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Deficiency Records for Sherbrooke Village

A list of the most recent deficiencies for Sherbrooke Village. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.

A list of the most recent deficiencies for 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 meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Health 2024-06-26 2024-08-19 N
Provide and implement an infection prevention and control program. Health 2024-06-26 2024-08-19 N
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. Health 2024-06-26 2024-07-25 N
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2024-06-26 2024-07-25 N
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Health 2024-06-26 2024-07-25 N
Ensure services provided by the nursing facility meet professional standards of quality. Health 2024-06-26 2024-07-25 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 2024-06-26 2024-07-25 N
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 2024-06-26 2024-07-25 Y
Conduct testing and exercise requirements. Fire Safety 2024-06-26 2024-07-25 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 2024-06-26 2024-07-25 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2024-06-26 2024-07-25 N
Ensure proper usage of power strips and extension cords. Fire Safety 2024-06-26 2024-07-25 N
Have proper medical gas storage and administration areas. Fire Safety 2024-06-26 2024-07-25 N
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. Health 2024-08-20 2024-07-15 Y
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
Reasonably accommodate the needs and preferences of each resident. Health 2023-08-31 2023-10-06 Y
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 2023-08-31 2023-10-06 Y
Administer the facility in a manner that enables it to use its resources effectively and efficiently. Health 2023-08-31 2023-10-06 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
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
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2024-06-26 Not Fixed N

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