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? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-29 | 2024-02-01 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-11-02 | 2023-06-01 | N |
| Respond appropriately to all alleged violations. | Health | 2023-04-25 | 2023-05-11 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-01-20 | 2023-02-10 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-01-20 | 2023-02-10 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-10-27 | 2022-12-02 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-10-27 | 2022-12-02 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-10-27 | 2022-12-02 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-10-27 | 2022-12-02 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-27 | 2022-12-02 | Y |
| 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 | 2022-10-27 | 2022-12-02 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-10-27 | 2022-12-02 | Y |
| 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 | 2022-10-27 | 2022-12-02 | Y |
| Post nurse staffing information every day. | Health | 2022-10-27 | 2022-12-02 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-10-27 | 2022-12-02 | Y |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-10-27 | 2022-12-02 | Y |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2022-10-27 | 2022-12-02 | Y |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-10-27 | 2022-12-02 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-10-27 | 2022-12-02 | Y |
| Report COVID19 data to residents and families. | Health | 2022-10-27 | 2022-12-02 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-11-02 | 2022-12-02 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-11-02 | 2022-12-02 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2022-11-02 | 2022-12-02 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-11-02 | 2022-12-02 | N |
| 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 | 2022-11-02 | 2022-12-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-02 | 2022-12-02 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-11-02 | 2022-12-02 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-11-02 | 2022-12-02 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-11-02 | 2022-12-02 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-11-02 | 2022-12-02 | N |
| Meet requirements for the use and maintenance of medical gas equipment. | Fire Safety | 2022-11-02 | 2022-12-02 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-11-02 | 2022-12-02 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-06-13 | 2022-06-14 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-16 | 2021-10-22 | Y |
| 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 treatment and care according to orders, resident?s preferences and goals. | Health | 2019-08-16 | 2019-09-25 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 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 |
| 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 |
| 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 |
| Respond appropriately to all alleged violations. | 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 |
| 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 |
