MADISON SQUARE SENIOR LIVING II

Official classification

Type B

Official code

1569.185(e)

Regulation authority

HSC

What the official deficiency says

§1569.185 Fees for license or applications; use of revenues; collected; denial or forfeiture (e) The failure of an applicant for licensure or a licensee to pay all applicable and accrued fees and civil penalties shall constitute grounds for denial or forfeiture of a license. This requirement is not met as evidenced by: Based on file review, Licensee did not comply to the section cited above as Licensee has an outstanding fee balance of $742 whihc poses a potential risk for residents in care.

Official plan of correction

Licensee is to submit proof of annual licensing fee payment to LPA Yang by fax and/or email. POC is due Friday May 23, 2025.

Deadline recorded: May 23, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

Same violation POC is pending which is due on 10-9-2024. Once received, LPA will clear both POC's. Additionally, LPA will update Licensee if and when office meeting will be scheduled between the Department and Licensee.

Deadline recorded: Oct 9, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

Licensee will submit a plan of facility procedure for R2's monthly medication to ensure refills are received in a timely manner. POC is due to LPA on 10-8-2024. Additionally, LPA will update Licensee if and when office meeting will be scheduled between the Department and Licensee.

Deadline recorded: Oct 8, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.312(d)

Regulation authority

HSC

What the official deficiency says

§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.

Official plan of correction

- R1 and Conservator consented to Apple AirTag on R1. - Licensee will update R1's LIC 602 with PCP and reassess R1's needs and service plan to ensure R1 gets the care and supervision needed. -Provide LPA of appointment date by POC due date Additionally, LPA will update Licensee if and when office meeting will be scheduled between the Department and Licensee.

Deadline recorded: Oct 8, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(g)(2)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements - General (g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement is not met as evidenced by: Based on observation, Licensee did not comply with the section as LPAs observed S1 to be working at the facility without a criminal clearance transfer associated to the facility, which poses a potential health and safety risk to residents in care.

Official plan of correction

Licensee completed LIC 9182 for S1. Licensee is to conduct an audit of facility roster and associate any additional staff needed to roster. Licensee is to inform LPA Yang by 10/4/2024 of completion. Failure to correct by POC due date may result to $100 civil penalty per day until received/corrected.

Deadline recorded: Oct 4, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

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 and interview, Licensee did not comply to the section cited above as Licensee stated LIC 624 was not submitted for R2 for an incident that occurred on 08/24/2024, which poses a potential risk to residents in care.

Official plan of correction

Licensee is to submit a statement of understanding of the reporting requirements of 22 CCR Section 87211. POC is due 10/4/2024, failure to provide POC by POC due date may result to $100 civil penalty per day until received/corrected.

Deadline recorded: Oct 4, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

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 interview, Licensee did not comply with the section cited above as Licensee did not submit an incident report for R1 to Licensing as discussed on 12/6/2023, which poses a potential risk to residents in care.

Official plan of correction

-Licensee will submit the requested LIC 624 for R1 to LPA Yang. -Additionally, Licensee will review CCR 87211 Reporting Requirement and notify LPA once completed. - POC is due by Friday, December 22, 2023.

Deadline recorded: Dec 3, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.605

Regulation authority

HSC

What the official deficiency says

§1569.605 Liability insurance; coverage requirements On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. This requirement is not met as evidenced by: Based on interview, Licensee did not comply with the section cited above as Administrator informed LPA via email that facility does not have liability insurance, which poses a potential risk to residents in care.

Official plan of correction

Licensee was provided a physcial copy of license. Licensee will submit proof of facility liability insurance to LPA Yang by January 5, 2024.

Deadline recorded: Jan 5, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87309(a)(1)

Regulation authority

CCR

What the official deficiency says

87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above as LPA and Administartor observed two kitchen knives to be stored in an unsecured drawer which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/07/2023 Plan of Correction Knives were retrieved and locked immediately. Licensee will submit a statement of compliance that all dangerous items will be stored immediately after usage. Statement is due to LPA Yang by 5PM December 7, 2023.

Official classification

Type A

Official code

87202(a)(1)

Regulation authority

CCR

What the official deficiency says

87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. (1) Nonambulatory persons. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and file review, the licensee did not comply with the section cited above in 2 out of 4 non-ambulatory residents are residing in an ambualtory only room which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/07/2023 Plan of Correction Administrator will assist in relocating R2 and R3 to non-ambulatory approved rooms in the facility. This matter will be discussed with management for additional assistance if R2 and R3 are not willing to relocate to shared bedrooms.

Official classification

Type A

Official code

1569.618(c)(3)

Regulation authority

HSC

What the official deficiency says

1569.618 Administration and management of residential care facilities; substituted qualifications; employee scheduling Date Composed: 07/15/2010 Effective Date: §1569.618 Administration and management of residential care facilities; substituted qualifications; employee scheduling (c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by: Deficient Practice Statement Based on file review, the licensee did not comply with the section cited above as LPA observed no first aid training and no CPR training on file, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/07/2023 Plan of Correction Administrator will submit a compliance statement to LPA Yang by 5PM, December 7, 2023. Proof of CPR and First Aid certification is to be submitted to LPA Yang by Friday December 22, 2023.

Official classification

Type A

Official code

1569.17(b)(1)(B)

Regulation authority

HSC

What the official deficiency says

§1569.17 Fingerprints and criminal records of individuals in contact with clients; exemptions; criminal records clearances (b) In addition to the applicant, the provisions of this section shall apply to criminal record clearances and exemptions for the following persons: (1) (B) Any person, other than a client, residing in the facility. Residents of unlicensed independent senior housing facilities that are located in contiguous buildings on the same property as a residential care facility for the elderly shall be exempt from these requirements. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview, the licensee did not comply with the section cited above as LPA observed 1 of 2 staff working at the facility without a criminial record clearance which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/07/2023 Plan of Correction Licensee will submit proof that S1 have moved from the home untill criminal record clearance is received. Licensee will also submit a LIC 500 to confirm adequate staffing, submit the following to LPA Yang by 5PM, December 7, 2023

Official classification

Type B

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by: Deficient Practice Statement Based on file review, the licensee did not comply with the section cited above as LPA observed 4 of 4 resident files to be incomplete, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/03/2024 Plan of Correction LIC 311F was previously provided. POC visit will be conducted to confirm completion.

Official classification

Type B

Official code

87412(a)(11)

Regulation authority

CCR

What the official deficiency says

87412 Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General. This requirement is not met as evidenced by: Deficient Practice Statement Based on file review, the licensee did not comply with the section cited above as LPA observed no LIC 503 present for S1 and S2 which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/03/2024 Plan of Correction POC visit will be conducted to confirm completion.

Official classification

Type B

Official code

87468(c)(2)(A)

Regulation authority

CCR

What the official deficiency says

87468 Personal Rights (c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20 " x 26 " in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above as LPA observed PUB 475 to be missing from facility which was discussed during pre-licensing inspection, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/03/2024 Plan of Correction POC visit will be conducted to observe proof of correction.