Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lutheran Social Ministries Cranes Mill during CMS and state inspections, most recent first.
The facility failed to maintain pharmaceutical services standards, including a missing tamper-resistant seal on a resident's Morphine bottle, incomplete DEA Form-222 for narcotic orders, and improper disposal of a Metoprolol pill by an LPN. The DON acknowledged the need for improved processes and adherence to proper procedures.
A resident with moderate cognitive impairment and a sacral pressure ulcer was left exposed during a treatment, visible from the hallway, as an LPN prepared for the procedure without ensuring privacy. The LPN acknowledged the oversight when prompted by a surveyor and then pulled the privacy curtain. The incident was reported to the facility's administration.
A facility failed to follow infection control practices during a pressure ulcer treatment for a resident with moderate cognitive impairment. An LPN did not sanitize a jar of Iodoform packing strips before returning it to the treatment cart and left soiled dressings in the resident's trash can. The facility's policy did not address these issues, and the DON confirmed the lapses.
Deficiencies in Pharmaceutical Services and Medication Handling
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with professional standards, as evidenced by several deficiencies. During an inspection of the narcotic medication cart, it was discovered that the tamper-resistant seal on a bottle of Morphine Sulfate for a resident was missing. The Licensed Practical Nurse (LPN) on duty stated that she received the medication in that condition and did not report the missing seal to the Director of Nursing (DON). The Controlled Medication Utilization Record (CMUR) for the Morphine did not show any usage since it was received, indicating a lack of proper tracking and accountability. Additionally, the facility did not accurately complete the required Federal narcotic acquisition forms (DEA Form-222) for several orders. The forms lacked details such as the number of packages received and the date of receipt, which are necessary for accurate reconciliation. The DON acknowledged the need for a streamlined process for receiving and reconciling narcotics, as the current system was insufficient. Furthermore, during a medication pass observation, an LPN improperly disposed of a Metoprolol Succinate pill that fell onto a resident's bed by placing it in an open trash receptacle instead of using the designated Drug Buster for safe disposal. The DON confirmed that the nurse should have used the Drug Buster, which is available in each medication cart, highlighting a lapse in following proper medication disposal procedures.
Failure to Provide Privacy During Pressure Ulcer Treatment
Penalty
Summary
The facility failed to provide physical privacy during a pressure ulcer treatment for a resident with moderate cognitive impairment and a full thickness sacral pressure ulcer. On the day of the incident, the resident was observed awake and alert in bed with a private duty companion present. The resident's medical records indicated a physician's order for daily cleansing and dressing of the pressure ulcer. During the scheduled observation of the treatment, the resident was positioned on their left side with their slacks pulled down, exposing their incontinence brief and making them visible from the hallway. The Licensed Practical Nurse (LPN) responsible for the treatment left the door open and prepared for the procedure for 10 minutes while the resident remained exposed. The surveyor, upon noticing the lack of privacy, questioned the LPN, who acknowledged the need for privacy and subsequently pulled the privacy curtain. The incident was later discussed with the facility's Administrator and Director of Nursing. A review of the facility's policy for dressing changes revealed that providing privacy was a required step in the procedure.
Infection Control Lapse During Pressure Ulcer Treatment
Penalty
Summary
The facility failed to adhere to proper infection control practices during the treatment of a pressure ulcer for Resident #21, who was admitted with a full thickness sacral pressure ulcer and had moderate cognitive impairment. On the day of the observation, the LPN sanitized the over bed table and prepared the necessary supplies for the treatment. However, the LPN brought a glass jar of Iodoform packing strips into the resident's room and placed it on the over bed table without sanitizing it before returning it to the treatment cart. Additionally, the LPN left the soiled packing strip and cover dressings in the resident's trash can instead of removing them from the room to the dirty utility room. The facility's policy and procedure for a clean dressing change did not address the removal of trash from the room or the sanitization of items before returning them to the treatment cart. The Director of Nursing confirmed that the jar should have been sanitized and that soiled dressings should be removed from the resident's room.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near West Caldwell
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Complete Care At West Caldwell Llc | 1.3 mi | ★★★★★ | 1 | 0 |
| St Catherine Of Siena | 1.8 mi | ★★★★★ | 0 | 0 |
| Green Hill | 3 mi | ★★★★★ | 6 | 0 |
| Alaris Health At Cedar Grove | 3.7 mi | ★★★★★ | 28 | 0 |
| Canterbury At Cedar Grove | 3.8 mi | ★★★★★ | 13 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.