The Lutheran Village At Miller's Grant

In the surveyor’s words

From the most serious findings on record at The Lutheran Village At Miller's Grant, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Jun 26, 2025

  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. […]

• No harm, potential for more than minimal, widespreadF756Sep 2, 2022

  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. […]

• No harm, potential for more than minimal, widespreadF812Sep 2, 2022

  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. […]

• No harm, potential for more than minimal, isolatedF628Jun 26, 2026

  Based on record review and staff interview, it was determined that the facility failed to provide written notification of the bed-hold policy to the resident representative. This was evident for 1 (Resident #5) out of 1 resident reviewed for hospitalization during the annual survey. The findings include: On 6/23/2026 at 9:33 AM, record review revealed that Resident #5 was hospitalized on [DATE]. On 6/23/2026 at 9:45 AM, record review revealed that documentation did not indicate the bed-hold policy had been provided to the resident or resident representative at the time of hospitalization. On 6/23/2026 at 11:26 AM, an interview with the Assistant Director of Nursing revealed that the bed-hold policy had not been provided when the resident was transferred to the hospital. […]

• No harm, potential for more than minimal, isolatedF641Jun 26, 2026

  Based on record review and staff interview, the facility failed to accurately code residents' status on the Minimum Data Set (MDS) assessments. This was evident for 2 (Residents #6 and #8) of 13 residents reviewed for MDS accuracy.The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each Resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments must be accurate to ensure that each Resident receives the care they need. The findings include: 1) On 6/23/2026 at 8:43 AM, record review revealed that Resident #6 had an active physician's order for Aspirin (an antiplatelet medication) 81 mg daily, which was initiated on 10/01/2025. […]