Madison Square Senior Living

Regular observation and documentation of resident changes

Observation of the Resident- The licensee shall ensure that residents are regularly observed for changes in ... and that appropriate assistance is provided when such observation reveals unmet needs. When a physical health condition are observed, the licensee shall ensure that such changes such as unusual weight gains or losses or deterioration of mental ability or changes are documented and brought to the attention of the resident's physicial. This requirement was not met based on report, interview and records review. This posed an immedicate risk to R1.

Requirement for building permit before construction

Alterations to Existing Building or New Facilities (a) Prior to construction or alterations, all facilities shall obtain a building permit. This requirement was not met based on statements and records. This posed a potential risk

Review and revise record after changes

Based on record review, the licensee did not comply with the section cited above in 3 of 4 residents R1, R2, R4, did not have reappraisals/ service plans within 12 months, which poses/posed a potential health, safety or personal rights risk to persons in care.

Night supervision when dementia residents require it

Care of Persons with Dementia (b) Licensees shall be responsible for the following: (2) For facilities with fewer than 16 residents, ensuring there is at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal, or observation, to require awake night supervision. This requirement was not met based on based on records and statements. This posed an immediate risk to R1.

Provide signal systems for large or multi-floor facilities

Maintenance and Operation (i) Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system… This requirement was not met based on observations and statements. This posed an immediate risk to residents.

Based on interview and records review, the licensee did not comply with the section cited above in 2 out of 5 resident files as a physical examination was not conducted, which poses/posed a potential health, safety or personal rights risk to persons in care.

Facility must clear fire safety for nonambulatory persons

(a) All facilities shall maintain a fire clearance approved... Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify ... (1) Nonambulatory persons.This requirement is not met as evidenced by: Based on observation and records review, the licensee did not comply with the section cited above in1 of 1 residents (R2) currently is non-ambulatory residing in a room cleared for ambulatory only which poses an immediate health, safety or personal rights risk to persons in care.This poses an immediate risk to residents.

Applicant and licensee fees are charged by statute

Licensing Fees (a) An applicant or licensee shall be charged fees as specified in Health and Safety Code section 1569.185.This requirement was not met based on records and interview.

Based on records review and interviews, the licensee did not comply with the section cited above in 2 of 2 staff (s1 and S2) do not have a clearance prior to work in the facility which poses an immediate health, safety or personal rights risk to persons in care.

Based on records review the licensee did not comply with the section cited above in 2 of 2 staff (S1 and S2) which poses/posed a potential health, safety or personal rights risk to persons in care.

Facility must clear fire safety for nonambulatory persons

Based on observation and records review, the licensee did not comply with the section cited above in1 of 1 residents (R2) currently is non-ambulatory residing in a room cleared for ambulatory only which poses an immediate health, safety or personal rights risk to persons in care.

Maintain required personnel records for staff

Based on records review, the licensee did not comply with the section cited above in 2 of 2 staff which poses/posed a potential health, safety or personal rights risk to persons in care.

Maintain records of centrally stored medication dosages

Based on records review, the licensee did not comply with the section cited above in 4 of 4 client files reviewed which poses/posed a potential health, safety or personal rights risk to persons in care.

Maintain separate complete record for each resident

Based on records review the licensee did not comply with the section cited above in 4 of 4 files reviewed which poses/posed a potential health, safety or personal rights risk to persons in care.