Below average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sanford Senior Care Sheldon during CMS and state inspections, most recent first.
Staff failed to timely report an allegation of abuse after a CNA took and shared a photo of a cognitively impaired resident lying on the floor after a fall, with the resident’s brief down and the CNA visible in the background. Another CNA viewed the photo on the CNA’s phone and, despite recognizing it was inappropriate, waited about a week before informing administration. Two CNAs discussed the photo with a third CNA, who then immediately reported it to the DON. Facility policy required that any alleged or suspected abuse be reported to administration and appropriate agencies immediately and no later than 2 hours after the allegation was made.
A facility failed to prepare and serve meals in the correct texture for several residents with ordered diet modifications. During meal service, staff served a regular egg roll to a resident who should have received a pureed item, gave brownies cut into bite-sized pieces instead of pureed brownies for residents on a Level 6 diet, and omitted a required sauce listed on the diet spreadsheet. The residents had documented MDS, care plan, and physician-ordered diet requirements for mechanically altered foods, but staff did not consistently follow those orders.
Improper hand hygiene and glove use during meal prep: Dietary staff began meal service without washing hands on entering the kitchenette, used a single gloved hand to handle bread wrappers, bread, eggs, cheese, and plated food, and moved between non-ready-to-serve and ready-to-eat items without changing gloves or performing hand hygiene. The DON stated staff were expected to wash hands before touching food and before donning gloves, and the facility policy required fresh gloves when changing tasks and use of utensils when possible.
Failure to notify physician and representative of significant weight loss. A resident with dementia, impaired cognition, and nutritional risk had documented weight loss from 129 lbs to 116.9 lbs, including a significant loss over a short period. The record lacked documentation that the physician or resident's representative were informed, and the DON confirmed no notification was found.
Care plan not updated after a resident fall. A resident with moderate cognitive impairment, a stroke history, and fall risk had an unwitnessed fall after reportedly trying to look into the hallway and possibly climbing over a locked wheelchair foot pedal. Staff found the resident on the floor with blood around the head, used a mechanical lift with 3 staff to assist her, and sent her to the ER. The fall packet noted the care plan should be updated, but no new interventions were added, and the DON stated care plans should include new interventions after a fall.
A resident with a history of stroke developed limited ROM in both upper extremities, but the clinical record lacked documentation that the facility consulted the physician for a therapy evaluation after the decline was noted. During toileting, staff had difficulty positioning the resident's arm on the grab bar, and the resident cried out to go slower. The MDS coordinator said staff had to maneuver the resident's arms into clothing, and the facility's restorative program addressed ambulation but not ROM.
A resident with dementia and severe cognitive impairment was care planned for a regular diet with Boost TID due to nutritional risk, but the record showed significant weight loss and the dietary flowsheet documented supplements only with breakfast and dinner rather than three times daily. The chart also lacked documentation that the physician or resident representative was notified of the significant weight change, despite the facility policy requiring notification and weekly weights for residents at nutritional risk.
A resident at risk for pressure ulcers developed a stage 4 sacral ulcer after staff failed to assess, document, and intervene despite repeated reports of skin breakdown. CNAs observed and reported worsening skin issues, but licensed nurses did not consistently assess, notify the physician or family, or initiate treatment. The resident was eventually hospitalized with a severe pressure wound and died from MRSA cellulitis related to the ulcer.
The facility failed to notify the physician and family of significant weight loss for two residents and a choking incident for one resident. A resident with no cognitive impairment experienced significant weight loss without physician or family notification, contrary to facility policy. Another resident with moderate cognitive impairment also had significant weight loss and a choking incident, yet the facility did not inform the physician or family. The DON did not see the need for notification, although the resident's physician expected to be informed.
The facility failed to notify the LTC Ombudsman of hospitalizations for two residents. Hospital transfers were omitted from the monthly notification forms, as the Social Worker was not instructed to include them. The facility's policy requires such notifications to ensure the ombudsman can advocate effectively for residents.
