El Bethel LLC

Based on documentation review, record review and interview, the manager failed to develop and administer a training program for all staff regarding fall prevention and fall recovery, including initial training and continued competency training, for one of three personnel sampled. Findings include: 1 . A review of facility documentation revealed a "Fall Prevention and Fall Recovery" policy. However, the policy did not specify when personnel received initial training or continued competency training. 2 . In an interview, E1 reported personnel would be trained on fall prevention and fall recovery annually. 3 . A review of E2's personnel record revealed documentation of fall prevention and fall recovery training from 2023. However, documentation of fall prevention and fall recovery training after 2023 was not available for review at the time of inspection. 4 . In an exit interview, the findings were discussed with E1 and no additional information was provided.

Based on documentation review and interview, the manager failed to designate, in writing, a caregiver who was present on the assisted living facility's premises and accountable for the assisted living facility when the manager was not present on the assisted living facility premises. Findings include: 1 . A review of facility documentation revealed documentation of a manager designee was not available for review at the time of inspection. 2 . In an exit interview, the findings were discussed with E1 and no additional information was provided.

Based on record review and interview, the manager failed to ensure a caregiver provided current documentation of cardiopulmonary resuscitation (CPR) training certification specific to adults, for one of three personnel sampled. Findings include: 1 . A review of E3's personnel record revealed documentation of CPR training completed on June 2025 from NationalCPRFoundation. 2 . A review of the NationalCPRFoundation website revealed a frequently asked questions (FAQ) section. One of the questions in the FAQ states, "Do you offer hands-on training?" The answer posted was "No, we do not offer hands-on training." 3 . In an exit interview, the findings were discussed with E1 and no additional information was provided.

Based on observation and interview, the manager failed to ensure a rechargeable fire extinguisher was serviced at least once every 12 months. Findings include: 1 . During an environmental inspection of the facility, the Compliance Officer observed a fire extinguisher with a tag that expired September 2025. 2 . In an exit interview, the findings were discussed with E1 and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure a pet was licensed consistent with local ordinances. Findings include: 1 . A review of facility documentation revealed documentation of a license for O1 was not available for review at the time of inspection. 2 . In an exit interview, the findings were discussed with E1 and no additional information was provided.