Inspection Reports for
Sky Park Gardens

The visit found one Type B deficiency related to resident personal rights and supervision following an incident where a dementia resident pushed another resident causing injury. Facility had ongoing roof leaks causing water damage and potential safety hazards. The facility was requested to submit delayed egress fire clearance verification by 1/2/2026.

The facility was found to have ongoing maintenance issues including roof and patio repairs, mold and asbestos contamination in resident rooms, fire safety deficiencies such as a non-operational light fixture in the fire exit stairwell, and insufficient administrator oversight. Some deficiencies had cleared plans of correction, while others required further remediation and updates.

The complaint alleging staff did not ensure resident's medication was provided was substantiated based on interviews and record reviews. The delay in medication delivery and failure to document administration were confirmed.

The investigation substantiated the allegation that staff failed to provide scheduled medication to resident 3 on 11/3/2025, with the medication administered late on 11/7/2025 and not recorded on the Medication Administration Record (MAR). This posed an immediate/potential health risk to residents.

The inspection identified multiple deficiencies including fire safety issues with sprinkler system and water gong not in good repair, failure to conduct quarterly fire drills for each shift, medication administration record discrepancies, lack of proper medication labeling, incomplete medication dosage records, and absence of regular food service consultations.

The complaint investigation was triggered by multiple allegations received on 12/23/2024, including failure to provide transportation to medical appointments, failure to meet dietary needs, pest control issues, untimely response to resident calls, and illegal eviction. The allegation of facility disrepair was substantiated, while all other allegations were unsubstantiated.

The investigation substantiated the allegation that the facility was in disrepair with maintenance issues such as leaking faucets and ceiling leaks. All other allegations including failure to provide transportation, meal service, pest control, timely response to calls, and illegal eviction were unsubstantiated based on interviews, record reviews, and observations.

The inspection found several deficiencies including five out of six fire extinguishers being expired, one resident bathroom sink faucet lacking hot water, absence of a grab bar in one resident bathroom, and failure to conduct quarterly emergency drills since COVID. The facility was otherwise observed to be clean and well-maintained with proper medication storage and secure outdoor areas.

The inspection found multiple deficiencies including five out of six fire extinguishers being expired, one resident bathroom sink faucet lacking hot water, absence of a grab bar by the toilet in one resident bathroom, and failure to conduct quarterly emergency drills since COVID. Technical advisories were also provided for minor repairs and cleaning.

The complaint investigation was substantiated based on observations of rat feces in rooms #136, 145, and 146, and unclean conditions including dirty carpet and debris on floors. The licensee did not ensure a clean and healthful environment.

The investigation found substantiated evidence of a rodent infestation with rat feces observed in multiple resident rooms and the facility being unclean, posing a potential health and safety risk to residents.

The complaint investigation was substantiated based on observations of rodent infestation and unclean conditions. The preponderance of evidence standard was met.

The investigation found substantiated evidence of a rodent infestation and unclean conditions, including rat feces in multiple resident rooms and dirty carpets, posing a potential health and safety risk to residents.

The complaint was substantiated. The allegation was that staff failed to treat residents with dignity and respect. Interviews with residents and staff were conducted, with 6 out of 10 residents confirming concerns and all staff denying the allegations. The Department found the allegations valid based on the preponderance of evidence.

The investigation found that 6 out of 10 residents interviewed had concerns about staff not treating residents with dignity and respect, including staff entering rooms without knocking, leaving lights on, and not closing doors. Facility staff denied these allegations. The complaint was substantiated based on the preponderance of evidence.

The complaint was substantiated based on interviews with 10 residents and 10 staff. Six residents expressed concerns about staff behavior related to dignity and respect. Staff denied the allegations. The preponderance of evidence supported the complaint.

The investigation substantiated the complaint that facility staff failed to treat residents with dignity and respect. Interviews with residents revealed that 6 out of 10 residents reported staff entering rooms without knocking, turning on lights without turning them off, and not shutting doors, posing potential health and safety risks.

The visit was in response to a complaint investigation (control number: 27-AS-20230802083802) where Resident #1 reported water being too hot in their room, confirmed by measurements exceeding regulatory limits.

The inspection found that the resident bathroom sink water temperature measured at 128.5°F, exceeding the regulatory limit of 120°F, posing a potential health and safety risk to residents. A deficiency was cited for failure to maintain water temperature within required regulations.

The visit was in response to a complaint investigation (control number: 27-AS-20230802083802) where Resident #1 reported water being too hot in their room, confirmed by measurements exceeding regulatory temperature limits.

The inspection found that the resident bathroom sink water temperature measured at 128.5°F, exceeding the regulatory limit of 120°F, posing a potential health and safety risk to residents.

The complaint alleged that a resident was assaulted by another resident while in care. The allegation was substantiated based on resident medical and file reviews, and facility incident reports.

The investigation found that despite facility staff efforts to separate potentially combative residents, an altercation occurred on 11/18/2022 where one resident assaulted another. The allegation was substantiated with no injuries sustained by the assaulted resident.

The complaint was substantiated. The allegation was that a resident was assaulted by another resident while in care. The investigation included review of resident medical records, facility incident reports, and interviews. The preponderance of evidence standard was met.

The investigation substantiated the allegation that a resident was assaulted by another resident. The facility staff attempted to intervene and separate residents to prevent altercations, but an assault occurred on 11/18/2022. No injuries or fractures were sustained by the assaulted resident.

The licensing evaluator found that the previously cited deficiencies under Title 22 Regulations had been cleared and the licensee complied with the terms of the POC by the due date. However, a new citation will be issued for failure to request an exception for a resident with a prohibited health condition.

The facility corrected the previously cited deficiencies under Title 22 Regulations and complied with the terms of the POC by the due date. However, a new citation will be issued for failure to request an exception for a resident with a prohibited health condition.

The inspection found the facility generally compliant with infection control, safety, and documentation requirements, but noted deficiencies including expired medication, incomplete medication signing, lack of updated assessments for dementia residents, and failure to follow up on a resident's pressure injury leading to hospitalization.

The facility was inspected for physical plant conditions, infection control, staff certifications, and resident care documentation. Deficiencies were found related to expired medication, incomplete medication signing, outdated assessments for residents with dementia, and failure to provide timely treatment for a resident's pressure injury, posing immediate risk to resident health and safety.