AEGIS OF MADISON.

WAC 388-78A-2450: The facility failed to verify work references prior to hiring for 4 of 4 staff members (Staff B, C, D, and E). Staff B had no application or resume on file, Staff C had only one of two employers checked, and Staff D and E had references checked without documentation of dates. These failures placed residents at risk of receiving care from staff without verified work history. WAC 388-78A-2474: The facility failed to ensure 3 of 4 staff (Staff B, D, and E) completed required facility orientation and training before working with residents. Staff B had no documentation of orientation, Staff D received orientation after already working with residents, and Staff E completed orientation 14 days after starting work with residents. This placed residents at risk of receiving care from untrained staff.

WAC 388-78A-2210: Resident 1 did not receive insulin injections (Humalog Kwikpen and Basagler Kwikpen) as prescribed at 9:00 PM on 07/21/2025 due to no nurse being available at the facility. Resident 1 also missed blood sugar check documentation. WAC 388-78A-2210: Resident 2 did not receive a fentanyl pain patch applied as prescribed on 07/20/2025 due to no nurse being available at the facility.

—: The facility failed to have medication available for the named resident, resulting in three missed doses of ordered blood pressure medication.

WAC 388-78A-2305: The facility failed to ensure medication was administered as ordered for a resident with diabetes. Insulin was administered when blood glucose levels were below 100 mg/dL on 18 occasions in August 2024 and 2 occasions in September 2024, contrary to the prescription order to hold if blood glucose <100. This placed the resident at risk for compromised safety and health complications. WAC 388-78A-3100: The facility failed to identify and secure hazardous chemicals and equipment. Unsecured chemical bottles (Pledge stainless steel polish, ammonia glass cleaner, peroxide multi-surface spray) were found in an unlocked cabinet in the Sky Lounge accessible to all residents, and an oxygen tank was found unsecured in a resident room. This placed 84 residents at risk for harm and poisoning.

—: The facility failed to follow medication policy and procedures when a resident returned from leave with narcotics not accounted for, and when the facility dispensed routine medications in nine envelopes for the resident's leave. —: The facility failed to provide medication as ordered by the physician when it gave the wrong dose of pain medication on two consecutive days to a named resident.

—: The assisted living facility posted and emailed a photo of a resident without written consent from the resident or their collateral contact, violating the resident's right to privacy.