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Inspection visit

Incident investigation

MADISON SQUARE SENIOR LIVING IILicense 3450029403 citations on this visit
3 citations recorded

Inspector’s narrative

What the inspector wrote

Licensing Program Analyst (LPA) Cassie Yang arrived to the facility to conduct a case management visit regarding three incident reports the Department received. LPA met with Caregiver and explained the purpose of the visit. Administrator then arrived to the facility shortly afterwards. The first incident report was regarding R1 who left the facility unsupervised at approximately 5:30AM and was found an hour later by local law enforcement. The date of occurrence was 06-15-2024, which the Department was not notified until 10-01-2024. Note that facility was cited on 12-14-2023 and 9-19-2024 for failing to met reporting requirements. The second incident report occurred on 09-21-2024 regarding R1 again who left the facility unsupervised at approximately 2:20pm and was found by local law enforcement at approximately 3:40pm. Base on file review of R1's LIC 602A Physician's Report for Residential Care Facilities for the Elderly, it revealed R1 cannot leave the facility unassisted. The third incident report occurred on 09-25-2024 regarding R2 was transported to the emergency room as R2 was out of three medications, which R2 returned to the facility with new prescriptions orders. Based on interview conducted with Administrator revealed the empty bottles were placed to the side as a reminder for refills but was left forgotten. File review of R2's Centrally Stored Medication and Destruction Record revealed Gabapentin was refilled 7-22-2024, a month worth supply, and then the next refill was on 9-26-2024. LPA observed medication for 8-22-2024 to 9-25-2024 to be missing. As a result, please see LIC 809-D for the deficiencies observed today. Additionally, $250 civil penalty assessed as reporting requirement violation was recently cited within a 12 month period. Exit interview and a copy of report and appeal rights provided.

Citations

3 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.

  • 1569.312(d)Type A

    §1569.312 Basic services requirements Every facility required to be licensed under this chapter shall provide at least the following basic services: (d) Being aware of the resident's general whereabouts, although the resident may travel independently in the community.This requirement is not met as evidenced by: Based on file review, Licensee did not comply with the section cited above as R1 was reported to AWOL twice within this year which LIC602 stated R1 cannot leave facility unassisted, which poses an immediate risk for residents in care.

  • 87211(a)(1)(D)Type B

    87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (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 of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.This requirement is not met as evidenced by: Based on file review, Licensee did not comply as LPA did not receive an incident report for R3 on an incident occuring on 9-16-2024 and receiving an incident report for R1 which occurred approximately three months prior to reporting to CCLD which poses a potential risk for residents in care.

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  • Assist residents with self-administered medication

    87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:(4) The licensee shall assist residents with self-administered medications as needed.This requirement is not met as evidenced by: Based on file review and interview, Licensee did not comply to the section above as it was observed that R2 was out of three medication refills for approximately a month prior to being sent out to the hospital for new refill orders which poses an immediate risk for residents in care.

FAQ · About this visit

Common questions about this visit

What happened during the October 7, 2024 inspection of MADISON SQUARE SENIOR LIVING II?

This was an other inspection of MADISON SQUARE SENIOR LIVING II on October 7, 2024. 3 citations were issued: 2 Type A (serious) and 1 Type B.

Were any citations issued to MADISON SQUARE SENIOR LIVING II on October 7, 2024?

Yes, 3 citations were issued (2 Type A, 1 Type B). The first citation was for: "§1569.312 Basic services requirements Every facility required to be licensed under this chapter shall provide at least t..."

What type of inspection was this?

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

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