Deficiency Records for Ascension Living Sherbrooke Village
Updated as of February 01, 2020
This is not the most recent data for Ascension Living Sherbrooke Village. For the most recent information, click here.
A list of the most recent deficiencies for Ascension Living Sherbrooke Village. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-10-01 | 2019-10-01 | Y |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-08-16 | 2019-09-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-08-16 | 2019-09-25 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-08-16 | 2019-09-25 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2019-08-16 | 2019-09-25 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-08-16 | 2019-09-25 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-08-16 | 2019-09-25 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-08-16 | 2019-09-25 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-08-16 | 2019-09-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-08-16 | 2019-09-25 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-08-16 | 2019-09-25 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-08-16 | 2019-09-25 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-08-16 | 2019-09-25 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2019-08-16 | 2019-09-25 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-08-16 | 2019-09-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-16 | 2019-09-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-08-16 | 2019-09-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-08-16 | 2019-09-25 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-08-16 | 2019-09-25 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-06-06 | 2019-07-19 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-06-06 | 2019-07-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-06-06 | 2019-07-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-03-14 | 2019-04-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-12-27 | 2019-02-11 | Y |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2018-08-24 | 2018-10-05 | N |
| Have exits that are accessible at all times. | Fire Safety | 2018-08-24 | 2018-10-05 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-08-24 | 2018-10-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-08-24 | 2018-10-05 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2018-08-24 | 2018-10-05 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2018-08-24 | 2018-10-05 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2018-08-24 | 2018-10-05 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2018-08-24 | 2018-10-05 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2018-08-24 | 2018-10-05 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-08-24 | 2018-10-05 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-08-24 | 2018-10-05 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-08-24 | 2018-10-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-08-24 | 2018-10-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-08-24 | 2018-10-05 | N |
| Respond appropriately to all alleged violations. | Health | 2018-08-24 | 2018-10-05 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-02-16 | 2018-04-05 | Y |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2017-09-12 | 2017-10-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-09-12 | 2017-10-25 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2017-09-12 | 2017-10-25 | N |
| Try to resolve each resident's complaints quickly. | Health | 2017-09-12 | 2017-10-25 | N |
| Allow residents to easily view the results of the nursing home's most recent inspection. | Health | 2017-09-12 | 2017-10-25 | N |
| 1) Protect current or future residents from giving up their Medicaid or Medicare benefits; or 2) follow federal rules for admissions. | Health | 2017-09-12 | 2017-10-25 | N |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2017-09-12 | 2017-10-25 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2017-09-12 | 2017-10-25 | N |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2017-09-12 | 2017-10-25 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-09-12 | 2017-10-25 | N |
| Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. | Health | 2017-09-12 | 2017-10-25 | N |
| Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. | Health | 2017-09-12 | 2017-10-25 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-09-12 | 2017-10-25 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2017-09-12 | 2017-10-25 | N |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2017-09-12 | 2017-10-25 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2017-03-07 | 2017-04-20 | Y |
