Lutheran Senior Life Passavant Community.

“Direct care staff person A completed only 10 of the required 12 annual training hours during the 2024 training year.”

“Direct care staff person A did not receive annual training in 2024 in required areas including medication self-administration, meeting resident needs, dementia care, infection control, personal care service needs, safe management techniques, and care for residents with mental illness.”

“Direct care staff person A did not receive required annual training in 2024 in resident rights, the Older Adult Protective Services Act, and falls and accident prevention. This was a repeat violation.”

“Hot water temperature in a bathroom sink in a bedroom measured 123.5 degrees Fahrenheit, exceeding the maximum allowed temperature of 120°F.”

“The ice cream freezer near the main kitchen did not have a thermometer to monitor freezer temperature.”

“An unsealed and undated plastic bag containing 6 frozen pizza crusts was found in walk-in freezer #4.”

“An unsealed and undated plastic bag containing 6 frozen pizza crusts was found in walk-in freezer #4, creating a concern about outdated or spoiled food.”

“A prescription medication for a resident was not properly labeled with pharmacy label information including the resident's name, medication name, prescription date, dosage, and prescriber information.”

“Resident assessment was not updated to reflect a significant change in condition. Multiple staff interviews indicated the resident required total assistance with feeding, but the assessment had not been updated to document this change.”

“The home failed to report a medication error incident to the Department within 24 hours. On the date specified, staff did not administer prescribed medications to a resident, but the home did not report this incident to the Department's personal care home regional office or complaint hotline.”

“A resident experienced multiple unwitnessed falls (documented on multiple occasions) resulting in head injuries, abrasions, bruises, and other injuries. From September 2022 to present, the resident exhibited increased tiredness, lethargy, dizziness, nausea, and confusion, including falling asleep on the toilet and during meals. The home failed to address these falls and changes in condition, and did not update the resident's support plan to address these needs.”

“Staff documented in the resident's December 2023 medication administration record (MAR) that prescribed medications were administered at bedtime, but these medications were not actually administered to the resident. The information was recorded but the medication administration did not occur.”

“A resident prescribed specific medications did not receive those medications at bedtime on the specified date. The home failed to follow the prescriber's orders for medication administration.”

“A resident prescribed specific medications did not receive those medications at bedtime on the specified date. The medication error was not reported to the resident, the resident's designated person, or the prescriber as required.”

“A resident's support plan (dated as specified) was not updated to reflect documented behaviors including being overly protective of other residents, becoming anxious when other residents are absent, physical contact with other residents (kissing, helping with clothes), following staff into other residents' rooms, and complaints about staff care. The support plan was not revised as the resident's condition and behaviors changed.”

“An administrator completed only 9 hours of Department-approved training in the calendar year 2022, falling short of the required 24 hours of annual training relating to job duties.”

“The ventilation fan located in the 3rd floor common bathroom was not operational at the time of inspection, and there was no window or other means of mechanical ventilation in the bathroom.”

“Approximately 12 freezer burned cheese sticks in an undated zip lock freezer bag and approximately 10 pieces of banana in an undated zip lock freezer bag were found in the third floor kitchenette's floor freezer. Leftover food shall be labeled and dated.”

“The most recently conducted fire drill observed by a fire safety expert was completed on 5/26/2023, but the previously conducted fire drill observed by a fire safety expert was completed on 3/11/2022, indicating a gap in annual fire safety inspection and fire drill compliance.”

“During the fire drill conducted on 4/10/2023, the home did not have a maximum safe evacuation time specified in writing by a fire safety expert and exceeded safe evacuation times on subsequent drills on 6/10/2023 (7 minutes 45 seconds vs. specified 4 minutes 30 seconds) and 7/22/2023 (5 minutes 58 seconds vs. specified 4 minutes 30 seconds).”

“Resident #1 and Resident #2's medical evaluations completed within required timeframes did not include a Height assessment, with the field left blank on the Department-specified form.”

“Multiple medication labeling discrepancies were identified: Resident #3's medication labels did not match prescribed frequency (6 times weekly vs. label showing different frequency; twice daily vs. label showing three times daily). Resident #4's labels showed discrepancies in frequency and dosage instructions not matching the medication administration records.”