Sherbrooke Village

In the surveyor’s words

From the most serious findings on record at Sherbrooke Village, in the surveyor’s own words.

• Immediate jeopardy, patternF880Oct 27, 2022

  Based on observation, record review, interview, and facility policy review, the facility failed to properly contain COVID-19. This failure resulted in an Immediate Jeopardy, when resident (Resident (R) 69) was identified to have COVID-19 and was in the communal area, unmasked for several hours increasing the risk of exposure for staff and other residents residing on the [NAME] Unit. The failure placed residents and staff on the [NAME] Unit at risk for exposure, contracting COVID-19, and adverse outcomes up to and including death, and to failed to ensure Emergency Medical Technicians (EMT) wore source control. On 10/24/22 at 9:00 PM, the Director of Nursing and Administrator were notified of the Immediate Jeopardy (IJ) at F880-K Infection Control. […]

• Actual harm, isolatedF697Apr 10, 2026

  Based on observation, interview and record review, the facility failed to provide reasonable accommodation or intervention for pain management for two of two residents (Residents #118 and #2). One resident had uncontrolled pain for 20-hours after being discharged from a local hospital with a pelvic fracture. The facility did not administer any pharmacological or non-pharmacological approaches for pain control. The facility nurse did not try to get orders for pain medication from the on-call provider (Resident #118). Facility staff also failed to provide pain control interventions for one resident during a wound treatment (Resident #2). The sample was 24. The census was 121. […]

• No harm, potential for more than minimal, widespreadF837Aug 20, 2024

  Based on interview and record review, the facility failed to have a licensed Administrator, who was legally responsible for establishing and implementing policies regarding the management and operation of the facility. This had the potential to affect all residents of the facility. The census was 128. The Interim Administrator was notified on [DATE] of the Past Non-Compliance. The Director of Business Operations (DBO) filed and received a Temporary Emergency License (TEL). The deficiency was corrected on [DATE]. Review of Administrator A's State of Missouri Nursing Home Administrator's License showed it was valid through [DATE]. […]

• No harm, potential for more than minimal, widespreadF868Oct 27, 2022

  Based on interviews and review of facility documentation, the facility failed to ensure the quality assessment and assurance committee attendees included the Medical Director or Designee. This failure had the potential to affect all 93 residents who currently live in the facility. Review of the document titled Quality Assurance and Performance Improvement (QAPI) Program, dated 09/2020, revealed at a minimum the following individuals serve on the committee: Administrator, Director of Nursing, Medical Director, Director of Quality, Infection Preventionist, Two other associates, Others as deemed necessary. During review of the QAPI attendance records 01/2022 through 09/2022 the Medical Director was not listed as attending. […]

• No harm, potential for more than minimal, patternF550Apr 10, 2026

  Based on observation, interview and record review, the facility failed to ensure one resident was treated in a dignified manner (Resident #98), and failed to ensure staff followed the facility's cell phone policy, which affected 4 residents (Residents #12, #3, #100 and #140). The sample size was 24. The census was 121. Review of the facility's resident rights policy, dated 1/28/26, showed:-Policy: The facility shall treat residents with kindness, respect, and dignity and ensure resident rights are being followed. The resident/resident representative will be informed of their rights upon admission. Review of the facility's employment policies and procedures, undated, showed:-Personal cell phones: Use of personal cell phones or other similar devices while on duty is prohibited. […]