The Nantucket Residence

Type of visit: Case Management - Incident

On 8-2-23 at 1:05pm, Licensing Program Analysts (LPAs) Michael Bilger and Arvin Villanueva arrived unannounced to conduct a case management visit regarding an incident which occurred on 7-8-23. LPAs met with Administrator Orchid Damrichob and explained the purpose of the visit. LPAs reviewed incident report dated 7-10-23, physician's report for resident1 (R1), needs and service plan for R1, LPAs also interviewed Administrator. Based on record review and interview, it was revealed that R1 sustained an unwitnessed fall on 7-8-23 resulting in a hip fracture. It was further revealed that after discovery of the fall facility staff notified hospice and sent R1 to hospital after receiving consent from R1's responsible person. Additionally, based on interview and record review, R1 was and continues to receive hospice services and has a history of agitation and wandering. Needs and service plan reviewed revealed R1 requires constant supervision, supervision with ADLs, and assist with all ADLs including toileting. Based on review of incident report, facility staff heard a call for help from R1 and found R1 on floor, called Administrator and assisted R1 back to bed. A review of hospice waiver states facility will provide additional staff as necessary to meet needs of residents in care. During the incident on 7-8-23, 1 care staff was on duty for 6 residents. Two of six residents received hospice services, multiple other residents have dementia care needs and incontinent needs. As a result of today's case management, citations are issued under Title 22, Division 6 and Health and Safety Codes. A civil penalty in the amount of $500 is issued in addition to citation due to injury relating to violation of Health and Safety Code Section 1569.312(a). At the time of the complaint visit, the issuance of an additional Civil Penalty was still being determined and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code § 1569.49(f). An exit interview was conducted with Orchid Damrichob and a copy of this report was left with Orchid. Appeal rights provided.the state’s words, verbatim · CDSS document, Aug 2, 2023

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.312(a) · Plan of correction due date: Aug 3, 2023

Basic Service Requirements. Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision as defined in Section 1569.2. This requirement was not met as evidenced by: Based on record review and interview, R1 sustained a fall with injury due to lack of appropriate required supervision as stated in R1's plan of care. This posed an immediate health, safety and resident rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 2, 2023

Plan of correction: Licensee to develop and submit an updated plan of care for R1 outlining needs for care and supervision. Plan to be integrated with hospice care plan. Plan to be submitted to LPA by POC due dates.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(g) · Plan of correction due date: Aug 3, 2023

Incidental Medical and Dental Care. (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health...This requirement was not met as evidenced by: Based on interview and record review, Licensee did not ensure an immediate call to 9-1-1 following the discovery of a R1's fall and pain on 7-8-23. This posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 2, 2023

Plan of correction: Licensee will read regulation 87465(g) and submit a signed decalration of understanding to LPA by POC due date. Licensee will ensure completed staff training on regulation 87465(g). Training date to be submitted to LPA by POC due date with proof of completed training to be submitted to LPA no later than 2 weeks from date of citation issuance.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(d)1) · Plan of correction due date: Aug 3, 2023

Administrator Qualifications and Duties. (d) The administrator shall have the qualifications...(1) Knowledge of the requirements for providing care and supervision appropriate to the residents. This requirement was not met as evidenced by: Based on interview and record review, Administrator did not ensure a care and supervision level for R1 consistent with R1's written plan of care resulting in a fall with injury. This posed and immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 2, 2023

Plan of correction: Licensee to review regulations regarding care and supervision and regulatory definition of care and supervision, and submit a signed declaration of understanding to LPA by POC due date. Sections referenced: H&S Code 1569.312(a) and H&S Code Section 1569.2.

