) that was connected to an oxygen concentrator with oxygen tubing. The oxygen concentrator was set to deliver oxygen to the resident at a rate of 2 liters per minute. The tubing that delivered the oxygen from the concentrator was dated 12/20/22. On 1/24/23 at 12:17 PM, the surveyor went to the resident's room but the resident wasn't there. The resident was in Physical Therapy (PT). The resident's Private Aide was in the resident's room and said the resident would be…

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 observation, interview, and record review, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure a.) expired narcotic medications were removed from active inventory b.) dispensed and received medication from the pharmacy were reconciled for accuracy which resulted in the wrong dosage stocked in the active inventory for one of one of the electronic emergency (backup) machine observed, and c.) proper disposal of medication during medication administration observation for one of two nurses. The deficient practice was evidenced by the following: 1. On 1/24/23 at 9:34 AM, during an interview with the surveyor, the Registered Nurse/Unit Manager (RN/UM) stated every nurse had their own log on for the backup machine and the pharmacy provider [name redacted] performed their own count weekly. The medications that were not at PAR level (minimum and maximum quantity limits that was set for a certain medication) were sent with the regular delivery and marked nurse supervisor, back up replacement. When the…

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 observation, interview, record review and review of pertinent facility documentation, it was determined that the facility failed to ensure medication administration without significant error when the surveyor observed two nurses administer 25 doses to six residents. The deficient practice was identified for one of six residents, Resident #245 as evidenced by the following: On 1/25/23 at 9:25 AM, the surveyor observed the Licensed Practical Nurse (LPN) preparing medications for Resident #245 in the following order: Docusate 100 milligram (mg), 1 tablet Eliquis 5 mg, 1 tablet (a blood thinner, used to lower the risk of strokes and blood clots in people with an irregular heartbeat known as Atrial Fibrillation) Furosemide 20mg, 1 tablet Sertraline 100 mg, 1 tablet Vitamin C 1000mg, 1 tablet Bupropion 100mg, 1 tablet Eliquis 5 mg, 1 tablet mg On 1/25/23 at 9:33 AM, the LPN confirmed she had seven medications in the unit dose cups and stated she was ready to administer the medication to Resident #245. The LPN…

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 observation, interview, record review and policy review, it was determined that the facility failed to a.) failed to sanitize and air dry steam table pans in a manner to prevent microbial growth and b.) failed to maintain the kitchen environment and equipment in a sanitary manner to prevent contamination from foreign substances and potential for the development a food borne illness. This deficient practice was evidenced by the following: On 1/23/23 at 10:30 AM, in the presence of the Registered Dietitian, General Manager (GM) and the [NAME] President of Culinary Services, the surveyor observed the following: 1. In the food preparation area, on metal dishware drying shelving unit, the surveyor observed five half sized steam table pans and eight quarter sized pans which were stacked with water between them. 2. On a shelf in the dairy walk in fridge the surveyor observed a half empty bag of salami with an open date of 1/10/23 and the GM stated that this item should be discarded after 5 days. 3. In the dry storage area, the surveyor observed a random sampling of dented cans…

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 observation, interview, and record review, it was determined that the facility failed to follow appropriate measures to prevent and control the spread of infection for failure to properly wear personal protective equipment (PPE) while entering a resident's room who was on droplet precautions. The deficient practices were evidenced by the following: On 1/24/23 at 12:20 PM, the surveyor observed a Certified Nursing Assistant (CNA) at the door of a resident who was on transmission-based droplet precautions. The CNA donned (put on) a disposable gown and had a KN95 mask on her face and no eye protection or gloves. The CNA took the resident's lunch tray, opened the door and entered the resident's room. The CNA then closed the door and approximately one minute later she opened the resident's door, removed her gown and washed her hands. At 12:25 PM, the surveyor interviewed the CNA, who stated that she should have worn an N95 mask and eye protection in addition to the gown. She stated that she put gloves after entering the residents room. The CNA stated that she did not wear eye…

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 observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to: a.) thoroughly investigate the development of a facility-acquired full-thickness tissue loss pressure ulcer, and b.) initiate an investigation for a large bruise that developed on a resident's arm in accordance with their abuse and neglect policy. This deficient practice was identified for 2 of 3 residents reviewed for skin conditions (Resident #10 and #12), and was evidenced by the following: 1. According to the facility's Abuse Policy revised 4/1/19 included the following: The investigation is the process used to try to determine what happened. The designated facility personnel will begin the investigation immediately. The information gathered is given to administration .The investigation will include: Who was involved; Residents' statements; For non-verbal residents, cognitively impaired residents or residents who refused to be interviewed, attempt to interview the 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.

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to provide written notification to the beneficiary of the potential liability charges for services not covered, when the resident was discharged from Medicare Part A services with benefit days remaining. This deficient practice was identified for 1 of 4 residents reviewed for beneficiary notice reviews (Resident #4), and was evidenced by the following: On 2/23/21 at 1:57 PM, the surveyor observed Resident #4 sitting in a chair in his/her room. The surveyor interviewed the resident who stated that he/she recently received a bill from the facility for [dollar amount redacted] and that he/she did not know what the bill was for, as it was not itemized. The resident showed the surveyor the bill which was dated for Balance Forward services through 12/31/20. The resident further stated that he/she was admitted to the attached Assisted Living section and then had a fall which resulted in a hospitalization and the resident was subsequently admitted to the facility 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 observation, interview, and record review, it was determined that the facility failed to ensure a resident was transferred using a two-person assist when operating a mechanical lift in accordance with the facility policy to prevent accidents and injuries. This deficient practice was identified for 1 of 2 residents reviewed for accidents (Resident #12). The evidence was as follows: On 2/17/21 at 11:17 AM, the surveyor observed Resident #12 in a private room sitting upright in a high-back wheelchair with a mechanical lift pad under his/her body. There was a soft gel cushion to the seat of the resident's wheelchair. The resident was wearing bilateral geri-sleeves (an arm sock used to prevent skin tears) to the arms. The surveyor attempted to interview the resident but the resident did not verbally respond to the surveyor. On 2/22/21 at 10:14 AM, the surveyor interviewed the Certified Nursing Aide (CNA) routinely assigned to Resident #12. The CNA informed the surveyor that the resident was alert but was unable to follow commands or verbally respond in a coherent manner. The CNA…

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.