Five Palms Care Home

Certified administrator requirements and substitute coverage

87405 Administrator - Qualifications and Duties. (a) All facilities shall have a qualified and currently certified administrator. This requirement is not met as evidenced by: Based on LPAs'/licensee observation, interviews and record review, the licensee did not comply with the section cited above in not maintaining required facility documentation updated, which poses a potential risk to the health, safety, or personal rights to persons in care.

Certified administrator requirements and substitute coverage

Keep prescriptions in original containers

Based on LPA's/Licensee observation, records review and interviews with Administrator, the facility failed to leave medication in original container pre-pouring into more than 24 hour container which poses an immediate health and safety risk to resident in care.

Update reappraisal at required intervals

Based on LPA's/Licensee observation, interview and record review, the licensee did not comply with the section cited above in seven out of ten residents (R1, R2, R3, R4, R5, R6 & R7) care plans were not updated within the last 12 months which poses/posed a potential health, safety or personal rights risk to persons in care.

Maintain facility in clean, safe, sanitary condition

Based on LPA's/Licensee observation, record review and interview with Licensee, the licensee did not comply with the section cited above by not making provisions to ensure construction area was free of hazards which poses an immediate health, safety or personal rights risk to persons in care.

Report specified resident events within seven days

Based on LPA's/Licensee observation, interview and record review, the licensee did not comply with the section cited above in having construction crew members present in the hallway near lateral exit making loud noise and having unlocked materials including sharps replacing the hallway flooring, while there were seven residents in the adjacent living room playing bingo, there were no posters alerting residents about construction zone, Licensee did not notify the Department and resident's responsible parties which poses/posed a potential health, safety or personal rights risk to persons in care.

Mark taps at high-temperature threshold

Based on LPA/Licensee observed water temperature in resident's bathroom measured at 158.5, 158.5, 160.7 degrees F in the main building which poses an immediate health, safety or personal rights risk to persons in care.

Based on LPA's/Licensee observation, interview and record review, the licensee did not comply with the section cited above by not having a current register of resident's form on file which poses/posed a potential health, safety or personal rights risk to persons in care.

Complete admission suitability appraisal

Type B - 87457 Pre-Admission Appraisal 87457 Pre-Admission Appraisal: (c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria… This requirement is not met as evidenced by: Based on records reviewed, Licensee did not complete an evaluation of resident’s condition prior to admission and keep it in the file which poses a potential health, safety or personal rights risk to persons in care.

Type B: 1569.269(a)(6) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based on LPA’s record review and interview the facility failed by allowing R1 leave the facility unassisted on 8/31/25, when R1’s physician report states that R1 is not able to leave the facility unassisted which poses an immediate health and safety risk to residents in care.

Report serious outbreaks and major accidents

Type B: 87211(a)(2) 87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports..: (2) Occurrences, such as...major accidents which threaten the welfare, safety or health of residents..., shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. This rerquirement was not met as evidence by: Based on LPA’s record review and interview, the facility failed to submit an incident report when R1 went AWOL on 8/31/25 which possessed a potential health and safety risk to residents in care.

Report serious outbreaks and major accidents

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports..: (2) Occurrences, such as...major accidents which threaten the welfare, safety or health of residents..., shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. This rerquirement was not met as evidence by: Based on LPA's observations, records review and interview with Administrator, the facility did not notify CCL within 24 hours of occurreence of R1's death which poses a potential risk to the health & safety of the residents.

87506 Resident Records (d) All resident records shall be available to the licensing agency to inspect, audit, & copy upon demand during normal business hours…(e) Original records...shall be retained for a min of 3 years following termination of service to the resident. This requirement was not met as evidence by: Based on LPA's record review and interview with Licensee, the facility did not have available R1's records when requested by CCL, which poses a potential health and safety risk to residents in care.