A facility failed to ensure an accurate MDS assessment for a resident with severe cognitive impairment and mental illness. The resident's MDS inaccurately documented their PASRR status, despite having a Level 2 PASRR indicating the need for specialized behavioral health services. The MDS Coordinator did not correctly answer the PASRR-related question, leading to the deficiency.
A facility failed to reposition a resident with spinal cord dysfunction as per provider orders, which required repositioning every hour in a chair and every two hours in bed. The care plan did not reflect the updated orders, and records showed non-compliance on multiple dates. Staff interviews revealed a lack of documentation for refusals and absences, and the DON acknowledged the need for improved compliance.
The facility failed to complete daily skin assessments for a resident with a spinal cord injury and pressure ulcer risk, and did not follow physician orders for oxygen administration for a resident with cognitive impairment and coronary artery disease. Documentation was lacking for both skin assessments and oxygen therapy adjustments, contrary to the facility's policies.
A facility failed to ensure a physician evaluated a gradual dose reduction (GDR) for a resident's psychotropic medication. The resident, diagnosed with Alzheimer's and dementia with psychotic disturbance, was prescribed Amitriptyline 50 mg at bedtime. Despite a consultant pharmacist's recommendation for a GDR in May, there was no documented physician response. The DON confirmed the absence of a GDR evaluation during the survey.
Failure to Timely Report Allegation of Abuse Involving Inappropriate Resident Photograph
Penalty
Summary
Facility staff failed to timely report an allegation of abuse involving a cognitively impaired resident. The resident had diagnoses including depression, hypertension, and psychomotor defect following cerebral infarction, with a BIMS score of 8 indicating severe cognitive impairment. After the resident experienced a fall and was on the floor wearing a brief and T‑shirt, a CNA (Staff B) took a photo showing the resident on the floor with the brief down to the ankles and a pillow under the resident’s head, with Staff B visible in the background. Staff B then shared this photo in a staff work group chat. Another CNA (Staff A) later viewed the photo on Staff B’s phone in the hallway and questioned why Staff B had the photo; Staff B responded that it was in their work group chat. Staff A did not immediately report the incident to administration, instead “sitting on it” for approximately a week before deciding to turn it in, acknowledging she knew it was not right for Staff B to have the photo. During this period, Staff A and another CNA (Staff D) discussed the photo with a third CNA (Staff C), describing the image but not showing it to her. Staff C, upon learning of the photo, immediately reported the matter to the DON. The DON confirmed that Staff A, Staff C, and Staff D informed her that about a week earlier Staff B had shown them the photo of the resident on the floor after the fall. The facility’s abuse and neglect policy required that alleged or suspected violations involving mistreatment, neglect, exploitation, or abuse be reported immediately to the administrator and to designated agencies not later than 2 hours after the allegation is made. The DON stated that staff should have reported the allegation to administration right away.
Failure to Serve Texture-Modified Meals as Ordered
Penalty
Summary
The facility failed to prepare and serve food in a form designed to meet individual needs and according to residents’ assessed diet orders for 5 of 9 residents reviewed. The cited residents had varying cognitive status and swallowing or chewing-related diet needs, including mechanically altered diets such as Level 6 Soft and Bite Sized, Minced and Moist, Pureed, and mechanical soft diets. Their MDS assessments, care plans, and diet orders reflected these texture-modified requirements, including specific instructions such as no straws, ground meats, thickened liquids, and pureed items with meals. During meal service observation, staff prepared modified meals but did not consistently follow the documented diet spreadsheet or resident diet orders. One resident ordered for a minced and moist diet was served a regular egg roll instead of a pureed egg roll, and staff acknowledged the error when questioned. For residents ordered a Level 6 Soft and Bite Sized diet, staff served brownies cut into bite-sized pieces rather than pureed brownies, and the Dietary Manager acknowledged that the pureed brownie was required for those residents. Staff also did not provide the Smooth and Thick Sweet and Sour Sauce listed on the diet spreadsheet for residents on the pureed, minced and moist, and soft and bite sized diets. The Dietary Manager stated the kitchen had a diet spreadsheet available for staff use during meal preparation and service. The facility’s Texture-Modified Diets-Food and Nutrition Services policy stated that food and nutrition services alter the texture and consistency of foods prescribed by the attending physician and that all diet orders, including texture modifications, must have a physician’s order. Despite these documented orders and care plan interventions, the observed meal service did not match the prescribed consistencies for the affected residents.
