Sheffield Care Center

In the surveyor’s words

From the most serious findings on record at Sheffield Care Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF727Aug 21, 2025

  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. […]

• No harm, potential for more than minimal, widespreadF865Aug 21, 2025

  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. […]

• No harm, potential for more than minimal, patternF943Aug 21, 2025

  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. […]

• No harm, potential for more than minimal, patternF851Sep 26, 2024

  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. […]

• No harm, potential for more than minimal, patternF812May 25, 2021

  Based on observations, interviews, and record reviews, the facility failed to keep the kitchen clean. An ice machine had a layer of calcium or lime, broken tile in front of the dishwasher and wooden cupboards storing kitchen equipement were tacky to the touch during the initial kitchen walk through. The facility reported a census of 27. Findings include: On 5/17/21 at 11:00 AM, an initial walk through was done with the Dietary Manager (DM) present. The following was observed: a. broken floor tile in the dishwashing area. b. wooden cabinets were sticky to touch. c. a line of hard build up was on the ledge above where door opens on a ice machine. In an interview at the time of the walk through, the DM stated: a. […]