87109 Transferability of License(b)The licensee shall notify the licensing agency and all residents receiving services, or their representatives, in writing as soon as possible and in all cases at least thirty (30) days prior to the transfer of the property or business... This requirement is not met as evidenced by: Based on interview & record review, the licensee did not comply with the section cited above in the licensee did not notify Community Care Licensing within thirty (30) business days of the transfer of the facility to a Limited Liability Corporation which poses a potential health, safety or personal rights risk to persons in care.

Maintain fire clearance before retaining specified persons

Based on LPAs/Licensee observation, interview and record review, the licensee did not comply with the section cited above in one out of eight residents is bedridden which poses an immediate health, safety or personal rights risk to persons in care.

Onsite food stock levels for nonperishables and perishables

Based on LPA's/Licensee observation and interview, the licensee did not comply with the section cited above in having adequate supply of perishables available for at least two days for a minimum of 15 residents which poses an immediate health, safety or personal rights risk to persons in care.

Ensure hazardous items are locked and not unattended

Based on observation, the licensee did not comply with the section cited above in that LPAs and administrator observed paint and insect killer outside and accessible to clients, which poses an immediate health, safety or personal rights risk to persons in care.

Passageways and stairways kept clear

Based on observation, the licensee did not comply with the section cited above in LPAs and administrator observed 1 exit to be obstructed in C1 room, medical equipment and wheelchair found in front of emergency exit, which poses an immediate health, safety or personal rights risk to persons in care.

Maintain facility in clean, safe, sanitary condition

Based on observation, the licensee did not comply with the section cited above in LPAs and administrator found LPAs observed refrigerators and behind stove to be soiled and unclean also food not properly stored open in the refrigerator and freezer, food was not covered with signs of freezer burn, which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in that 4 of 5 staff records did not contain documentation of completed training records as required. Annual training for dementia, hospice, and medication annual training have not been completed, which poses/posed a potential health, safety or personal rights risk to persons in care.

Fire approval and staff access to unlock systems

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (2) alcohol…cleaning supplies and disinfectants. This requirement was not met, as evidenced by: Based on observations made by LPA/Administrator, the facility staff did not ensure that two bottles of alcohol antiseptic 80% topical solution hand sanitizer were on the shelf of unlocked closet located in the hallway accessible to residents in care, which poses an immediate risk to the health and safety of residents in care.

Facility personnel sufficiency and competence

87411 Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, & competent to provide the services necessary to meet resident needs. In facilities licensed for 16 or more, sufficient support staff shall be employed to ensure provision of personal assistance/care… This requirement was not met as evidence by: Based on interviews conducted with staff, the licensee did not ensure residents with a diagnosis of dementia needs were met timely as stated in their program plan due to the staff was not alerted that emergency personnel were knocking and ringing the doorbell in the front entrance of the facility, which poses an immediate risk to the health and safety of residents who has a diagnosis of dementia.

Maintain facility in clean, safe, sanitary condition

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. Based on LPA's/staff observations and interviews with Licensee the heater in the back of the building is not working properly, which is an immediate risk to the health and safety of residents in care.

Passageways and stairways kept clear

87307 Personal Accommodations and Services (d) The following space and safety provisions shall apply to all facilities:(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement has not been met as evidence by: Based on LPA's/staff observation that exit door located in resident's room#8 was blocked with a recliner. Staff immediately removed recliner obstructing the exit from the passageway, which poses an immediate risk to the health and safety of residents in care.

***AMENDED DOCUMENT - no deficiencies were cited.80061 Reporting Requirements (a)Each licensee shall furnish to the licensing agency reports as required by the Dprt...a report shall be made to the licensing agency within the agency's next working day during its normal business hours....(1)(A) Death of any client from any cause. This requirement has not been met as evidence by: ***AMENDED DOCUMENT - no deficiencies were cited.Based on LPA’s records review and interviews conducted with staff, facility did not ensure that CCL was notified of death of R1 on 7/31/22. Facility submitted a death report for R1 on 8/3/22 which poses a potential health & safety risk to residents in care.