Improper Hand Hygiene and Glove Use During Meal Preparation
Penalty
Summary
The facility failed to prepare, serve, and distribute food in accordance with professional standards by not practicing accepted hygiene practices during meal service in the kitchenette and dining area. During a continuous observation, a Dietary Aide entered the kitchenette and began making scrambled eggs without completing hand hygiene. The staff member cracked eggs, donned a single glove on the left hand, opened a bread wrapper, placed bread in the toaster, monitored the eggs, transferred the eggs to a plate, carried the plate with the gloved hand, covered the food, and placed it on the steam table. The same gloved hand was then used to hold bread while buttering with the right hand. Another Dietary Aide washed hands at the steam table, moved to the food prep area, donned a single glove, placed a pre-assembled grilled cheese sandwich on a skillet, obtained bread from the wrapper, and placed bread in the toaster, with the gloved hand touching both the wrapper and the bread. The staff member returned to the steam table with one gloved hand after being told the sandwich had burned and a new one would need to be started. The first Dietary Aide then cracked an egg into the skillet using gloved and ungloved hands, obtained new bread from the package with the same gloved hand, got cheese from the refrigerator, and used the gloved hand to place cheese on the sandwich. The grilled cheese was removed and plated for serving, and the same gloved hand was used to remove toast from the toaster, stabilize it while buttering, and add the egg for serving. The Dietary Manager stated that hands should be washed when entering the kitchenette prior to touching food items and before donning gloves and after glove removal, and that staff should not touch non-ready-to-serve food with a gloved hand and then return to ready-to-eat food without changing gloves and performing hand hygiene.
Failure to Notify Physician and Representative of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician and the resident's representative of a significant weight loss for Resident #11. The resident had long and short term memory problems, severely impaired cognitive skills for daily decision making, and a diagnosis of non-Alzheimer's dementia. The resident required supervision or touching assistance with eating, and the care plan identified the resident as being at nutritional risk related to dementia. The weight record showed the resident weighed 129 pounds on 9/2/25, 125.4 pounds on 9/16/25, 120.7 pounds on 10/7/25, 117.5 pounds on 10/14/25, and 116.9 pounds on 10/21/25. This reflected a 6.4% loss and then a 9.4% loss in 50 days. The clinical record lacked documentation that the facility notified the physician or the resident's representative of the significant weight change, and the DON stated on 11/6/25 that she found no notification of the physician or family of the significant weight loss. The facility's Weight and Height policy stated that significant weight change should be reported to the physician and family and/or resident.
Care Plan Not Updated After Resident Fall
Penalty
Summary
The facility failed to update a resident’s care plan with a new intervention after a fall for 1 of 2 residents reviewed with falls. Resident #4 had a MDS assessment showing a BIMS score of 11, indicating moderate cognitive impairment, and was independent in ambulation but required set-up assistance with transfers. The resident’s diagnoses included cerebral infarction or stroke. The existing care plan, started on 4/17/25, identified the resident as at risk for falls related to weakness and medication use and included interventions such as slow position changes, eyeglasses, verbal reminders not to ambulate or transfer without assistance, low bed position with brakes locked, call light and personal items within reach, proper footwear, and a clutter-free environment. On 7/28/25 at 11:30 p.m., the resident was found on the floor with bright red blood under and around the head. The nurse documented that the resident said she had been going to peek into the hallway and then found herself on the floor; the fall packet also stated the nurse believed the resident may have climbed over the foot pedals of a locked wheelchair and lost balance. The resident reported head pain, and staff used a total mechanical lift with 3 staff members to get her up and transport her to the ER. The fall packet indicated the care plan would be updated and that immediate intervention and leadership notification were required if no long-term intervention could be found, but those items were not checked as completed. The care plan did not identify any new interventions after the fall, and the DON stated that after a fall, care plans should be updated to include new interventions to try to prevent further falls.