Type of visit: Required - 1 Year

On 5-3-23 at 9:46am, Licensing Program Analyst (LPA) Michael Bilger arrived at this facility unannounced to conduct an annual inspection visit. LPA met with the administrator Orchid Damrichob and explained the purpose of the visit. LPA Bilger inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside of the facility to ensure compliance with Title 22 regulations. Facility is a 6 bed residential care facility for the elderly with a current census of 5. Facility has 4 bedrooms and 2 bathrooms for resident use. Facility has a formal dining room and a formal living room. LPA also conducted the inspection using the CARE tool. Facility currently provides care for 0 bedridden, 2 hospice, 5 non-ambulatory (total residents), and 0 ambulatory residents. The facility has an approved COVID Mitigation plan LIC 808 form in place. The facility conducts routine symptom screening for employees, residents, and visitors as necessary. LPA observed the facility to have hand washing, COVID - 19 informational, and social distancing signs posted throughout the facility. The facility has a designated infection control lead. Common touch surfaces are cleaned after each use. Water temperature reads 105*F to 120*F in the bathroom and room temperature reads 78*F. LPA observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguisher was checked 2-17-23. Facility has an emergency food and water kit. LPA observed toxins unsecured in an outside shed during tour. LPA also observed a broken window screen on the left side of facility property. Medication storage area was observed to be locked and inaccessible to residents in care. Medications were reviewed and contained accompanying regulatory required Physician’s orders. First aid kit was observed to have adequate supplies and accessible to staff. {Cont. on 9099C} During this inspection 5 resident files and 4 staffing files were reviewed for regulatory compliance. Staffing files did not contain evidence of completed regulatory training requirements for staff including general staff training and medication training requirements. All staff noted on LIC 500 contained criminal background clearances. LPA completed 2 resident interviews and 2 staff interviews. Resident files reviewed contained all required contents including updated admission agreements, medical assessments, and updated appraisal forms as required. Facility’s liability insurance is current and update to date per regulatory requirements. Facility does not contain any bodies of water. LPA observed personal rights, resident council and complaint information posted. Facility has appropriate internet access available for resident use. LPA observed facility’s activity calendar and sufficient equipment and supplies to meet activity program needs of residents in care. LPA reviewed facility’s disaster plan to ensure regulatory compliance. Facility conducts quarterly fire drills. Facility has 1 resident with bedrails with physician orders in place. LPA requested an updated copy of LIC 308 and LIC 500. Per California Code of Regulations, Title 22 and health and safety codes, deficiencies were observed during this visit. Exit interview was held and a report was given to Administrator Orchid Damrichob. Appeal rights provided.the state’s words, verbatim · CDSS document, May 3, 2023

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Allegation investigated: Staff do not distribute resident's medication as prescribed Staff did not observe resident for change in condition Licensee does not maintain a record for centrally stored medications

