Sherwood Assisted Living

East wing had multiple light fixtures and electrical outlets with exposed wires.

Missing annual inspections, dry system 3-year full flow trip test, annual trip test, annual forward flow test, and FDC hydrostatic test reports.

Failed to provide smoke detector sensitivity report.

Missing annual fire wall inspection report; wall or ceiling penetrations found in East wing, with multiple missing ceiling tiles.

Kitchen extinguisher mounted over 5 feet high.

Failed to provide annual inspection report for exit signs/emergency lights.

Fire drills were not conducted once per shift per quarter; documentation missing for 1st/3rd quarter 2025 and 4th quarter 2024.

Failed to provide fire/smoke damper 4-year inspection report.

Fire alarm system required troubleshooting; system in trouble state.

Missing annual inspection report; room 220 and maintenance office doors failed to latch; doors propped open; East wing cross-corridor door damaged.

Kitchen hood vent grease filters had heavy grease accumulation.

Missing reports for semi-annual kitchen suppression system inspections.

Failed to provide carbon monoxide alarm testing and maintenance report.

The facility failed to allow residents to receive visitors of their choosing by implementing a policy prohibiting former employees from visiting residents for 12 months, without assessing the individual wishes of the residents.

The facility failed to ensure residents were able to receive visitors of their choice, resulting in denied visitation and risk of psychosocial harm.

The facility failed to allow a resident to exercise their right to participate in planning care and to refuse services by moving the resident into a locked memory care unit against their will, resulting in the resident feeling distressed.

Failed to document necessary care and services in the service plans for 3 residents (R1, R3, R4), including hospice status, mobility/transfer needs, and dietary orders.

Failed to secure medications in 1 of 4 resident rooms; medication (steroid cream) was found unsecured on a dresser in R1's room.

Failed to obtain and administer medication in a timely manner for R2; resident missed 8 of 10 doses of gabapentin due to pharmacy/refill issues without proper physician notification.

Facility failed to administer medication according to physician parameters; diltiazem was given when blood pressure was outside the specified hold parameters.

Facility failed to ensure 1 of 3 sampled staff received their second step tuberculosis skin test within the required time frame.

Facility failed to provide Medicaid policy disclosures for 2 of 4 sampled residents; one lacked a signed policy, another was incomplete.

Facility failed to follow food safety practices; food items stored on the floor, improper hand hygiene observed among staff during service.

Facility failed to ensure residents in the memory care unit had access to a call system in common areas.

Facility failed to ensure 1 of 2 sampled staff completed required continuing education credits.

Facility failed to provide updated Disclosure of Services for 2 of 4 sampled residents after decreasing the scope of services provided.

Facility failed to investigate or document investigative actions for an unwitnessed fall/incident involving Resident 5 (R5).

Deficiency corrected

Failed to ensure medication was administered as prescribed for R1; diltiazem was administered despite the resident's systolic blood pressure falling below the physician's required threshold.

Facility failed to secure hazardous items in the memory care unit; cleaning chemicals and hand sanitizer were left in accessible common areas.

Staff C, a Resident Care Assistant, had not completed mandatory continuing education training as required.

Facility failed to provide nursing services when observable changes occurred in physical/mental functioning for 6 of 9 sampled residents.

The facility failed to obtain and administer medications in a timely manner for 3 of 9 sampled residents (R2, R4, R6). R6 missed numerous doses of multiple medications due to 'medication non-availability'.

Facility failed to ensure 2 of 5 sampled staff received TB testing within the required time frames.

Facility failed to secure potentially hazardous supplies (cleaning chemicals, mouthwash, razors) in memory care, leaving them accessible to residents with cognitive impairments.

Facility failed to ensure 1 of 2 sampled staff completed required continuing education credits.

Facility failed to have a system to address and resolve grievances for 13 residents/representatives, resulting in unresolved concerns.

The facility failed to ensure medications were stored in a secure, locked manner for 5 of 9 sampled residents. Numerous medications were found in unlocked cabinets in resident bathrooms or on top of dressers, posing risks of access, tampering, or ingestion.

Facility failed to implement infection control practices, specifically hand hygiene by staff during medication administration and meal service for 2 of 2 staff observed.

Facility failed to meet minimum fire safety requirements; fire doors were consistently propped open with stuffed animals, buckets, or crates in multiple areas.

Facility failed to provide a safe, sanitary, and well-maintained environment, including water damage in resident rooms, uneven parking lot surfaces, and broken exterior fencing.

Facility failed to ensure weekly menus were posted in resident-accessible areas.

Facility failed to identify changes in condition for 4 of 9 sampled residents (R6, R5, R7, R3), placing them at risk for unmet and unidentified care needs.

Facility failed to follow physician orders for 3 of 9 residents regarding medication administration, storage, monitoring vital signs, and documentation. R6 missed 8 medication doses due to non-availability; R3 had unsecured medications and elevated heart rate not reported; R7's metformin dosing was inconsistent with orders.

Facility failed to maintain confidentiality of resident records. Protected health information (lists of diabetic residents, care plans, and medical charts) was openly displayed or accessible to visitors, public, and other residents.

Failure to follow safe food handling, storage, and sanitation practices, including soiled food bins, ice machines containing residue, food stored on floors, and lack of hand hygiene by staff.

Facility failed to provide completed disclosure of services, provide updated disclosure upon service decrease, or supply promised personal care products.

Facility failed to document in the service plan the plan to provide necessary care and services for 7 of 10 sampled residents (R6, R2, R7, R10, R8, R5, R9), placing residents at risk for unmet needs and untrained staff.

Facility failed to report a fall resulting in serious injury/hospitalization for 1 of 9 residents (R2) to the Complaint Resolution Unit (CRU) within 24 hours.

Facility failed to ensure residents were provided the policy for 2 of 9 sampled residents, putting them at risk regarding financial circumstances.

Facility failed to provide reliable call systems for residents and staff in South Hamptons Memory Care and Assisted Living units, and some staff lacked pagers to receive alerts.

Facility failed to investigate and document findings regarding a resident's new skin impairment.

The licensee failed to obtain medications in a timely manner for one resident, resulting in the resident not receiving prescribed medications and being placed at risk for decreased quality of life. This is an uncorrected and recurring deficiency.