Inspection Report
Annual Inspection
Deficiencies: 4
Apr 7, 2025
Visit Reason
Annual survey conducted on 4/7/2025 to assess compliance with state regulations for disaster preparedness, personnel requirements, initial health evaluations, and tuberculosis screening.
Findings
The facility was cited for multiple repeat Type 2 violations including failure to document resident and visitor involvement in fire and tornado drills, lack of CPR certified staff on duty at all times, missing initial health evaluations and TB testing for several employees, and failure to maintain required tuberculosis screening records.
Severity Breakdown
Type 2: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to identify resident and visitor involvement in fire and tornado drills. | Type 2 |
| Failure to ensure at least one direct care staff person with current CPR certification was on duty at all times. | Type 2 |
| Failure to ensure employees had initial health evaluations and tuberculin skin tests as required. | Type 2 |
| Failure to provide documentation of tuberculosis screening for employees. | Type 2 |
Report Facts
Dates without CPR certified staff on overnight shift: 13
Number of employees lacking initial health evaluation and TB testing: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Executive Director | Interviewed regarding missing CPR certifications and employee health evaluations. |
| E3 | Caregiver | Lacked initial health evaluation and TB testing documentation. |
| E4 | Caregiver | Lacked initial health evaluation and TB testing documentation. |
| E5 | Caregiver | Lacked initial health evaluation and TB testing documentation. |
| E6 | Caregiver | Lacked initial health evaluation and TB testing documentation. |
Document
Deficiencies: 0
6024261 View POC 001 SOC
Visit Reason
The document outlines internal audits and compliance requirements related to employee health and safety certifications and evaluations.
Findings
The document details procedures for ensuring all direct care team members complete CPR certification by May 1, 2025, initial health evaluations, and TB testing, with audits and enforcement actions for non-compliance.
Report Facts
CPR certification deadline: May 1, 2025
Initial health evaluation audit deadline: May 1, 2025
TB test documentation audit deadline: May 1, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kirsten DeAngelis | Executive Director | Named as responsible for ensuring compliance with employee health and safety requirements |
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