Shepherd Of The Valley Liberty
Inspection Findings
F-Tag F0835
F 0835
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and interview, the facility administration failed to ensure an effective system was in place to maintain current cardiopulmonary resuscitation (CPR) certification for the licensed nurses for the highest practicable well being of all residents. This had the potential to affect all 61 residents residing in the facility.
Findings include:Review of personnel files on [DATE REDACTED] at 2:39 P.M. with Human Resources Director (HRD) #742 revealed Licensed Practical Nurse (LPN) #694's CPR (cardiopulmonary resuscitation) certification expired 03/2025 and was renewed on [DATE REDACTED]. LPN #696's CPR certification expired [DATE REDACTED] and was renewed on [DATE REDACTED]. LPN #684's CPR certification expired 02/2025 and was renewed on [DATE REDACTED]. LPN #690's CPR certification expired on 01/2025 and was renewed on [DATE REDACTED]. LPN #697's CPR certification expired on 03/2024 and was renewed on [DATE REDACTED]. LPN #691's CPR certification expired 06/2025 and was renewed on [DATE REDACTED]. Registered Nurse (RN) #713's CPR certification expired 02/2024 and was renewed on [DATE REDACTED]. LPN #686's CPR certification expired on 02/2025 and was renewed on [DATE REDACTED]. The Director of Nursing (DON)'s CPR certification expired 07/2025 and was renewed [DATE REDACTED]. Interview on [DATE REDACTED] at 2:39 P.M. with HRD #742 verified the above findings. HRD #742 stated CPR certification was tracked and some lapses in the nurses CPR recertification were found through the tracking process.Interview on [DATE REDACTED] at 9:34 A.M. with the DON revealed corporate takes care of CPR so the DON would not have been aware some nurses working in the facility did not remain current with CPR certification. The DON stated she took her CPR recertification through the American Heart Association and offered staff to attend if they wanted CPR certification. The DON stated they had very few codes in the facility. The DON confirmed staff who performed CPR were required to maintain current CPR certification. Review of the facility policy titled Cardiopulmonary Resuscitation Certification, updated [DATE REDACTED], revealed it was the policy of the facility to ensure all direct care staff be trained and maintain certification for cardiopulmonary resuscitation. All nursing and direct care staff were required to maintain current CPR certification. This certification was a condition of employment. Failure to obtain certification within 30 days of expiration would result in removal from the work schedule and might lead to disciplinary action.This deficiency represents non-compliance investigated under Complaint Number 2584291.
Residents Affected - Many Note: The nursing home is disputing this citation.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
SHEPHERD OF THE VALLEY LIBERTY in GIRARD, OH inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in GIRARD, OH, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from SHEPHERD OF THE VALLEY LIBERTY or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.