Below average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Sheffield Care Center during CMS and state inspections, most recent first.
Missing Required RN Coverage: The facility failed to ensure RN coverage for at least 8 consecutive hours a day, 7 days a week. Nursing schedules and timecards showed no RN on duty on two dates, and the DON and Administrator both verified the lack of RN coverage. The facility had 37 residents, only 3 RNs on staff, and used agency staff as needed, while its policy required an RN for at least 8 consecutive hours daily.
Failure to Address Repeated QAPI Deficiencies: The facility failed to correct repeated deficiencies in abuse, neglect, and exploitation training and infection prevention and control that had been cited in prior surveys. The QAPI plan called for an ongoing process to monitor quality and safety, identify problems, and correct deficiencies, but the Administrator stated she was unaware of the repeated issues until they were identified during the survey.
Failure to Complete Required Abuse Reporter Training: The facility failed to ensure required dependent adult abuse mandatory reporter training was completed within 6 months of hire for 2 of 5 employees reviewed, including a dietary aide and a housekeeper. Record review showed one employee had no documentation of the training and another completed it late. The BOM and Administrator both confirmed the facility expected the training within 6 months of hire, and the Abuse Prevention Policy addressed abuse prevention, identification, and reporting.
Failure to Lock Smoking Materials: A resident with intact cognition, CVA, anxiety, and depression had a care plan directing staff to store his smoking supplies at the nurses' station, but he continued to keep cigarettes and a lighter on his wheelchair and smoke unsupervised. He stated he rolled his own cigarettes in his room and smoked frequently, and staff observed him leaving to smoke without obtaining or returning his smoking materials. The DON acknowledged the care plan had not been updated to address locking the smoking materials.
Care plans were not updated for two residents to reflect current needs. One resident with severe cognitive impairment had repeated unwitnessed falls, including a fall with hip and leg pain and another fall with revised interventions, but the care plan still showed older interventions and did not include the fall-related updates. Another resident with severe cognitive impairment, BPH, Alzheimer's disease, and Parkinson's disease was observed receiving catheter care, yet the care plan did not document the indwelling urinary catheter. The DON acknowledged the omissions.
Failure to provide adequate supervision and effective fall interventions for a resident with severe cognitive impairment, CVA, hemiplegia, repeated falls, and unsteady gait. The resident had multiple falls involving improper footwear, getting up unassisted, alarm failure or absent alarm placement, and inconsistent alarm use. Staff and the DON acknowledged the TAR did not track the bed alarm, the facility lacked an alarm policy, alarm pads were not replaced per manufacturer directions, and the root cause analyses did not fully identify why the resident kept falling.
A resident with severe cognitive impairment and diagnoses including BPH, Alzheimer's disease, and Parkinson's disease had a urinary catheter with an order for monthly and PRN changes. Surveyors observed the catheter drainage bag on the floor and later hanging on the bed while still touching the floor without a dignity bag. The facility policy directed staff to keep the catheter tubing and drainage bag off the floor to help prevent CAUTIs, and the DON stated the bag was expected to be in a dignity bag and not touching the floor.
Medication Cart Left Unlocked and Unattended The facility failed to keep a medication cart locked or under direct observation of authorized staff for at least 7 minutes in a hallway near the nurse's station. The cart was observed unlocked and unsupervised while housekeepers walked past it multiple times, and an LPN later verified it was still unlocked. The facility policy requires medication compartments and carts to be locked when not in use, and the DON confirmed medications were expected to be locked when unsupervised.
Failure to Follow Hand Hygiene and PPE Practices: An RN did not perform hand hygiene when changing gloves during wound care for a resident with diabetes and foot/leg wounds, and a CNA did not perform hand hygiene when changing gloves during peri and catheter care for a resident with severe cognitive impairment. Staff also reused the same two black PPE gowns for a resident on EBP by hanging them back on the door and using them again before laundering.
The facility failed to submit accurate staffing data to CMS for FY 2024, Quarters 1-3, due to changes in the time clock system that led to incorrect report formatting. This resulted in a one-star staffing rating and issues like low weekend staffing and no RN hours, despite schedules showing appropriate coverage.
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with an indwelling catheter and did not handle isolation laundry with appropriate PPE. A resident's room lacked EBP setup, and a laundry aide did not wear a gown when handling isolation laundry, contrary to facility policy. The facility's Director of Nursing and Administrator were unaware of EBP requirements until the survey.
The facility did not ensure that two Dietary Aides completed the required Dependent Adult Abuse Mandatory Reporter Training within six months of their hire dates. Despite the facility's policy mandating such training, both employees' files lacked certification of completion. The Administrator and Administrative Assistant acknowledged this oversight.
