Inspection Report
Annual Inspection
Deficiencies: 2
Oct 17, 2024
Visit Reason
Annual Licensure Survey conducted to assess compliance with disaster preparedness and personnel requirements regulations.
Findings
The facility failed to document residents requiring assistance during fire and tornado drills and did not post evacuation route maps in resident areas. Additionally, the facility did not ensure at least one CPR-certified staff member was on duty during all night shifts, posing a risk to resident safety.
Severity Breakdown
Type 3 Violation: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to document residents who required assistance during fire and tornado drills and failed to post evacuation route maps on floors occupied by residents. | Type 3 Violation |
| Failed to ensure at least one CPR-certified staff member was working on the night shift on multiple dates. | Type 3 Violation |
Report Facts
Dates without CPR certified staff on night shift: 34
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E10 | Business Office Manager | Verified employee CPR cards and night shift staffing. |
| E13 | Certified Nursing Assistant (CNA) | Regular night shift staff; not CPR certified. |
| E14 | Certified Nursing Assistant (CNA) | Regular night shift staff; CPR certified. |
| E15 | Certified Nursing Assistant (CNA) | Regular night shift staff; CPR certified but worked limited shifts. |
| E12 | Certified Nursing Assistant (CNA) | Regular night shift staff; not CPR certified. |
| E2 | Health and Wellness Director | Reported no nurse present during night shifts. |
| E11 | Night shift staff not CPR certified. |
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