Residence at Skyway Park LLC, the

A complaint revisit was completed on 11/18/25 for all previous deficiencies cited on 6/3/25. Deficiencies were cited. The regulations governing Assisted Living Residences were revised. The new Chapter VII regulations were implemented on 7/1/25.The deficiencies cited for Event 8BP412 were cited prior to the regulation revisions that were implemented on 7/1/25. Based on record review and interview the residence failed to ensure that only medications ordered by an authorized practitioner were prepared for and administered to residents, affecting three of five sample residents (#29-#31). (Cross Reference U1568)This deficiency was cited previously during a complaint investigation that concluded on 6/3/25. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:1. Resident #31 was admitted to the residence on 2/2/21.The October 2025 and November 2025 medication administration records (MAR) had the following medications listed and were being administered with no signed and dated practitioners' orders on file: clopidogrel, o.. Based on record review and interview, the residence failed to ensure staff documented, before the end of their shift, any out-of-the-ordinary event or issue regarding a resident that they personally observed, or was reported to them, affecting four of six residents whose environment was viewed. (#14, #23, #28, #30)This deficiency was cited previously during a complaint investigation that concluded on 6/3/25. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:On 11/18/25 at 2:40 p.m., during an environmental review of Resident #30 and Resident #32 ' s room, there were three black trash bags on the ground in the living room area. On one of the trash bags, there was a note that read, "Please .. Based on record review and interview, the residence failed to ensure that each qualified medication administration person (QMAP) accurately documented each medication administration event at the time the event was completed for each resident, affecting 48 current residents. This deficiency was cited previously during a complaint investigation that concluded on 6/3/25. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:1. Resident #29 was admitted to the residence on 7/19/15. On 11/18/25 at approximately 8:00 a.m., the medication administration record (MAR) for Resident #29 was signed off as administered by Staff #5; however, Staff #5 was in the process of dispensing.. Based on records review and interviews, the residence failed to comply with authorized practitioner orders for three of five sample residents (#4, #23, and #27) with medication compliance issues found. This deficiency was cited previously during a complaint investigation that concluded on 6/3/25. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings Include:Resident #27 was admitted to the residence on 11/1/15 with diagnoses of chronic obstructive pulmonary disease (COPD), insomnia, constipation, seizures, hypokalemia and autonomic neuropathy. A practitioner' s order, dated 9/22/25, directed the residence to administer to Resident #27 two inhalations of tiotropiu..

A certification complaint, prompted by #CO41081 was completed on 11/18/25. Deficiencies were cited. Based on interview and record review, the facility (residence) failed to provide sufficient support to members (residents) in the use of prescription and non-prescription medications, affecting five of nine sample residents (#3, #4, #23, #27, and #31).This deficiency was cited previously during a complaint investigation that concluded on 6/3/25. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Administration of medications without authorized practitioner' s orders.a. Resident #31 was admitted to the residence on 2/2/21.The August 2025 and September 2025 medication administration records (MAR) had the following medications listed and were being administered with no signed and dated practitioners' orders on file: ferrous gluconate, preserVision, and tamsulosin HCl.b. Similar deficient practice was found for Resident #3. Additionally, Resident #3' s MAR did not match the signed and dated practitioner orders provided.c. InterviewOn 9/16/25 at 1:06 p.m., the resident care coordinator acknowledged they did not have all the practitioners' orders for the medications being administered by the residence. He explained that the residence received the medication orders from the practitioner, and what was liste.. Based on record review and interview, the facility (residence) failed to meet minimum staffing numbers affecting 49 current members (residents).Findings include: 1. Record Review The staff schedule for October and November 2025 revealed that there were fewer than one staff member for every 16 members during the overnight shift for the following dates: 10/1/25-10/31/25 from 10:00 p.m. to 6:00 a.m.11/1/25-11/18/25 from 10:00 p.m. to 6:00 a.m. 2. Interviews On 11/18/25 at 3:42 p.m., the administrator stated he was not aware of the staffing ratio regulation. On 11/18/25 at 3:55 p.m., the resident care coordinator stated she was not aware of the staffing ratio regulation and thought the residence only needed a certain number of staff based on resident needs.