Carmel Village Retirement Community

Based on observation, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA observed one exterior egress gate requiring a key to exit and two interior doors with non-operational alarms. Based on observation, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA observed one exterior egress gate requiring a key to exit and two interior doors with non-operational alarms.

Based on observation, the licensee did not comply with the section cited above which poses a potential health and safety risk to persons in care. During the tour of the facility, LPA observed gnats in 8 out of 20 residents apartments, the main kitchen, dining room, and other common areas. LPA also observed 6 small trash bags with soiled contents in hallways throughout building 1, building 2 and building 3.

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.

All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by: Based on interviews conducted, S1 admitted to ingoring R1's refusal to get out of bed and physically forcing resident to get out of bed, stand, and walk to the bathroom for a shower, which poses an immediate health, safety and personal rights risk to residents in care.

87303 Maintenance and Operation(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provisions of maintenance services and procedures for the safety and well-being of residents, employees and visitors.This requirement is not met as evidenced by: Based on observation and interviews conducted, the licensee did not comply with the section cited above, which poses a potential health and safety or risk to persons in care. LPA observed water stains on ceiling panels of Building 2, third floor where leaks were resported. Interviews confirmed water damage occurred due to rain between Dec 2024 and Dec 2025 with no record that repairs had not been made.

87458 Medical Assessment (a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional ...This requirement is not met as evidenced by: Based on observation, interview, and record review, the licensee did not comply with the section cited above by not maintaining a Physician’s Report that was signed and dated which poses a potential health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in four out of sixteen apartment units which poses an immediate health, safety or personal rights risk to persons in care.

87465 Incidental Medical and Dental Care. (h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement has not been met as evidenced by: Based on LPA file review and interview, this was not followed in one of one residents, which poses a potential health and safety risk for residents in care.

87468.1(a)(1) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by facility employee yelled at resident which posed a protentional personal rights risk to residents in care.***THIS IS AN AMENDED DEFICIENCY PAGE.***

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.

87463(c) Reappraisals. The licensee shall arrange a meeting … when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first. This requirement was not met as evidence by: 5 out of 8 staff interviewed reported R1 had begun engaging in unusual behavior such as sitting/crawling on the ground. No reappraisal was conducted to assess R1’s change in condition. This poses a potential risk to residents in care.

87211(a)(2)Reporting Requirements:(a)Each licensee shall furnish to the licensing agency such reports...(2)Occurrences, such as epidemic outbreaks...shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. CONTINUED BELOW This requirement was not met as evidenced by:3 of 3 interviewees indicated "Dropping the ball with reporting requirements" and 2 fax cover letters dated 7/26/22 reporting 8 COVID-19 positive cases past the reporting requirement. This poses a potential risk for residents in care.