Inspection Reports for Madison Square Senior Living

A case management visit was conducted to review facility compliance, discuss outstanding issues including building alterations without permits, administrator hiring status, and annual fee payments.

A deficiency was noted due to alterations made without a required building permit. Other issues discussed included maintaining and updating care plans and training for resident conditions.

The inspection was an unannounced annual inspection conducted to ensure compliance with health, safety, and licensing regulations at Madison Square Senior Living Facility.

The inspection found no immediate health, safety, or personal rights violations during the facility tour. However, deficiencies were cited related to resident participation in decision-making, specifically the failure to update reappraisals/service plans within 12 months for 3 of 4 residents reviewed.

The visit was conducted as a follow-up on the March 27, 2025 visit to investigate an incident involving resident R1's fall with injury requiring hospitalization and subsequent death.

The investigation found deficiencies including lack of adequate supervision for R1, failure to meet prescribed care needs, medication administration errors, and absence of a signal system for resident assistance. Two Type A deficiencies were cited posing immediate health and safety risks, and a $500 civil penalty was assessed.

The inspection was conducted as a case management visit following receipt of an incident report regarding a resident's fall with injury requiring hospitalization and subsequent death.

No deficiencies were noted during the inspection. The Licensing Program Analyst reviewed records and requested additional documentation to be submitted by a specified date.

The inspection was conducted as a case management visit to review the facility's process of increasing non-ambulatory capacity for an additional room that was previously ambulatory only.

The Licensing Program Analyst inspected the home to ensure ambulatory occupancy in the room under review and confirmed that fire safety measures are in place. The licensee is still completing Fire Marshal requirements for the increase. No deficiencies were noted during the inspection.

An in-office non-compliance conference was held to discuss recent compliance history and develop a non-compliance plan with the licensee.

A non-compliance plan was developed and agreed upon by the licensee. No new citations were issued as a result of the meeting.

The visit was conducted as a Plan of Correction (POC) follow-up to verify compliance with previously issued citations related to medical assessments.

The facility had not completed updated LIC 602 forms for identified residents nor scheduled appointments for physical assessments as required. No additional deficiencies were noted during this visit, but civil penalties continue to accrue due to failure to correct prior citations.

The inspection was an unannounced Required-1 Year Inspection conducted to ensure compliance with Title 22 regulations for the care home.

The facility was generally compliant with regulations, including proper furnishing, sanitation, food storage, and safety measures. However, one deficiency was cited related to medical assessments where physical examinations were not conducted for 2 of 5 resident files reviewed.

The visit was an unannounced office meeting conducted remotely to discuss recent compliance issues and review plans of correction from prior visits dated 10/31/23 and 11/17/23.

The licensee is currently in compliance with regulatory requirements, and no deficiencies were cited during this meeting. Technical Support Program consultation was offered and accepted to assist with medication administration and other issues.

The inspection visit was conducted as a Plan of Correction (POC) inspection to verify correction of deficiencies issued on 10/31/2023 related to incomplete resident and staff files.

The Licensing Program Analyst reviewed 4 resident files and 2 staff files and found all files complete for required documents. No deficiencies were cited as a result of this visit, and the plans of correction were cleared.

The inspection visit was conducted as a Plan of Correction (POC) inspection for deficiencies issued on 10/31/2023, to verify correction of cited deficiencies including fire clearance and criminal record clearance violations.

Clearance issues for staff have been resolved, but one resident (R2) continues to reside in a room cleared only for ambulatory residents, posing an immediate risk. Annual fees remain unpaid, resulting in a citation. The administrator is still correcting resident and staff file issues with a plan of correction due by 11/21/2023.

The inspection was an unannounced annual inspection conducted to ensure compliance with health and safety regulations using the CARE inspection tool.

The inspection found multiple deficiencies including a non-ambulatory resident residing in an ambulatory-only room, incomplete resident and medication files, incomplete staff files lacking required criminal record clearances, and staff not having completed required training. Plans of correction were established with due dates.

The visit was an unannounced required Annual Inspection conducted by the Licensing Program Analyst to assess compliance with regulations and facility conditions.

The facility was found to be in good repair with no citations issued. All required safety, health, and emergency equipment were present and functioning properly. The facility had no COVID-19 cases to date and infection control protocols were followed with no issues.

The visit was conducted as an annual required and post licensing inspection of the Madison Square Senior Living Facility.

No deficiencies were cited during the post licensing visit.

The inspection was a Required-1 Year unannounced visit to conduct an annual inspection focusing on the infection control domain.

The facility was found to be in substantial compliance with no immediate health, safety, or personal rights violations observed. No deficiencies were cited during the inspection.