Sanford Senior Care Sheldon

In the surveyor’s words

From the most serious findings on record at Sanford Senior Care Sheldon, in the surveyor’s own words.

• Immediate jeopardy, patternF684Feb 1, 2024

  Based on observation, clinical record review, resident and staff interviews, the facility failed to appropriately perform assessments and interventions for the necessary care and services to maintain the residents' highest practical physical well- being for 5 out of 45 residents reviewed with signs and symptoms of COVID-19 (Residents #2, #3, #4,#5 and #6). Records showed 3 residents required hospitalization after emergency room (ER) visits, (Residents #2, #4 and #5). The failure to assess and test for COVID when signs and symptoms presented resulted in immediate jeopardy to resident health and safety. The facility identified a census of 45 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of [DATE] on [DATE] at 4:49 PM. […]

• Immediate jeopardy, patternF880Feb 1, 2024

  Based on observations, interviews and record review the facility failed to implement adequate infection control strategies and practices to mitigate the transfer of viruses by failure to test and isolate residents with respiratory signs and symptoms for 5 out of 45 residents reviewed (Residents #2, #3, #4, #5 and #6). Records showed three residents required hospitalization after emergency room (ER) visits, ( Residents #2, #4 and #5). The failure to test for COVID and isolate when signs and symptoms presented resulted in immediate jeopardy to resident health and safety. The facility identified a census of 45 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of [DATE] on [DATE] at 5:09 PM. […]

• Immediate jeopardy, isolatedF686Mar 13, 2025

  Based on observations, record review, staff and family interviews, the facility failed to complete accurate assessments and implement interventions for a resident to prevent the development of a Stage 4 pressure sore for 1 of 3 residents reviewed (Resident #1). Certified Nursing Assistant (CNA) staff identified a reddened area on a resident's coccyx in [DATE] and reported it to nursing staff. The record lacked assessments of the area, notification to the physician and treatment orders. On [DATE] an open area on the coccyx was identified and measured 1cm x1 cm. The facility failed to assess the area, implement interventions, implement treatments and notify the physician and family. On [DATE] the open area to the coccyx measured 1cm x 0.8 cm. […]

• Immediate jeopardy, isolatedF689Jun 29, 2023

  Based on clinical record review, staff interviews, facility record review and facility policy review, the facility failed to ensure residents at risk for elopement were unable to exit the facility unattended for 1 of 1 residents reviewed for elopement (Resident #18). The facility failure resulted in an Immediate Jeopardy to the health, safety, and security of the residents. The facility reported a total census of 49 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of [DATE] on [DATE] at 9:30 a.m The Facility Staff removed the Immediate Jeopardy on [DATE] through the following actions: A staff member is to monitor the door at all times until the Wanderguard servicing agent arrives to assess the system. […]

• No harm, potential for more than minimal, patternF805Nov 6, 2025

  Based on observations, clinical record reviews, staff interviews and policy review the facility failed to prepare and serve food in a form designed to meet individual needs and according to their assessments and care plans for 5 of 9 residents (Resident #4, #9, #30, #117 and #217) reviewed. The facility failed to prepare and serve 5 meals according to the residents' prescribed diet orders. The facility reported a census of 46 residents.Findings include: 1. Resident #4's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 9/15 indicating moderate cognitive impairment. The document revealed the resident received a mechanically altered diet during the last 7 days of the assessment period. […]