On 3-23-23 at 9:59am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced at facility to deliver findings for the allegations noted above. LPA met with Administrator Orchid Damrichob and explained the purpose of the visit. During the course of this investigation, LPA reviewed facility file documentation including facility care notes for resident1 (R1), appraisal needs and service plan for R1, physician orders for R1, and medication log sheets for R1. LPA also conducted a facility observation on 1-19-23 and conducted interviews with Administrator and R1. Allegation #1: Staff do not distribute resident’s medication as prescribed. LPA reviewed medication log sheets for October to December 2022, and January 2023. LPA also conducted a medication count with Administrator, and interviewed Administrator. Based on record reviews and interviews, it was determined that medication for R1, Losartan 50mg, was not indicated to be given as ordered on 11-30-22. Additionally, it was determined that medication for R1, Hydroxizine, was given from 12-1-22 to 12-16-22 after R1’s responsible person brought in medication and accepted by facility staff. {Cont. on 9099C} Substantiated It was further determined that R1 was receiving medication without a physician’s order on file at facility during the above noted time period. Additionally, based on medication count and review of medication logs, medication Trazodone had 19 pills present in a bottle which should have contained 22 pills, and medication Atrovastatin contained 21 pills in a bottle which should have contained 22 pills. Based on interviews and record reviews, the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED. Allegation #2: Staff did not observe resident for change in condition. LPA interviewed Administrator and reviewed care notes for R1. Based on interview and record reviews, it was determined that R1 was sent to the hospital on 1-4-23 due to a behavioral episode, and learned that R1 had contracted scabies. It was further determined that facility staff was aware of redness on R1, but not aware of scabies due to not providing evidence of an appropriate regulatory required observation of R1 including notifying family and Physician of R1. As a result, the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED. Allegation #3: Licensee does not maintain a record for centrally stored medication. LPA interviewed Administrator and reviewed medication log sheets for R1. This allegation refers to alleged inaccurate medication logs sheets regarding central stored medication for R1. Based on interview and record review, it was determined that medication log sheets for December 2022 were inaccurate in that medication Hydroxizine was noted on the log sheet for R1 and initialed by facility staff as given to R1, however, medication did not contain a written order from Physician and should not have been included on the log sheet as a result. Additionally, based on medication count and review of medication logs, medication Trazodone had 19 pills present in a bottle which should have contained 22 pills, and medication Atrovastatin contained 21 pills in a bottle which should have contained 22 pills, resulting in inaccuracies of R1’s medication records. As a result, the preponderance of evidence standard is met and this allegation is SUBSTANTIATED. As a result of this allegation, citations are issued under Title 22, Division 6 and listed on LIC 9099D. An exit interview was conducted with Orchid Damrichob and a copy of this report was provided to Orchid. Appeal rights provided. Allegation #2: Staff do not assist resident with grooming. LPA conducted interviews as noted above and conduct additional facility observation. Based on observation of facility and residents, LPA observed residents to be appropriately clothed, with adequate grooming including combed hair, trimmed fingernails, and shaved hair as appropriate. No foul odors were observed by LPA. Additionally, LPA observed used grooming supplies available to staff for assisting residents as needed. Based on interviews, it was determined that residents in care have been receiving grooming assistance from staff. As a result, there is not a preponderance of evidence to conclude resident is not receiving regular bathing assistance, and this allegation is UNSUBSTANTIATED. Allegation #3: Staff are not safeguarding resident’s personal belongings. Allegation referred to R1’s personal belongings as indicated by an allegation of R1 wearing another resident’s clothing item. Based on interview and record review, it was determined that R1 had worn a clothing item purchased by facility staff after R1’s admission. LPA observed item and receipt of purchase to concur item was purchased after admission. Based on review of R1’s inventory sheet, it was determined that R1’s items have been accounted for. As a result, there is not a preponderance of evidence to conclude facility did not ensure safeguarding of R1’s personal property during R1’s residency, therefore, this allegation is UNSUBSTANTIATED. An exit interview was conducted with Orchid Damrichob and a copy of this report was provided to Orchid. Appeal rights provided.the state’s words, verbatim · CDSS document, Mar 23, 2023 · control 27-AS-20230118124439

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Mar 24, 2023

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.the state’s words, verbatim · CDSS document, Mar 23, 2023

Plan of correction: Licensee will ensure completed staff training on assisting residents with medications and physician’s orders. Training date to be submitted to LPA by POC due date, with training to be completed no later than 2 weeks after the date of citation issuance. Proof of completed training to be submitted prior to citation clearance.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Mar 24, 2023

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.the state’s words, verbatim · CDSS document, Mar 23, 2023

Plan of correction: Licensee will submit a plan outlining facility’s procedures on proper on-going observation of residents in care. Plan to be submitted to LPA by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87506(a) · Plan of correction due date: Mar 24, 2023

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.the state’s words, verbatim · CDSS document, Mar 23, 2023

Plan of correction: Licensee will ensure completed training on maintaining appropriate medication records. Training date to be submitted to LPA by POC due date, with training to be completed no later than 2 weeks after the date of citation issuance. Proof of completed training to be submitted prior to citation clearance.

Type of visit: Case Management - Other

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.the state’s words, verbatim · CDSS document, Mar 23, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Mar 24, 2023

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.the state’s words, verbatim · CDSS document, Mar 23, 2023

Plan of correction: Licensee will read regulation 87468.1(a)(2) and submit a signed declaration of understanding to LPA by POC due date. Licensee and staff will complete training on infection control practices. Training date to be submitted to LPA by POC due date. Proof of completed training to be submitted to LPA no later than 2 weeks after date of citation issuance.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87405(h)(5) · Plan of correction due date: Mar 24, 2023

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.the state’s words, verbatim · CDSS document, Mar 23, 2023

Plan of correction: Licensee and staff will ensure completed training on safe medication handling procedures and physician orders. Training date to be submitted to LPA by POC due date. Proof of completed training to be submitted to LPA no later than 2 weeks from date of citation issuance. Licensee will read regulation 87405(h)(5) and submit a signed declaration of understanding to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Apr 3, 2023

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.the state’s words, verbatim · CDSS document, Mar 23, 2023

Plan of correction: Licensee will read regulation 87211(a)(1)(D) and submit a signed declaration of understanding to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87463(a) · Plan of correction due date: Apr 3, 2023

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.the state’s words, verbatim · CDSS document, Mar 23, 2023

Plan of correction: Licensee will read regulation 87463(a) and submit a signed declaration of understanding to LPA by POC due date.

