St.john Lutheran Care Center

A resident was injured when a staff member pushed their wheelchair too fast without footrests, causing the resident to fall and require stitches.

A resident's support plan was not signed by the assessor or the resident, nor did it document a refusal or inability to sign.

The resident/home contract was not signed by the resident.

Direct care staff provided rough care causing a resident pain and used verbally abusive language.

The resident's assessment and support plan were not updated to address significant changes in medical diagnosis.

The resident's initial assessment and support plan were not signed by the resident.

The resident home contract for resident #1 was incomplete, lacking the specific day of admission.

A direct care staff person did not receive required annual training in medication self-administration, personal care needs, safe management, and MH/ID care.

A direct care staff person lacked required annual training in fire safety, emergency preparedness, and falls/accident prevention.

The enabler bar on a resident's bed was loose and moved approximately 3 inches from the center.

Sanitary conditions were compromised as evidenced by improper blood glucose readings recorded on the medication administration record.

A kitchen trash receptacle had a broken lid and was left uncovered and unattended.

Staff left prescribed medications unattended on a resident's bedside desk and failed to observe the resident taking them.

Medications were not available in the home for one resident, and multiple partially filled medication bottles were left out on a table in a common area.

A copy of 55 Pa. code Chapter 2600 was not posted in a conspicuous and public place in the home.

Following an allegation of potential resident abuse, a staff member continued working without a plan of supervision being implemented.

A staff member used intimidating and verbal aggression toward a resident and another staff member, causing the resident visible distress.

Records indicated that a direct care staff member had not completed the required 12 hours of annual training for the 2022 calendar year.

An unlabeled spray bottle containing approximately 18 oz. of a light yellow liquid was found on a housekeeping cart.

A thick, yellow liquid was present on the back wall and shelf of a small refrigerator in the common area.

Exhaust fans were inoperable in the staff restroom and the common shower room, which lack windows.

A jelly donut, cherry pie, and vanilla pudding were stored in a refrigerator without being labeled or dated.