Sheffield Manor Nursing & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Sheffield Manor Nursing & Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF600May 6, 2026

  This citation pertains to intake #2792770. Based on observation, interview and record review, the facility failed to protect the resident's right to be free from psychosocial harm for one resident (R102) of three residents reviewed for abuse by Social Worker B. Findings include:On 02/16/2026, an alleged resident-to-resident abuse allegation was reported to the State Agency. The alleged incident occurred on 02/15/2026. Record review revealed on 02/15/2026 at approximately 01:30 P.M., it was alleged that R102 was hit in the face by R101. Incident summary revealed: R102 was sitting in the hall when R101 rolled past in a wheelchair, stopped and hit R102 in the face. R102 screamed, the staff immediately responded. R102 and R101 were separated. […]

• Actual harm, isolatedF686Oct 21, 2022

  Based on observation, interview, and record review, the facility failed to consistently administer prescribed skin treatments or implement interventions to promote healing for three (R9, R65, and R80) of five residents reviewed for pressure ulcers resulting in the development of new pressure ulcers, the worsening of existing pressure ulcers, and the potential for delayed healing of pressure ulcers. Findings include: The National Pressure Injury Advisory Panel (NPIAP) Pressure Injury 2019 Guidelines for Pressure Injuries identified the following: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. […]

• Actual harm, isolatedF697Aug 5, 2021

  Based on observation, interview, and record review, the facility failed to ensure a resident's pain medication was consistently available and provided, for 1 of 1 resident (R54) reviewed for pain, resulting in voiced feelings of anxiety, frustration, and unmet pain needs. Findings include: On 8/3/21 at 10:AM R54 was observed lying in bed. When asked how she was doing, R54 stated, I am in pain, they always wait until my [MEDICATION(S)] completely runs out before ordering some more, it can take 2-3 days before the new order comes in. My [CONDITION(S)] has gotten worse; it is now stage 4 and has spread to my bones. I have pain, right under my breasts now and I am to get [MEDICATION(S)] patches, I have only received 2 patches since it was ordered for me. […]

• No harm, potential for more than minimal, widespreadF921Feb 26, 2026

  Based on observation, interview, and record review, the facility failed to effectively clean and maintain the physical plant effecting 97 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage. Findings include:On 2/24/2026 at 9:00 A.M. during a tour of the kitchen the air vent covers and adjacent ceiling tiles over the tray line were heavily soiled with visible dust, fuzz strings and lint. The ceiling tile strips had areas of rust and corrosion over the steam table and dish room area. The Bakers pride convection (stove) was soiled with burnt ash and food residue. Both glass doors of the convection stove were soiled with yellowish colored stains and food residue that blocked visibility into the stove. […]

• No harm, potential for more than minimal, widespreadF814Aug 5, 2021

  Based on observation and interview the facility failed to maintain the exterior garbage disposal area in a clean and sanitary manner, resulting in the potential for the attraction of pests and rodents. This deficient practice has the potential to affect all 71 residents in the facility. Findings include: On 08/03/21 at 08:48 PM observed trash debris, three wooden pallets, and a purple tote filled with standing water, a black crate, and an unidentified object with a black electrical cord attached around the exterior garbage dumpster. […]