Type of visit: Post Licensing

On 8-2-22 at 10:13am, Licensing Program Analyst ( LPA) Michael Bilger arrived at this facility unannounced to conduct a post licensing visit.. LPA was greeted by Administrator Orchid Damrichob and LPA explained the purpose of the visit. Upon entry, it was observed that Staff1 (S1) was not wearing a face mask. Additionally, based on interview, it was determined that Staff2 (S2) contracted COVID which has not yet been reported to Licensing department. LPA Bilger inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside backyard of the facility to ensure compliance with Title 22 regulations. Facility is a 6-bed residential care facility for the elderly with a current census of 6. LPA was screened upon entry for temperature and asked to sign in. COVID screening questions were asked prior to entry. Facility has 3 bedrooms and 2 bathrooms. There is a formal living room and family/TV room for residents. All knives, toxins, and other chemicals were inaccessible to residents in care. "See something, Say something" poster was in place. Resident rights and rights of resident council notices posted. Emergency disaster plan and facility sketch updated and posted. The facility has submitted a COVID mitigation plan. The facility has central entry point and has implemented screening and sign in procedures at the front door area. The facility conducts routine symptom screening for employees, residents, and visitors. LPA observed the facility to have hand washing, COVID - 19 informational, and social distancing signs posted throughout the facility, on the front door, and back yard. The facility has a designated infection control lead. The facility is able to designate and dedicated a Covid-19 room/bathroom if needed. Common touch surfaces are cleaned after each use. Refrigerator temperature measured at 40*F. Freezer temperature measured at 0*F. Water temperature reads between 105*F and 120*F in the bathrooms and room temperature reads 74*F. LPA observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Facility has an emergency food and water kit. Fire extinguisher is fully charged and dated 2/11/22. Administrator certificate expires 2/28/2024. Per California Code of Regulations, Title 22, deficiencies were observed during this visit and noted on 809D. Exit interview was held and a report was given to Administrator Orchid Damrichob. Appeal Rights provided.the state’s words, verbatim · CDSS document, Aug 2, 2022

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Prelicensing

On 04/27/2022 at 9:00 am Licensing Program Analysts (LPAs) T. White and R. Campbell arrived announced to conduct a prelicensing inspection with applicant Paolo Gesmundo for this residential facility application. Administrator Certification for Paolo Gesmundo is #6062559740 that expires on 02/28/2024. LPAs conducted an inspection of facility including common areas, resident bathrooms, kitchen, dining room, storage, and outside yard area. Requested capacity is 6 residents, which 2 may be on hospice. The facility is clean and in good repair in areas toured. No hazards were noted in courtyard areas, hallways, doorways, etc. No equipment was stored in public areas. Fixtures and furniture all appear to be in good condition. Cleaning solutions are stored separately from food and are secured. There are no bodies of water on the premises. Smoke alarm was tested and operational. Fire extinguisher was in compliance and serviced February 11, 2022 and facility has carbon monoxide detectors. Adequate number of bedrooms (6) for capacity requested. Facility has supply of bedding and towels. Furniture appears appropriate in bedrooms. There is adequate closet/drawer space available. There are plenty of bathrooms for number of residents. Non-skid surfaces/mats were noted in the shower. Kitchen appears to be clean, well supplied with equipment. Facility has current staff files and adequate supply of forms. First aid kit was present at the facility. Laundry equipment present, working telephone, emergency lighting. Water temperature was measured at 119 and 116 degrees F. LPAs conducted Component III presentation. Exit interview conducted and copy of this report was provided to applicant for signature. Report sent to the applications unit as this facility is ready for licensure.the state’s words, verbatim · CDSS document, Apr 27, 2022

Type of visit: Office

On 03/16/2022 applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed the understanding of the California Code Title 22 Regulations. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Mar 16, 2022