Failure to Maintain Resident ROM
Penalty
Summary
The facility failed to ensure a resident received services to maintain or improve range of motion (ROM) for one resident reviewed. The resident had a history of cerebral infarction or stroke and, on an earlier MDS assessment, had no limitation in functional ROM of the upper or lower extremities. A later MDS assessment showed limitation in functional ROM of both upper extremities, but the clinical record lacked documentation that the facility consulted the physician about the noted decline for a therapy evaluation. The care plan identified the resident's limited ability to transfer related to weakness from the cerebral infarction and included PT/OT for strengthening per physician order and following PT/OT recommendations. During observation, staff assisted the resident with toileting and had difficulty getting the resident's left arm up to the grab bar; the resident cried out to go slower and staff had to try again before the resident could grasp the bar. The resident stated that since the stroke she had laid on the affected side and thought the left side was a problem because it had to do everything. The MDS coordinator stated the resident had difficulty raising her arms and staff had to maneuver her arms into clothing, and the DON stated the facility did not have a restorative aide. The facility's restorative Walk and Dine Program addressed ambulation but did not address the resident's ROM.
Failure to Provide Ordered Nutritional Supplements and Notify for Significant Weight Loss
Penalty
Summary
The facility failed to ensure Resident #11 received dietary supplements as planned to maintain or increase weight. The resident had non-Alzheimer's dementia, long- and short-term memory problems, and severely impaired cognitive skills for daily decision making. The care plan identified the resident as nutritionally at risk and directed a regular diet with Boost supplementation three times daily. The record showed progressive weight loss from 129 pounds on 9/2/25 to 125.4 pounds on 9/16/25, 120.7 pounds on 10/7/25, 117.5 pounds on 10/14/25, and 116.9 pounds on 10/21/25, with the loss identified as significant. A later weight obtained on 11/5/25 was 119.8 pounds. The clinical record lacked documentation that the facility notified the physician or the resident's representative of the significant weight change. The dietary sheet showed the resident on a regular diet with Boost TID, but the October dietary flowsheet documented supplements only with breakfast and dinner and did not show the supplement being given three times daily. Staff interviews reflected uncertainty about the supplement documentation, and the DON stated the resident had been discussed in weight meetings, but the record lacked specific notes showing physician or representative notification. The facility's Weight and Height policy required weekly weights for residents at nutritional risk, immediate notification of the resident, physician, and legal representative for significant weight change, and reweighing and documentation if weight varied by more than three percent.
Failure to Assess and Intervene for Pressure Ulcer Leads to Resident Death
Penalty
Summary
A resident with diagnoses including non-Alzheimer's dementia, diabetes mellitus, and hypertension, and who was assessed as having no cognitive impairment, was identified as being at risk for pressure ulcers but did not have any at baseline. The resident required partial to moderate assistance with activities of daily living and had a pressure-reducing device in bed. Over a period of time, certified nursing assistants (CNAs) observed and reported reddened and open areas on the resident's coccyx and buttocks to nursing staff. Documentation in bath sheets and progress notes indicated repeated observations of skin issues, including redness, open areas, and bleeding, but there was a lack of consistent and thorough assessment, documentation, and follow-up by licensed nursing staff. Despite multiple reports from CNAs about the resident's deteriorating skin condition, including descriptions of the area as "very red and sore," "openish," and "looked like hamburger," nursing staff failed to perform timely and accurate assessments, did not notify the physician or the resident's family, and did not initiate appropriate treatment interventions. Several nurses admitted in interviews that they either did not assess the area, did not document their findings, or assumed another nurse would handle the situation. There was also a lack of communication and follow-through between shifts, resulting in the resident's worsening condition going unaddressed. The resident's condition progressed to a stage 4 sacral decubitus ulcer, which was only identified after the resident was admitted to the emergency room with altered mentation and hypotension. Hospital records documented a large sacral pressure wound with purulent drainage, and the resident was diagnosed with sepsis likely originating from the ulcer. The resident subsequently died, with the death certificate listing MRSA cellulitis of the buttock due to a stage 4 sacral ulcer as the immediate cause of death. The facility's own policies required prompt assessment, documentation, and notification for pressure ulcers, but these procedures were not followed in this case.
