Lutheran Senior Life Passavant Community

One direct care staff person completed only 10 of the required 12 annual training hours for the 2024 training year.

One direct care staff person did not receive annual training in Resident Rights, the Older Adult Protective Services Act, or falls and accident prevention.

One direct care staff person did not receive annual training in several required areas, including medication self-administration and infection control.

Resident assessment was not updated to reflect a significant change in condition regarding the resident's need for total assistance with feeding.

Staff documented the administration of medication in the MAR that was not actually administered to the resident.

The home failed to address multiple unwitnessed falls and changes in resident condition, and did not update the resident's assessment and support plan.

The home failed to report a medication error incident to the Department within the required 24-hour timeframe.

A staff member completed only 9 hours of required annual training in 2022.

Undated frozen food, including cheese sticks and bananas, were found in a freezer bag in the 3rd floor kitchenette.

The ventilation fan in the 3rd floor common bathroom was not operational, and there was no other means of ventilation.

The facility failed to conduct an annual fire safety inspection and fire drill by a fire safety expert within the required timeframe.

The temperature in the main kitchen walk-in freezer was measured at 11 degrees Fahrenheit, which is above the required 0°F.

A resident admitted to the Secured Dementia Care Unit did not have a support plan developed within the required 72-hour timeframe.