Aegis of Madison

The facility failed to implement systems to promote safe medication services for four residents, resulting in them not receiving medications as prescribed.

Facility failed to provide documentation for annual inspection of fire resistance rated construction; wall penetrations found in 1st floor activity room and tel/comm room.

Theater room had an extension cord connected to a power strip; IT room in basement has a power strip plugged into a power block.

Waffle maker on top of an unused grill under kitchen hood was plugged into an extension cord.

Electric space heater plugged into a power strip instead of directly into an electrical receptacle.

Missing documentation for annual report, annual forward flow test, and 5-year hydrostatic test. Sprinkler heads loaded with debris in memory care (outside room 218) and kitchen dinette.

Failed to provide documentation showing kitchen suppression system is being tested semi-annually.

Failed to provide annual report and sensitivity test documentation for smoke detectors.

Failed to provide documentation showing 30 second exit signs and emergency light test.

Failed to provide documentation for carbon monoxide alarms tests.

Failed to provide documentation showing 1.5 hour power test of all exit signs and emergency lights.

Staff lounge egress door had multiple locking straps (straps have been removed).

Failed to provide annual report, log of weekly inspections, and log of monthly load tests for generator.

6th floor laundry emergency light failed to operate; Memory care patio has two non-working exit signs; Generator room emergency light failed to operate.

Room 314 had an unsecured oxygen tank.

Failed to provide documentation for annual fire door inspection. 6th floor laundry door did not latch; Basement laundry door missing handle.

Fire drills shall be conducted once per shift per quarter and documentation for the last 12 months shall be maintained.

The facility failed to ensure 2 of 6 sampled staff had required food worker cards, and 1 staff member obtained their card 29 days after hire, exceeding the 14-day requirement.

The facility failed to ensure 4 of 4 staff had required work reference checks before hire.

The facility failed to have screening for tuberculosis through approved methods for 4 of 4 staff within three days of employment.

The facility failed to ensure 3 of 4 staff completed required facility orientation and training.

Facility failed to ensure 2 of 5 sampled residents received medications as prescribed due to no licensed nurse on duty in the evenings of 07/20/2025 and 07/21/2025. Resulted in missed insulin/blood sugar checks for Resident 1 and a missed pain patch application for Resident 2.

The licensee failed to ensure two residents who required medication administration received their medication as prescribed, placing them at risk of harm. This is a recurring deficiency previously cited on February 23, 2024, and September 27, 2024.

Missing documentation for annual fire door inspections and testing schedule.

Missing documentation/inventory and inspection schedule for fire-rated construction.

Missing documentation for monthly testing and maintenance of carbon monoxide alarms.

Missing documentation for monthly 30-second activation testing in resident rooms.

Missing documentation for annual 90-minute battery power testing in resident rooms.

Annual inspection schedule for fire doors not established and documented.

Annual inspection schedule for fire-resistance-rated construction not established.

Carbon monoxide alarms and detectors not tested and documented on a monthly schedule.

Monthly 30-second activation testing not performed or documented for resident rooms.

Annual 90-minute power test not performed or documented for resident rooms.