Removal Plan
- All residents receive a full body skin review by RN Nurse Supervisor.
- All nursing staff are reminded of the importance of skin observations and following process.
- Additional education is provided to staff, including notifications to physicians and family, and this information is included in skin checklist packets.
- Skin processes and status are reviewed at each huddle using the huddle checklist.
- All care plans are reviewed and updated as appropriate by RN supervisors, Social Worker, and Activity Director.
- A tracking tool is initiated to show all ulcers and surgical wounds, and is reviewed at the Risk meeting.
- A Risk meeting is established including Administrator, Director of Nursing, RN Supervisors, Social Services, Activity Director, Quality Director, and Infection Preventionist to review residents with skin impairments and update care plans as needed.
- Reviews for each resident with ulcers and/or surgical wounds are conducted for signs and symptoms of pain and infection, noted on the residents treatment sheet.
- The Director of Nursing and/or RN Supervisors review the Matrix Even to review tasks and assessments that were completed as necessary.
- Audits to ensure skin observations are complete are conducted by the Director of Nursing or designee.
- The tracking tool is completed to track measurements, treatment and care plan updates by an RN supervisor or designee.
Failure to Notify Physician and Family of Significant Events
Penalty
Summary
The facility failed to notify the physician and family of significant weight loss for two residents and a choking incident for one resident. Resident #14, who had no cognitive impairment and was self-feeding, experienced a significant weight loss of 5% or more in the last month or 10% or more in the last six months. Despite the facility's policy requiring immediate notification of the physician and family in such cases, there was no documentation that this was done. The Director of Nursing (DON) could not confirm whether the physician or family were informed, although a meeting with the dietician for recommendations was held. Resident #27, with moderate cognitive impairment and requiring assistance with eating, also experienced significant weight loss. The clinical record lacked documentation of physician or family notification. Additionally, Resident #27 had a choking incident where the resident struggled to breathe due to aspiration, but the facility did not notify the physician or family. The DON did not believe notification was necessary as the nurses managed the situation, and the resident was fine afterward. However, the resident's physician expected to be informed of both the weight loss and the choking incident. The facility's policy mandates immediate notification of significant changes in a resident's status to the physician and family.
Failure to Notify Ombudsman of Resident Hospitalizations
Penalty
Summary
The facility failed to notify the long-term care (LTC) Ombudsman of resident hospitalizations for two residents. Resident #4 was hospitalized on multiple occasions and returned to the facility on specific dates, yet the monthly Transfers/Discharges forms provided by the facility for ombudsman notification did not include these hospital transfers. Similarly, Resident #8 was hospitalized and returned on a specific date, but their transfer was also omitted from the notification forms. The Social Worker at the facility stated that she did not include hospital transfers in the monthly notifications to the ombudsman because she was not instructed to do so. The facility's Ombudsman policy emphasizes the role of the ombudsman as an advocate for residents, promoting the highest quality of life by serving as a communication bridge. According to federal regulations, copies of notices for emergency transfers must be sent to the ombudsman when practicable, such as in a monthly list, which the facility failed to do.
