Observations
Based on a review of personnel records, the facility failed to ensure all personnel on all shifts were trained to perform assigned tasks during emergencies in one of two applicable personnel records reviewed.
Employee # 2 was hired as the facility director at this facility on January 1, 2026. At the time of the inspection, there was no documentation, in the personnel record, indicating emergency preparedness training was completed for this specific facility.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director, with support from the Regional Director, Human Resources Department, and Compliance Department, will ensure the deficiency identified in the personnel record for employee #2 is corrected. Emergency preparedness training was completed and documented for employee #2 on January 20, 2026, and the personnel record has been updated. To prevent recurrence, the Facility Director and Human Resources Department will ensure all staff location changes include completion and documentation of required emergency preparedness training within 7 days. Beginning March 1, 2026, Regional Director and Human Resources will track staff location changes and training completion, and Human Resources will continue to conduct personnel record reviews to verify compliance. |