Lutheran Social Ministries Cranes Mill

In the surveyor’s words

From the most serious findings on record at Lutheran Social Ministries Cranes Mill, in the surveyor’s own words.

• Actual harm, isolatedF686Feb 25, 2021

  Based 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… […]

• No harm, potential for more than minimal, patternF755Mar 14, 2025

  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. […]

• No harm, potential for more than minimal, patternF883Aug 22, 2023

  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]. […]

• No harm, potential for more than minimal, patternF607Feb 25, 2021

  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. […]

• No harm, potential for more than minimal, isolatedF583Mar 14, 2025

  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. […]