Elim Palmtrees Assisted Living LLC

Based on record review, documentation review, and interview, the manager failed to ensure that a personnel record for each employee included initial training and continued competency training in fall prevention and fall recovery for two of two employees sampled. Findings Include: 1. A review of E1’s personnel record revealed ongoing documentation of fall prevention and recovery training was not available for review. 2. A review of E2’s personnel record revealed initial and ongoing documentation of fall prevention and recovery training was not available for review. 3. In an exit interview with E1 and E2, the findings were reviewed and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure a disaster drill for employees was conducted on each shift at least once every three months and documented. The deficient practice posed a risk if employees were unable to implement a disaster plan. Findings include: 1. A review of facility disaster drills revealed the most recent documented disaster drills were dated more than a year prior to the on-site inspection. 2. In an exit interview with E1 and E2, the findings were reviewed and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure an evacuation drill was conducted at least once every six months. Findings include: 1. A review of facility evacuation drills conducted during the year prior to the onsite inspection revealed a form dated March 20, 2025. However, this form was not completed and did not document the time to complete evacuation, did not list residents requiring assistance to evacuate, and did not list residents who did not evacuate. Additionally, a second evacuation drill conducted on or before September 2025 was not available for review. 2. In an exit interview with E1 and E2, the findings were reviewed and no additional information was provided.

Based on observation and interview, the manager failed to ensure hot water temperatures were maintained between 95º F and 120º F in areas of an assisted living facility used by residents. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed the water temperature in a shared bathroom measured 127.9º F on a Department issued thermometer. 2. In an exit interview with E1 and E2, the findings were reviewed and no additional information was provided.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were maintained in a locked area inaccessible to residents. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed an office adjacent to the dining room was not locked and was accessible to residents. On an open shelf inside the office, the Compliance Officer observed containers of "WD-40" and superglue. 2. During an environmental inspection of the facility, the Compliance Officer observed a closet in a hallway near the front room. The closet was not locked and was accessible to residents. Inside the closet, the Compliance Officer observed cleaning chemicals, including bleach. 3. In an exit interview with E1 and E2, the findings were reviewed and no additional information was provided.

Based on observation and interview, the manager failed to ensure an exterior door was equipped with a ramp or other device to allow use by a resident using a wheelchair or other assistive device. Findings include: 1. During a facility environmental tour, the Compliance Officer observed a bedroom marked "bedroom 4" on the facility map. The bedroom did not have a window; however, the bedroom had a sliding glass door leading to the back patio. The Compliance Officer observed an approximately 8 inch step down from the room to the patio surface, and observed the door was not equipped with a ramp or other device to allow use by a resident using a wheelchair or other assistive device. 2. In an exit interview with E1 and E2, the findings were reviewed and no additional information was provided.