F0678

E

Noncompliant and Missing CPR Certifications Among Nursing Staff

Battle Creek, Michigan Survey Completed on 03-06-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that nursing staff maintained current, compliant CPR certifications as required by regulation, facility policy, and job descriptions. During surveyor review of the CPR certification binder, one RN had no CPR documentation on file, and two nurses (an RN and an LPN) held CPR certifications obtained solely through online courses (LearnTastic and National CPR Foundation) without any in‑person, hands‑on training. The Human Resources Director stated that CPR documentation is kept in a separate binder from personnel files, acknowledged awareness that some staff needed updated certifications, and was unsure whether the RN with no documentation was among them. No additional CPR documentation for that RN was produced before survey exit.

In telephone interviews, the RN and LPN with online certifications confirmed that their current CPR training was completed entirely online, without any in‑person, hands‑on component, and both reported they would be expected to assist if a code occurred during their shifts. The DON reported that at her previous facility, staff were required to complete CPR certification in person rather than online. The facility’s CPR policy requires that staff initiating CPR be certified in CPR/BLS and specifies that key clinical staff obtain or maintain American Red Cross or American Heart Association BLS/CPR certification. The facility’s nurse job description also lists current CPR certification as a required qualification. Regulation cited in the report requires that staff maintain current CPR certification for healthcare providers through a provider whose training includes a hands‑on session in a physical or virtual instructor‑led setting, which was not met for the two nurses with online‑only certifications and the RN with no documented certification.