Sheffield Care Center

Based on facility record review, staff interviews, and policy review, the facility failed to ensure a Registered Nurse (RN) worked 8 consecutive hours a day, 7 days a week. On 2/1/25 and 8/1/25 the facility failed to ensure they had an RN on duty for at least 8 hours for the entire 24 hours. The facility reported a census of 37 residents. Findings include: Review of the Nursing schedules and Timecards lacked a RN on 2/1/25 and 8/1/25.On 8/19/25 at 3:00 PM, the Director of Nursing (DON) verified she didn't work on 8/1/25. She said she didn't think about needing RN coverage. She said if she could get a day off, she takes it. On 8/19/25 at 3:56 PM, the Administrator verified the facility didn't have RN coverage on 8/1/25. She reported the DON did the best she could with RN coverage. She said the facility only had 3 RNs on staff and used agency staff for RN coverage as needed. On 8/19/25 at 6:26 PM, the Administrator reported she expected the facility to have 8 hours of RN coverage, 7 days per week. On 8/20/25 at 8:30 AM, the Administrator verified the facility didn't have RN coverage…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of the facility's Quality Assurance Performance Improvement (QAPI) plan, the facilities past surveys, and staff interview, the facility failed to correct their own deficiencies for 2 of 2 areas of concern. Findings include: The survey identified the following concerns at the current survey, previously cited at surveys in the past year:a. Abuse, Neglect, and Exploitation Trainingb. Infection Prevention and ControlThe facility's QAPI Plan revised April 2014 instructed the facility shall develop, implement, and maintain an ongoing facility wide QAPI Plan designed to monitor and evaluate the quality and safety of resident care, pursue methods to improve care quality, and resolve identified problems. In addition, the QAPI plan included the following objectives:a. Provide a means to identify and resolve present and potential outcomes related to resident care and services.b. Reinforce and build upon effective systems and processes related to delivery of quality care and services.c. Provide structure and processes to correct identified quality and/or safety deficiencies.d.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on personnel file reviews, facility policy review, and staff interviews, the facility failed to provide dependent adult abuse certification training within 6 months of hire for 2 of 5 employees reviewed (Staff C, Dietary Aide, and Staff D, Housekeeper). The facility identified a census of 37 residents.Findings include: 1. Staff C's personnel file documented a hired date of 12/2/24. The personnel file lacked documentation Staff C had completed Dependent Adult Abuse Mandatory Reporter Training within 6 months of hire. 2. Staff D's personnel file documented a hired date of 10/7/24. The personnel file included a Dependent Adult Abuse Mandatory Reporter Training Certificate completed 5/30/25.On 8/19/25 at 1:42 PM, the Business Office Manager (BOM) verified Staff C didn't complete the Dependent Adult Abuse Mandatory Reporter Training and acknowledged Staff D completed their Dependent Adult Abuse Certification late. The BOM said the facility expected new hires to complete Dependent Adult Abuse Mandatory Reporter Training within 6 months of hire. On 8/19/25 at 1:50 PM, the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations and staff interviews the facility failed to implement care plan interventions related to not locking smoking materials for one resident (Resident #27). The facility reported a census of 37 residents.Findings include: 1. Resident #27's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS included diagnoses of cerebrovascular accident (CVA or stroke), anxiety and depression. The Care Plan Focus initiated 5/7/24 related to smoking. The Focus reflected Resident #27 smoked for a long-time but recently decided to quit due to the cost of cigarettes however, he did occasionally smoke. Resident #27 had a history of extinguishing his cigarettes on his wheelchair, then keeping the cigarette butts, and storing them in his wheelchair bag. The Interventions directed to store Resident #27's smoking supplies in the north nurses' station. The Smoking - Safety Screen dated 7/26/25…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview, and facility policy review the facility failed to update a resident's Care Plan to accurately reflect the resident's needs for 2 of 2 residents reviewed (Residents #8 and #32). The facility reported a census of 37 residents.Findings include:1. Resident #8's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 5 indicating severe cognitive impairment. The MDS included diagnoses of non-Alzheimer's dementia, depression, and hypertension (high blood pressure). The Nurse Progress