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Inspection visit

Follow-up

NANTUCKET RESIDENCE, THELicense 3927011564 citations on this visit
4 citations recorded

Inspector’s narrative

What the inspector wrote

On 3-23-23 at 11:00am, Licensing Program Analyst (LPA) Michael Bilger conducted a case management visit regarding infection control practices, reporting requirements, and medication practices. LPA met with Administrator Orchid Damrichob and explained the purpose of the visit. LPA conducted facility observation on 1-19-23, reviewed facility file documentation for resident1 (R1), and conducted interview with Administrator on 1-19-23. Based on observation, record review and interviews, the following was determined: (1) On 1-19-23, it was determined that R1 contracted scabies and was not cleared of contagious disease. During facility tour, LPA did not observe isolation carts in place to promote appropriate infection control practices for residents, staff, and visitors. Additionally, based on interview, it was determined that an isolation cart was not present after facility staff learned of R1’s diagnosis of scabies. (2) Upon learning of R1’s scabies diagnosis after R1’s hospitalization on 1-4-23 for an unrelated condition, it was further determined through interview and record review that facility did not report incident to licensing department per regulatory requirements. Repot was eventually received on 1-26-23. (3) Based on review of care notes for R1 and interview conducted, it was determined that R1 experienced behavioral episodes between the dates of 11/6/2022 and 1/4/2023 which were not identified on R1’s needs and service plan upon his admission on 6/10/2022. Further interview and record review revealed needs and service plans were not updated to reflect new onset of behaviors and accompanying necessary interventions. {Cont. on 809C} (4) On 1-19-23, it was determined through interview that on 1-17-23, facility staff observed a R1’s responsible party handling medication for R1 which included the process of cutting one medication in half. It was further determined that facility staff did not effectively intervene during this event to promote a provision of safety for residents in care. As a result of today's case management, citations are issued under Title 22, Division 6 and listed on 809D. An immediate civil penalty in the amount of $250 is issued today in addition to citations due to repeat violation within a 12-month period. An exit interview was conducted with Orchid Damrichob and a copy of this report was left with Orchid. Appeal rights provided.

Citations

7 citations recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • 87465(a)(4)Type A

    87465(a)(4) Incidental medical and dental care. (a) A plan for incidental medical and dental care shall be developed by each facility…(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on interview and record review, licensee did not ensure R1 received appropriate assistance with self-administered medications as per Physician’s orders. This posed an immediate health and safety risk to residents in care.

  • 87466Type A

    87466 Observation of the resident. The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning…This requirement was not met as evidenced by: Based on interview and record review, licensee did not ensure proper observation of R1’s skin condition which included scabies. This posed an immediate health, safety, and resident rights risk to residents in care.

  • 87506(a)Type A

    87506(a) Resident Records. (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident…This requirement was not met as evidenced by: Based on interview and record review, licensee did not ensure a complete and accurate record for R1 for multiple medications. This posed an immediate health and safety risk to residents in care.

  • 87211(a)(1)(D)Type B

    87211(a)(1)(D). Reporting requirements. (a) Each licensee shall furnish to the licensing agency such reports…(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence…(D) Any incident which threatens the welfare, safety or health of any resident… This requirement was not met as evidenced by: Based in interview and record review, licensee did not ensure the timely reporting of R1 contracting scabies. This posed a potential health and safety risk to residents in care.

  • 87405(h)(5)Type A

    87405(h)(5). Administrator Qualification and Duties. (h)The administrator shall have the responsibility to: (5) Provide or ensure the provision of services to the residents with appropriate regard for the residents' physical and mental well-being and needs…This requirement was not met as evidenced by: Based on interview, licensee did not ensure a service of safety for R1 in that a responsible person was allowed to handle and cut medication for R1 without appropriate staff intervention occurring. This posed an immediate health and safety risk to residents in care.

  • 87463(a)Type B

    87463(a) Reappraisals. (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate…This requirement was not met as evidenced by: Based on interview and record review, licensee did not ensure the appropriate and required updates to R1’s needs and service plan. This posed a potential health and safety risk to residents in care.

  • 87468.1(a)(2)Type A

    87468.1(a)(2). Personal Rights of Residents in All Facilities. (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by: Based on interview and observation, licensee did not ensure a properly stored isolation cart outside of R1’s room during a scabies outbreak to promote safety. This posed an immediate health and safety risk to residents in care.

FAQ · About this visit

Common questions about this visit

What happened during the March 23, 2023 inspection of NANTUCKET RESIDENCE, THE?

This was a other inspection of NANTUCKET RESIDENCE, THE on March 23, 2023. 4 citations were issued: 2 Type A (serious) and 2 Type B.

Were any citations issued to NANTUCKET RESIDENCE, THE on March 23, 2023?

Yes, 4 citations were issued (2 Type A, 2 Type B). The first citation was for: "87465(a)(4) Incidental medical and dental care. (a) A plan for incidental medical and dental care shall be developed by ..."

What type of inspection was this?

This was a other inspection. other inspections are conducted by CCLD as part of their licensing oversight.

SourceView on CCLDView original report

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Data from CCLD public records. Last updated . If you believe any information is inaccurate, report it here.