Embrace North Assisted Living LLC

Based on record review and interview, the manager failed to ensure a personnel record for each employee included evidence of freedom from infectious tuberculosis. Findings include: 1. Upon arrival, E2 and E3 were the only caregiver on-site and during the survey. 2. A review of E2's personnel record did not reveal documented evidence of : -Evidence of freedom from infectious tuberculosis; 3. A review of E3''s personnel record did not reveal documented evidence of: -Evidence of freedom from infectious tuberculosis; 4. In an interview, E2 reviewed and acknowledged E2's and E3's personnel record did not include the above required information.

Based on record review and interview, the manager failed to ensure a personnel record for each employee included cardiopulmonary resuscitation and first aid training. Findings include: 1. Upon arrival, E2 and E3 were the only caregiver on-site and during the survey. 2. A review of E2's personnel record did not reveal documented evidence of : -Cardiopulmonary resuscitation training; -First aid training. 3. A review of E3''s personnel record did not reveal documented evidence of: -Cardiopulmonary resuscitation training; -First aid training. 4. In an interview, E2 reviewed and acknowledged E2's and E3's personnel record did not include the above required information.

Based on record review and interview, the manager failed to ensure a personnel record for each employee included orientation. Findings include: 1. Upon arrival, E2 and E3 were the only caregiver on-site and during the survey. 2. A review of E2's personnel record did not reveal documented evidence of : -The individual's completed orientation 3. A review of E3''s personnel record did not reveal documented evidence of: -The individual's completed orientation 4. In an interview, E2 reviewed and acknowledged E2's and E3's personnel record did not include the above required information.

Based on observation and interview, the manager failed to ensure an the facility provided an outside activity space with a hard surfaced section for wheelchairs and had an available shaded area. Findings include: 1. During a facility tour, the compliance officer observed the facility did not have an outside activity space that has a hard surfaced section for wheelchairs and available shaded area. 2. In an interview, E1 acknowledged there was no outside activity space that has a hard-surfaced section for wheelchairs and available shaded area.