Note dated 6/27/25 at 4:44 PM reflected Resident #8 fell and complained of left hip and leg pain. The Intervention listed the facility sent him to the emergency room for evaluation. The Fall Investigation dated 6/27/25 at 4:31 PM indicated Resident #8 had an unwitnessed fall. The facility sent him to the emergency room (ER) for evaluation. The Intervention reflected the facility would update his Care Plan upon return from the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and policy review the facility failed to provide adequate nursing supervision to prevent accidents for 1 of 3 residents reviewed (Resident #13) for falls. The facility failed to complete a thorough root cause analysis (RCA) and failed to implement new and/or effective fall interventions after a fall occurred. The facility reported a census of 37 residents.Findings Include: Resident #13's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 5 indicating severely impaired cognition. Resident #13 required partial/moderate assistance with bed mobility and transfers. The MDS documented Resident #13 used a walker and wheelchair for mobility. The MDS included diagnoses of cerebrovascular accident (CVA) (stroke), non-Alzheimer's dementia, hemiplegia (muscle weakness or partial paralysis on one side of the body), repeated falls, unsteadiness on feet, transient alternation of awareness, dizziness and giddiness, low…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, facility record review, staff interviews, and the facility policy, the facility failed to provide adequate care for a urinary catheter for 1 of 1 resident reviewed (Resident #32). The facility reported a census of 37 residents.Findings include: Resident #32's MDS assessment dated [DATE] identified a BIMS score of 2, indicating severe cognitive impairment. The MDS included diagnoses of benign prostatic hyperplasia (a non-cancerous enlargement of the prostate gland that commonly occurs in older men), Alzheimer's disease, and Parkinson's disease.The Nurse Progress Note dated 8/1/25 at 5:14 AM identified Resident #32 had a urinary catheter.The Clinical Physician Orders reviewed 8/20/25 listed an order dated 8/4/25 to change Resident #32's urinary catheter every month and as needed (PRN).On 8/18/25 at 10:22 AM, observed Resident #32's urinary catheter bag lying on the floor underneath his bed. On 8/19/25 at 1:45 PM witnessed Resident #32's urinary catheter bag hanging on the bed, lying on the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, policy review, and staff interviews, the facility failed to keep the medication cart locked or under direct observation of authorized staff for a minimum of 7 minutes in an area where residents could access it. The facility reported a census of 37 residents. Findings include:Findings include: On 8/18/25 at 12:26 PM, observed the south side medication cart in the hallway near the nurse's station unlocked and unsupervised. During that time, witnessed the following:a.12:26 PM - 1 housekeeper walked past the unlocked medication cart. b.12:27 PM - 1 housekeeper walked past the unlocked medication cart. c.12:30 PM - 2 housekeepers walked past the unlocked medication cart. d.12:33 PM - Staff B, Licensed Practical Nurse (LPN), approached the medication cart. Staff B verified the medication cart was unlocked. Review of the undated facility policy titled, Storage of Medications, directed compartments containing medication are locked when not in use. Trays or carts used to transport such items are not to be left unattended. Compartments include, but are not limited to,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and policy review, the facility failed to ensure infection control practices were followed during 3 resident observations (Resident #1 and Resident #32). Staff A, Registered Nurse (RN) failed to disinfect her hands between changing gloves while completing Resident #1's wound treatments. Staff F, Certified Nurse Aide (CNA), failed to complete hand hygiene between changing gloves during Resident #32's catheter and perineal (peri). In addition, the facility staff reused the same 2 personal protective gowns when caring for Resident #32 on enhanced barrier precautions (EBP) for one week before washing. The facility reported a census of 37 residents. Findings include: 1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score as 15, indicating intact cognition. The MDS included diagnoses of diabetes mellitus, cellulitis of left toe and non-pressure ulcer to left lower leg. The MDS reflected Resident #1 had applications…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on the Center for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Report (Fiscal Year Quarters 1, 2, and 3, 2024) review, facility staffing review, policy review, and staff interviews, the facility failed to submit staff reports for the PBJ Staffing Data Report. The facility reported a census of 56 residents. Findings include: The PBJ Staffing Data Reports for Fiscal Year 2024, Quarters 1, 2, and 3 all triggered for the following: a. Failed to Submit Data for the Quarter b. One Star Staffing Rating c. Excessively Low Weekend Staffing d. No RN hours d. Failed to have Licensed Nursing Coverage 24 Hours/Day Review of nursing staffing schedules for August and September 2024 revealed appropriate nursing staffing, 8-hour daily RN coverage, and 24 hours/day Licensed Nursing coverage. Interview on 9/26/24 at 11:51 AM, the Administrative Assistant/Office Manager acknowledged the facility didn't successfully submit the staffing data for quarters 1, 2, and 3 as they had changes to the facility's time clock system that she didn't know about. The submitted…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observations, and record review, the facility failed to initiate Enhanced Barrier Precautions (EBP) and they facility didn't know what they were. At the time of the survey 1 resident had a catheter (Resident #23) and didn't have EBP set up in his room. In addition, the facility failed to handle laundry from isolation rooms while wearing the appropriate Personal Protective Equipment (PPE). The facility reported a census of 35 residents. Findings include: Resident #23's Minimum Data Set assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. Resident #23 had an indwelling catheter. The MDS included a diagnosis of retention of urine. On 9/23/24 at 11:50 AM, Resident #23 stated he had a catheter and it drained into a leg bag inside of his pant leg. His room didn't have an EBP sign or cart with PPE set up. An email from the Administrator dated 9/26/24 at 1:26 PM documented the facility would initiate EBP for Resident #23 due to his…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on employee's file review, facility policy, and staff interview, the facility failed to assure 2 of 5 employees met the requirements for Mandatory Adult Abuse Training (Staff A and Staff B). The facility reported a census of 35 residents. Findings include: A review of Staff A's, Dietary Aide, employee file listed a hire date of 1/29/24. The file listed a due date of the two-hour Dependent Adult Abuse Mandatory Reporter Training as 7/29/24. The file lacked a certification of completion. A review of Staff B's, Dietary Aide, employee file listed a hire date of 2/2/24. The file indicated a due date of the two-hour Dependent Adult Abuse Mandatory Reporter Training as 8/29/24. The file lacked a certification of completion. Review of facility Abuse Prevention Policy, revised December 2016, stated: As part of the resident abuse prevention, the administration will: require staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior. In an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, staff interview and policy review, the facility failed to follow standard practices and protocol for infection prevention during wound care for 1 of 2 residents reviewed (Resident #28). The facility reported a census of 33 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] documented Resident #28 had a Brief Interview for Mental Status (BIMS) score of 13 indicating intact cognitive response. The MDS further documented the resident had diagnoses including medically complex conditions, cancer, anemia, coronary artery disease, heart failure, renal insufficiency, diabetes mellitus and cellulitis of right axilla (armpit). The Care Plan for Resident #28 revised 10/9/23 with a focus for the area to the right axilla documented under interventions and tasks to follow wound protocol per order and treatment to the area at right axilla per order. Clinical record review of Physician Orders for Resident #28 revealed an order for Aquacel Ag Foam External Pad…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews and policy review the facility failed to ensure assessments before and after outpatient hemodialysis treatments were completed for 1 of 1 resident reviewed for dialysis, (Resident #4). The facility reported a census of 30 residents. Finding include: Resident #4 ' s Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMs) score of 13, indicating intact cognition. The MDS identified Resident #4 required extensive assistance of two persons with bed mobility and limited assistance of one person with transfers, ambulation in room and toilet use. The MDS included diagnoses of hypertension (high blood pressure), cancer, anemia, coronary artery disease, diabetes mellitus, chronic kidney disease with dependence on renal dialysis (running blood through an external machine to rid the blood of toxins). The Care Plan with a revised date of 6/27/23 identified a need for hemodialysis on Tuesday, Thursday, and Saturday. The Care Plan…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.