Aegis of Madison

Two residents failed to receive physician-ordered medications as prescribed, creating risk of harm. This represents a severe violation given the fundamental failure in medication administration - a core assisted living function - and constitutes the third occurrence of this deficiency (previously cited February and September 2024), indicating a systemic pattern. The facility's response appears inadequate, as evidenced by the recurring nature of violations and imposition of a $500 civil fine, suggesting previous corrective actions failed to prevent recurrence.

This facility had multiple fire safety and life safety code violations across fire doors, fire-rated construction, emergency lighting, carbon monoxide detection, sprinkler system maintenance, and oxygen storage. Violations included non-functional fire doors, missing inspection documentation for critical systems, corroded sprinkler heads, improperly secured oxygen tanks near combustibles, and lack of required monthly/annual testing records. The facility responded with investigations and some corrective actions but required multiple re-inspections (February, May, June 2025) before achieving compliance, indicating delayed and incomplete initial response. The pattern of documentation failures across multiple life-safety systems and need for repeated follow-up inspections demonstrates systemic compliance gaps, though no immediate resident harm was documented.

The facility failed to obtain blood pressure medication when it ran out, resulting in the named resident missing three doses of a critical cardiovascular medication. This represents a pattern of behavior as the report notes this occurred 'again,' indicating systemic issues with medication management processes. The facility's response appears incomplete, as the investigation identified failed provider practices resulting in citations, but no evidence of comprehensive corrective action or systemic changes to prevent recurrence is documented.

This residential care facility was cited for multiple serious fire and life-safety code violations including malfunctioning fire doors that would not latch, unsecured oxygen tanks in resident areas, missing fire-rated construction inspections, non-functional emergency lighting, loaded sprinkler heads, and incomplete documentation of required safety system testing. A follow-up re-inspection found that most violations remained uncorrected, demonstrating a pattern of systemic neglect of critical life-safety systems. The facility's response was inadequate, with minimal corrective action taken between inspections and continued failure to establish basic safety inspection schedules. These failures represent serious fire safety risks in a vulnerable population setting.

The facility failed to ensure timely medication availability for 2 of 4 sampled residents, resulting in multiple missed doses of critical heart and blood pressure medications for Resident 1, and magnesium supplements for Resident 2 who subsequently developed dangerously low magnesium levels creating seizure and cardiac risks. The facility had an existing medication availability policy that was not followed, and nursing staff acknowledged medications should not have run out. The facility conducted an investigation, acknowledged the deficiency, submitted a corrective action plan, and successfully corrected all violations by the follow-up inspection on 02/20/2025, demonstrating adequate but not exemplary response to a serious medication management failure.

A resident placed food in a styrofoam container in a microwave, causing a fire in the 3rd floor laundry room on 12/7/2024. Staff immediately extinguished the fire with a fire extinguisher, called 911, evacuated/checked all residents with no injuries, and ventilated the area. The facility responded promptly and appropriately by removing the microwave, reminding the resident about proper procedures, notifying all stakeholders, and implementing preventive measures. No International Fire Code violations were observed during the follow-up inspection on 12/16/2024.

The September 2024 inspection found multiple moderate violations including unsafe food temperatures in memory care (rice at 105°F, broccoli at 98.4°F vs. required 135°F+), insulin administered 20 times contrary to hold parameters when blood glucose was below 100, missing tuberculosis screenings for 2 staff within required 3-day timeframe, and unsecured chemicals and oxygen tanks accessible to cognitively impaired residents. The facility promptly acknowledged all deficiencies, implemented corrective actions, and achieved full compliance by the November 2024 follow-up inspection, demonstrating a good systematic response with staff retraining and policy reinforcement across all cited areas.

The facility had multiple medication management violations including failure to account for narcotics when a resident returned from leave, dispensing nine envelopes of routine medications for off-site use, and administering wrong doses of pain medication on two consecutive days that preceded an unwitnessed fall. The facility conducted investigations and acknowledged the failures, but the report provides no evidence of comprehensive corrective actions, staff discipline, or systemic improvements to prevent recurrence of these medication errors.

The facility violated resident privacy rights by posting and emailing a photo of a resident without obtaining written consent from the resident or their representatives. The investigation confirmed this unauthorized disclosure through record review and interviews with the resident's collateral contacts. While the facility was cited for deficient practice, the report does not detail specific corrective actions taken beyond acknowledging the violation, indicating a moderately adequate but incomplete response to the privacy breach.

The facility failed to notify the physician when the resident exhibited a pattern of refusing prescribed Latanoprost eye drops in March and April 2023, representing a procedural violation in medication management protocols. The facility appropriately assessed the resident as unsafe for self-medication and continued to offer the eye drops as prescribed, but did not follow required physician notification procedures for repeated medication refusals. While no immediate harm occurred and the facility maintained appropriate medication offering practices, the gap in physician communication could affect treatment plan adjustments and represents incomplete care coordination.

This residential care facility had 17 violations identified during March 2023 inspection, including critical life-safety systems failures: incomplete sprinkler system testing/maintenance, non-functional fire alarm (in trouble status), blocked sprinkler access, compromised fire doors and fire-rated barriers, improper fire drill procedures, and missing emergency lighting testing. The facility demonstrated a good response by correcting all violations within two months, achieving full approval status by the May 2023 follow-up inspection, though the systemic nature of the maintenance and documentation failures across multiple fire protection systems indicates significant operational deficiencies that required comprehensive remediation. The presence of unsecured oxygen cylinders (1,100 cubic feet) and multiple fire safety system gaps created substantial resident safety risks prior to correction. All deficiencies were verified as corrected by the re-inspection, demonstrating adequate follow-through on required improvements despite the initial severity of findings.</response>=

The facility had three moderate compliance violations: inadequate fall/pain monitoring plans for a resident with chronic pain and fall history, unsecured hazardous chemicals accessible to cognitively impaired residents in multiple locations, and incomplete respiratory protection program implementation affecting five staff members during COVID-19. The facility acknowledged all deficiencies, submitted correction plans with a March 26, 2023 completion date, and successfully corrected all violations as verified by follow-up inspection on April 6, 2023, demonstrating adequate corrective action and compliance restoration.