Missing Required RN Coverage
Penalty
Summary
The facility failed to ensure a Registered Nurse (RN) worked 8 consecutive hours a day, 7 days a week. Based on facility record review, staff interviews, and policy review, nursing schedules and timecards showed no RN on duty on 2/1/25 and 8/1/25. The facility reported a census of 37 residents. On 8/19/25, the DON verified she did not work on 8/1/25 and stated she did not think about needing RN coverage and would take a day off if she could get one. The Administrator later verified the facility did not have RN coverage on 8/1/25 and on 8/20/25 verified the facility did not have RN coverage on 2/1/25. The Administrator stated the DON did the best she could with RN coverage, that the facility had only 3 RNs on staff and used agency staff as needed, and that she expected the facility to have 8 hours of RN coverage 7 days per week. The facility’s undated Registered Nurse policy stated the facility must use the services of an RN for at least 8 consecutive hours a day, 7 days a week.
Failure to Address Repeated QAPI Deficiencies
Penalty
Summary
The facility failed to correct repeated deficiencies in two areas of concern identified in prior surveys: abuse, neglect, and exploitation training, and infection prevention and control. The facility's QAPI plan, revised in April 2014, stated that it was to be an ongoing facility-wide program designed to monitor and evaluate the quality and safety of resident care, identify and resolve present and potential outcomes related to care and services, and correct identified quality and safety deficiencies. Despite those stated objectives, the current survey found that the same concerns had been cited in the past year. On 8/21/25 at 10:30 AM, the Administrator stated she was not aware of the repeated deficiencies until they were identified during this survey and said the facility would review its current process for each area of concern and provide staff education and training.
Failure to Complete Required Abuse Reporter Training
Penalty
Summary
The facility failed to provide dependent adult abuse mandatory reporter training within 6 months of hire for 2 of 5 employees reviewed, including a dietary aide and a housekeeper. Personnel file review showed one employee was hired on 12/2/24 and had no documentation of completing the required training, while another employee was hired on 10/7/24 and completed the training on 5/30/25, which was later than the facility’s expected timeframe. During interviews, the Business Office Manager verified one employee had not completed the training and acknowledged the other completed it late. The Administrator stated she expected staff to complete dependent adult abuse mandatory reporter training within 6 months of hire. The facility’s Abuse Prevention Policy, revised December 2016, required staff training and orientation on abuse prevention, identification and reporting abuse, stress management, and handling verbally or physically aggressive resident behavior, and the Administrator stated the facility did not have a specific policy related to dependent adult abuse training.
Failure to Lock Smoking Materials
Penalty
Summary
The facility failed to implement care plan interventions related to locking smoking materials for Resident #27. The resident's MDS assessment identified a BIMS score of 15, indicating intact cognition, and listed diagnoses of CVA, anxiety, and depression. The care plan focus initiated on 5/7/24 addressed smoking and stated the resident had smoked for a long time, had recently decided to quit due to the cost of cigarettes, but still occasionally smoked. The care plan also noted a history of extinguishing cigarettes on the resident's wheelchair and keeping cigarette butts stored in the wheelchair bag. Interventions directed that the resident's smoking supplies be stored at the north nurses' station. The Smoking - Safety Screen dated 7/26/25 indicated the resident needed the facility to store the lighter and cigarettes. On 8/18/25, the resident stated he smoked and rolled his own cigarettes in his room, went outside to smoke around 20-30 times a day, and could go unsupervised. On 8/20/25, the resident was observed going outside to smoke, lighting his own cigarette, and extinguishing it in the proper container, but he did not stop at the nurses' station to get his smoking materials or return them after smoking. He later stated he kept his cigarettes and lighter in his bag on his wheelchair so he would not forget them, and a CNA reported that he kept his lighter and cigarettes on him. The DON acknowledged that the care plan had not been updated related to locking the resident's smoking materials.
