Lutheran Social Ministries Cranes Mill

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to: a.) prevent an avoidable facility-acquired Stage III (full thickness tissue loss) pressure ulcer to the sacrum for a resident assessed to be at mild risk for developing a pressure ulcer, b.) re-assess the resident for pressure ulcer risk upon development of the wound, c.) appropriately assess including a suspected stage of the pressure ulcer in a timely manner to prevent worsening, d.) ensure the accountability for off-loading the sacral pressure ulcer in accordance with the Wound Consultant recommendations, e.) ensure all staff that provide direct care to the resident had knowledge of the presence of the pressure ulcer to prevent the wound from worsening, f.) a comprehensive care plan was updated upon the development of the wound, g.) perform wound [...]

Inspectors wroteBased 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; [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]