St Michael's Manor II

Based on observation, record review, documentation review, and interview, the manager failed to ensure that before providing assisted living services to a resident, a manager or caregiver provided current documentation of first aid (FA) training and cardiopulmonary resuscitation (CPR) training certification specific to adults according to the facility's policy, for one of two applicable personnel reviewed. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency. Finding Include: 1. Upon arriving at the facility, The Compliance Officer observed E2 working at the facility and providing assisted living services to residents. 2. A review of E2’s personnel record revealed a CPR/FA card from the National CPR Foundation. 3. A verification of the National CPR Foundation website on September 30, 2025, confirmed that the organization only offers online courses and does not provide any hands-on training. This CPR training is invalid as it does not include a demonstration of the individual's ability to perform CPR. 4. In an interview, E4 acknowledged E2 only having a CPR/FA certificate from the National CPR Foundation.

Based on record review and interview, the manager failed to ensure that before or at the time of acceptance of an individual, the individual submitted documentation dated within 90 calendar days before the individual was accepted by an assisted living facility, and included whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints and was dated and signed by a medical practitioner or registered nurse. Findings include: 1. A review of R1’s medical record revealed R1's pre-admission determination, which included whether R1 required continuous medical services, continuous or intermittent nursing services, or restraints, and was dated and signed by a medical practitioner. However, this was not completed within 90 days before R1 was admitted to the facility. 2. A review of R2’s medical record revealed R2's pre-admission determination, which included whether R2 required continuous medical services, continuous or intermittent nursing services, or restraints, and was dated and signed by a medical practitioner. However, this was not completed within 90 days before R2 was admitted to the facility. 3. In an interview, E4 acknowledged R1’s and R2’s pre-admission determination was not completed within 90 days before R1 and R2 was admitted to the facility.