Care plans not updated to reflect resident needs
Penalty
Summary
The facility failed to update the care plan to accurately reflect the needs of 2 residents reviewed. Resident #8 had an MDS assessment showing a BIMS score of 5, indicating severe cognitive impairment, with diagnoses of non-Alzheimer's dementia, depression, and hypertension. After an unwitnessed fall on 6/27/25 with left hip and leg pain, the facility sent the resident to the ER for evaluation and documented that the care plan would be updated upon return from the hospital. A later fall investigation dated 7/25/25 documented another unwitnessed fall in the resident's room, with prior interventions listed as gripper socks and a seat alarm, and a new intervention to change scenery if restless and move the resident to the north dining room in a recliner to watch TV. The care plan, however, still showed the last revised intervention as 5/14/24 and did not include the fall-related updates or the new intervention. Resident #32 had an MDS assessment showing a BIMS score of 2, indicating severe cognitive impairment, with diagnoses of benign prostatic hyperplasia, Alzheimer's disease, and Parkinson's disease. On 8/19/25, staff were observed providing perineal care and catheter care, and physician orders reviewed on 8/20/25 included an order dated 8/4/25 to change the catheter every month and as needed. The resident's care plan did not document the use of an indwelling urinary catheter. During interview, the DON acknowledged the care plan was not updated to identify Resident #32's catheter and Resident #8's fall with fracture.
Failure to provide adequate supervision and effective fall interventions
Penalty
Summary
The facility failed to provide adequate nursing supervision to prevent accidents for one resident with a history of falls. Resident #13 had severely impaired cognition, required partial/moderate assistance with bed mobility and transfers, used a walker and wheelchair, and had diagnoses including CVA, non-Alzheimer's dementia, hemiplegia, repeated falls, unsteadiness on feet, transient alteration of awareness, dizziness and giddiness, low back pain, and muscle spasm of the back. The resident's care plan identified a risk for falls and included interventions such as fall mats, gripper socks, a motion sensor, and checking that the alarm worked. The resident experienced multiple falls with inconsistent or ineffective interventions documented afterward. After a fall in the bathroom area, staff found the resident without gripper socks and documented the root cause as improper footwear. After another fall in the dining room, the resident stood up unassisted and fell, and the documented root cause focused on impaired cognition and not asking for help. Another fall occurred when the bed alarm did not sound, and the resident was found on the floor near the bed; the documented root cause again focused on cognitive impairment and getting up unassisted. A later fall occurred when the resident was found on the floor in her room with bare feet because she removed her gripper socks, and the note stated the bed alarm did not work. Another fall occurred in the common area when the resident tried to transfer herself unassisted and sustained a skin tear to the right wrist. Staff interviews and record review showed the facility did not complete a thorough root cause analysis and did not consistently identify or implement effective fall interventions. The DON acknowledged she completed fall documentation for one incident and verified the resident did not have the alarm in place at the time of the fall. She also acknowledged the TAR did not contain the bed alarm for nursing staff to sign off, and stated the facility did not conduct a thorough root cause analysis. The Administrator reported the facility did not have an alarm policy in place. The Social Worker reported she programmed alarms, acknowledged the facility did not replace alarm pads every 45 days per manufacturer directions, and stated alarms were not a fall intervention and would not prevent a fall. The facility also had older alarms that did not work, the alarm volume at the nurses' desk was very low, and the resident's sensor pad lacked a start date and end date.
Improper urinary catheter bag placement
Penalty
Summary
The facility failed to provide adequate care for a urinary catheter for 1 of 1 resident reviewed, Resident #32, who had a BIMS score of 2 indicating severe cognitive impairment and diagnoses including benign prostatic hyperplasia, Alzheimer's disease, and Parkinson's disease. The resident had a urinary catheter, with an order for the catheter to be changed every month and as needed. During observations, the catheter bag was seen lying on the floor underneath the bed and later hanging on the bed while still lying on the floor without a dignity bag. The facility's Catheter Care policy stated the purpose was to prevent catheter-associated urinary tract infections and directed staff to keep the catheter tubing and drainage bag off the floor. The DON stated the catheter bag was expected to be in a dignity bag and not touching the floor.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to keep the medication cart locked or under direct observation of authorized staff for at least 7 minutes in an area where residents could access it. On 8/18/25 at 12:26 PM, the south side medication cart in the hallway near the nurse's station was observed unlocked and unsupervised. During that period, a housekeeper walked past the cart at 12:26 PM, another housekeeper walked past at 12:27 PM, and two housekeepers walked past at 12:30 PM. At 12:33 PM, Staff B, an LPN, approached the cart and verified that it was unlocked. The facility policy titled, Storage of Medications, states that compartments containing medication are locked when not in use and that trays or carts used to transport such items are not to be left unattended. During an interview on 8/21/25 at 8:27 AM, the DON confirmed medications were expected to be locked when unsupervised.