Inaccurate MDS Assessment for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the status of a resident, specifically for one resident out of the 17 reviewed. The resident in question had a diagnosis of non-Alzheimer's dementia and bipolar disorder, and was identified as having severe cognitive impairment with a score of 5 on the Brief Interview for Mental Status (BIMS). Despite this, the MDS inaccurately documented that the resident was not considered to have a serious mental illness by the state Level 2 Preadmission Screening and Record Review (PASRR), even though the resident had a PASRR Notice indicating the need for specialized behavioral health services. The discrepancy arose because the MDS Coordinator, a Registered Nurse, did not correctly answer the PASRR-related question on the MDS. The facility's policy required each discipline to complete its section of the MDS, with the MDS Coordinator responsible for submission. However, the coordinator acknowledged the resident had a Level 2 PASRR, which should have been reflected in the MDS assessment.
Failure to Reposition Resident as Ordered
Penalty
Summary
The facility failed to adhere to professional standards of care by not repositioning a resident with spinal cord dysfunction according to the provider's orders. The resident, who had a diagnosis of traumatic spinal cord dysfunction and an unhealed pressure ulcer, was supposed to be repositioned every hour while in a chair and every two hours while in bed, as per the provider's order dated 9/4/24. However, the care plan did not reflect the updated repositioning schedule, and the facility's repositioning records showed non-compliance with these orders on multiple dates between 9/4/24 and 9/30/24. Additionally, there was a lack of documentation for several days within this period. Interviews with staff revealed that there was a failure to document the resident's refusals to reposition and absences from the facility for medical appointments and family outings. The Director of Nursing acknowledged the need for improvement in compliance with repositioning orders and documentation. The facility's policy on provider orders, last revised on 2/14/24, did not include instructions for care, treatments, and services beyond medications, which may have contributed to the oversight.
Deficiencies in Skin Assessments and Oxygen Administration
Penalty
Summary
The facility failed to complete required skin assessments for a resident diagnosed with traumatic spinal cord dysfunction and an unhealed pressure ulcer. The resident's care plan required daily skin inspections due to immobility, but the facility's records showed multiple days where these assessments were not completed. The Director of Nursing acknowledged the oversight in skin assessment documentation and noted that follow-up with the nursing staff had occurred. Additionally, the facility did not adhere to physician orders for oxygen administration for another resident with moderate cognitive impairment and coronary artery disease. The resident's care plan required oxygen therapy adjustments to maintain saturation levels above 90%. However, documentation was lacking for the administration of increased oxygen levels, assessments of the resident's respiratory status, and follow-up on low oxygen saturation levels. The facility's policy required oxygen administration to be carried out with a medical provider order and regular assessments, which were not consistently documented.
Failure to Evaluate Gradual Dose Reduction for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a physician evaluated a gradual dose reduction (GDR) for a psychotropic medication for one of the residents reviewed. The resident, diagnosed with Alzheimer's disease with late onset and dementia with psychotic disturbance, was prescribed Amitriptyline 50 mg at bedtime starting from November 20, 2023. The facility's records indicated that the resident was due for a dose evaluation in May 2024, but there was no documented response from the physician regarding the GDR recommendation made by the consultant pharmacist on May 30, 2024. During the survey, the Director of Nursing (DON) was unable to confirm whether a GDR had been conducted for the resident's Amitriptyline. The lack of a physician's response to the consultant pharmacist's recommendation was confirmed during the exit conference with facility staff. This oversight indicates a failure in the facility's process to ensure appropriate medication management and evaluation for dose reduction as required.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 77 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Sheldon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Prairie View Home | 10.2 mi | ★★★★★ | 0 | 0 |
| Good Samaritan - George | 13.5 mi | ★★★★★ | 19 | 0 |
| Pleasant Acres Care Center | 15 mi | ★★★★★ | 14 | 0 |
| Sibley Specialty Care | 15.3 mi | ★★★★★ | 1 | 0 |
| Prairie Ridge Care Center | 15.6 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Sanford Senior Care Sheldon.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.