The lapse in life-saving training stretched back more than a year in the worst case. Registered Nurse #713's CPR certification expired in February 2024 and wasn't renewed until the day federal inspectors arrived in September 2025. Licensed Practical Nurse #697's certification had been expired since March 2024.
Human Resources Director #742 discovered the violations through the facility's own tracking system during a September inspection. Eight other licensed nurses had also worked with expired certifications, some for several months beyond their expiration dates.
"CPR certification was tracked and some lapses in the nurses CPR recertification were found through the tracking process," the human resources director told inspectors.
The Director of Nursing said she was unaware that nearly a third of her licensed staff lacked current life-saving credentials. She explained that "corporate takes care of CPR" and she wouldn't have known about the expired certifications.
Licensed Practical Nurse #684's certification expired in February 2025. LPN #686's expired the same month. LPN #690's certification lapsed in January 2025, while LPN #694's expired in March 2025. LPN #696's certification expired on an undisclosed date, and LPN #691's expired in June 2025.
Even the Director of Nursing herself worked with an expired certification. Her CPR training expired in July 2025 and wasn't renewed until inspectors arrived.
The nursing director acknowledged the facility had experienced "very few codes" but confirmed that staff performing CPR were required to maintain current certification. She said she obtained her recertification through the American Heart Association and offered staff the opportunity to attend if they wanted CPR training.
The facility's own policy, updated earlier in 2025, stated that all direct care staff must be trained and maintain certification for cardiopulmonary resuscitation. The policy designated current CPR certification as a condition of employment.
Staff who failed to obtain certification within 30 days of expiration faced removal from the work schedule and potential disciplinary action, according to the written policy.
None of the nine nurses with expired certifications had been removed from patient care duties during the months their training remained invalid.
The violations came to light during a complaint investigation in September 2025. Federal inspectors classified the deficiency as having minimal harm or potential for actual harm, but noted it could affect all residents in the 61-bed facility.
CPR certification ensures medical staff can respond effectively when residents experience cardiac arrest or stop breathing. The American Heart Association and other certifying organizations require periodic renewal to maintain skills in chest compressions, rescue breathing, and automated external defibrillator use.
The nursing home is disputing the citation.
The inspection revealed a breakdown in the facility's oversight system, where corporate management handled CPR training but failed to ensure nurses maintained valid certifications before they expired. The human resources director's tracking system ultimately caught the violations, but only after multiple staff members had worked for months without current life-saving credentials.
All nine nurses eventually renewed their certifications on the day inspectors conducted their review, suggesting the facility was aware of the problem but had delayed addressing it until federal oversight arrived.
The case illustrates how administrative gaps can compromise resident safety even when facilities have written policies requiring proper certification. Despite clear requirements that CPR training remain current as a condition of employment, nearly one-third of the facility's licensed nursing staff continued patient care duties with expired credentials.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Shepherd of the Valley Liberty from 2025-09-22 including all violations, facility responses, and corrective action plans.
Additional Resources
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