Failure to Follow Hand Hygiene and PPE Practices
Penalty
Summary
Infection prevention and control practices were not followed during wound care for a resident with intact cognition and diagnoses of diabetes mellitus, cellulitis of the left toe, and a non-pressure ulcer to the left lower leg. During observed wound treatment to the resident’s right first toe and left leg, an RN changed gloves after removing a dirty dressing from the left second toe but did not perform hand hygiene before putting on new gloves. The RN again changed gloves after completing care to the first toe and did not perform hand hygiene before applying the new gloves. The facility policy stated that hand hygiene is to be performed after removing gloves and before applying non-sterile gloves, and the DON stated staff were expected to complete hand hygiene when changing gloves. In addition, infection control practices were not followed during catheter and peri care for a resident with severe cognitive impairment and diagnoses of BPH, Alzheimer’s disease, and Parkinson’s disease. During observed care, CNAs performed hand hygiene and donned gloves, but one CNA removed gloves and applied a new pair without hand hygiene before continuing care. Staff also reused the same two black personal protective gowns for the resident’s enhanced barrier precautions by hanging them back on the door after use and reusing them for the same resident over the course of a week before laundering. Staff stated the gowns were reused for residents on EBP, and the DON acknowledged the gowns were reused and that housekeeping changed them on Monday mornings.
Failure to Submit Accurate Staffing Data to CMS
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information to the CMS Payroll Based Journal (PBJ) for Fiscal Year 2024, Quarters 1, 2, and 3. This failure was identified through a review of the PBJ Staffing Data Report, facility staffing review, policy review, and staff interviews. The facility, which reported a census of 56 residents, did not submit the required staffing data due to changes in the facility's time clock system. The Administrative Assistant/Office Manager was unaware of these changes, which resulted in the submitted reports being in an incorrect format for PBJ reporting. Consequently, the facility did not successfully submit the data for the specified quarters. The PBJ Staffing Data Reports for the mentioned quarters triggered several issues, including a failure to submit data for the quarter, a one-star staffing rating, excessively low weekend staffing, no RN hours, and a lack of licensed nursing coverage 24 hours a day. Despite these findings, a review of nursing staffing schedules for August and September 2024 showed appropriate nursing staffing, with 8-hour daily RN coverage and 24-hour licensed nursing coverage. The facility's staffing policy, revised in October 2017, states that licensed nurses and certified nursing assistants are available 24 hours a day to provide direct resident care services, and staffing numbers are determined by the needs of the residents based on their care plans.
Failure to Implement Enhanced Barrier Precautions and Proper Laundry Handling
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with an indwelling catheter, as required to prevent the spread of multidrug-resistant organisms (MDROs). Resident #23, who had intact cognition and a diagnosis of urine retention, did not have EBP set up in his room, which was confirmed during an interview with the resident. The facility's Director of Nursing and Administrator were unaware of EBP requirements until they reviewed information online during the survey. Additionally, the facility did not handle laundry from isolation rooms with the appropriate Personal Protective Equipment (PPE). A laundry aide reported that she did not wear a gown when handling isolation laundry in red bags, although she used a mask, gloves, and face shield. The aide described her process of handling the laundry, which involved placing the bag on the ground and shaking its contents into the washing machine, without wearing a gown as required by the facility's policy. The facility's failure to implement EBP and handle isolation laundry with appropriate PPE was noted during the survey. The facility's linen, laundry, and textile handling policy required staff to handle all used laundry as potentially contaminated and to use standard precautions, including wearing gowns when sorting and rinsing. The facility's lack of adherence to these guidelines contributed to the identified deficiencies.
Failure to Complete Mandatory Abuse Training
Penalty
Summary
The facility failed to ensure that two of its five employees, specifically Staff A and Staff B, met the requirements for Mandatory Adult Abuse Training. Staff A, a Dietary Aide, was hired on January 29, 2024, and was required to complete the two-hour Dependent Adult Abuse Mandatory Reporter Training by July 29, 2024. However, their employee file lacked a certification of completion. Similarly, Staff B, also a Dietary Aide, was hired on February 2, 2024, with a training due date of August 29, 2024, but their file also lacked the necessary certification. The facility's Abuse Prevention Policy, revised in December 2016, mandates staff training on abuse prevention, identification, and reporting, among other topics. During interviews, both the Administrator and the Administrative Assistant/Office Manager acknowledged that the employees should have completed the training within six months of their hire date, but they did not.
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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.
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Nursing homes near Sheffield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rockwell Community Nursing Home | 6.9 mi | ★★★★★ | 4 | 0 |
| Franklin General Hospital | 10.5 mi | ★★★★★ | 0 | 0 |
| Rehabilitation Center Of Hampton | 10.8 mi | ★★★★★ | 2 | 0 |
| I O O F Home And Community Therapy Center | 16.8 mi | ★★★★★ | 3 | 0 |
| Heritage Care And Rehabilitation Center | 17.8 mi | ★★★★★ | 7 | 0 |
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