Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Manor Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A resident was hit in the face by another resident, and the resident later reported that this was not the first time and that she did not feel safe around him. Social Services stated a safety assessment was completed after the abuse allegation, but there was no documentation of a follow-up or psychosocial assessment in the EHR, and the DON also could not locate documentation after a prior similar incident.
Unsanitary kitchen and damaged laundry flooring. Surveyors observed heavily soiled kitchen vents, ceiling tiles, stove surfaces, fryer grease, sink drains, and floors with embedded crumbs, grease, and food residue. In the laundry area, peeling paint, cracked concrete, soiled flooring, and broken or cracked tiles were noted in the washing machine area, clean linen room, and dirty laundry room. The DM and MD acknowledged cleaning and flooring issues, and the DM said staffing responsibilities were being adjusted after the prior cleaning person left.
Unsafe food storage, thawing, and sanitation practices were observed in the dietary area. The tray line was over 100 degrees with staff perspiring heavily, raw chicken sat on the counter, turkey cubes and ground beef were thawing improperly in sinks, vendor-delivered food was stored on the floor without a pallet, a dietary aide could not identify the sanitizing immersion time for pots and pans, and employee coats and hats were hanging among food supplies. The ADM, DON, and RD stated the dietary department was changing and addressing concerns, and the facility policy did not specifically address the cited issues.
A resident with multiple neurologic and psychiatric conditions, who was cognitively intact and required extensive one-person assistance with most ADLs, reported that a CNA became upset during incontinence care, criticized the resident for needing to be changed, and tossed a brief at the resident while the resident was on the toilet, causing emotional distress. The resident later told Social Services about the incident and expressed not wanting to be around that CNA. Despite this, assignment records showed the CNA continued to be assigned to the resident’s room on several later dates, and the resident reported that the CNA would enter the room, ignore the resident, and provide care only to the roommate, leading the resident to leave the room whenever the CNA appeared. The NHA stated they were unaware the CNA continued to have contact with the resident and that the aide should have been removed from the unit, in contrast to the facility’s Resident Rights policy requiring protection of each resident’s dignity and right to a comfortable living environment.
Failure to report and investigate suspected STD: A resident with severe cognitive impairment and diagnoses including vascular dementia had white bumps and swelling on the vaginal labia, and the MD ordered acyclovir for herpes treatment. STD testing later showed HSV type 1 and type 2, but the DON, Nurse Manager, and NHA/Abuse Coordinator did not report the incident to the Abuse Coordinator or State Agency and did not initiate an investigation, stating they did not consider it abuse and believed the labs showed only herpes antibodies.
Failure to Investigate Suspected Sexual Abuse Related to Genital Lesions and HSV Testing: A resident with severe cognitive impairment developed white bumps and swelling on the vaginal labia, was started on acyclovir, and had an STD panel ordered that later showed HSV-1 and HSV-2 positivity. The DON, NHA, and Nurse Manager did not treat the findings as a possible abuse concern or initiate an investigation, with the NHA stating the HSV antibodies meant the resident had herpes before and there was no reason to investigate.
A resident had a bottle of hydrogen peroxide stored on her bedside table on multiple observations, despite staff stating it should not have been there. The resident was alert and oriented times two, able to self-propel in a wheelchair, and could reach items on the table. Staff reported she had a history of behaviors including spitting and hitting others, and the DON identified the hydrogen peroxide as a hazardous material. Record review showed no order or assessment for self-administration and no care plan interventions related to self-administration.
Insufficient dietary staffing to maintain kitchen sanitation. The Dietary Manager stated the department was budgeted for 9 employees per day and that, after a stock person was let go, staff including the DM were covering duties such as cleaning equipment, rotating stock, and cleaning floors. The Administrator, DON, and RD confirmed the current staffing allocation but did not provide the exact budgeted hours or the basis for staffing, and no details were given to explain the lack of personnel for sanitation tasks.
Failure to Track and Investigate Resident HSV Infection: A resident with severe cognitive impairment was found with white raised bumps and swelling on the vaginal labia, and a physician ordered acyclovir and STD testing. Staff did not recognize the significance of the findings, did not discuss the event with the DON or abuse coordinator, and the IP stated the resident did not need monitoring. The NHA said the positive HSV labs meant there was no need to report or investigate, despite the DON later stating the unexplained HSV results should have been reported and investigated.
The facility failed to maintain an effective Antibiotic Stewardship program, leading to inappropriate antibiotic administration for three residents. One resident was prescribed Cipro without meeting infection criteria, another received Keflex without documented symptoms, and a third was incorrectly listed for Gentamycin ointment for a respiratory infection. The facility's protocols, based on McGeer's Criteria, were not followed, and there was a lack of necessary documentation in the residents' records.
A facility failed to implement Enhanced Barrier Precautions (EBP) during medication administration via a gastric tube for a resident. Despite signage indicating the need for EBP, an LPN did not wear a gown while administering medications. The resident required substantial assistance and had a medical device, necessitating EBP to prevent infection spread. The facility's policy required EBP for residents with medical devices.
A resident with severe cognitive impairment fell from a geri-chair due to inadequate positioning and lack of appropriate interventions, resulting in a laceration and emergency room visit. The care plan did not address the use of the geri-chair or fall prevention measures, and interventions were only implemented after the incident.
Failure to Document Safety Assessment After Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to protect one resident, R102, from psychosocial harm after a resident-to-resident abuse allegation involving R101. On 02/15/2026, R102 was reportedly sitting in the hallway when R101 rolled past in a wheelchair, stopped, and hit R102 in the face. Nurse A documented that R102 was punched in the face unprovoked on the left side, and R102 later stated that R101 had hit her before, tried to enter her room, and that she screamed and used the call light when he approached. R102 said she was afraid R101 would hit her again, did not feel safe, and ate in her room to stay away from him. R102 was cognitively intact per the MDS with a BIMS score of 15.
Unsanitary kitchen and damaged laundry flooring
Penalty
Summary
The nursing home failed to effectively clean and maintain the physical plant in the kitchen and laundry areas. During a kitchen tour, surveyors observed heavily soiled air vent covers and adjacent ceiling tiles over the tray line, rust and corrosion on ceiling tile strips over the steam table and dish room area, a Bakers Pride convection stove with burnt ash, food residue, yellowish stains, grease splatter, and collected food particles, a deep fat fryer with dark grease and floating debris, soiled and discolored water drains under the three-compartment sink, and floors throughout the kitchen and dish room that needed deep cleaning with crumbs, grease, and food preparation liquids embedded in cracked tile crevasses and edges. In the laundry facility, surveyors observed peeling floor paint on the concrete flooring in front of the washing machines, a crack in the concrete floor directly in front of the washing machines, soiled flooring on the sides and behind the washing machines, five cracked floor tiles in the clean linen room, and four broken or cracked floor tiles in the dirty laundry room. The Maintenance Director stated the flooring should be repaired and repainted and the cracked or broken tiles should be replaced, and acknowledged the floor could not be effectively cleaned due to the damaged flooring. The Dietary Manager stated the department had a cleaning schedule, staff should be cleaning as they worked, the floor should be cleaned at least twice a day, and the facility was making adjustments in staff responsibilities after the cleaning person previously assigned was no longer there.
Unsafe Food Storage, Thawing, and Kitchen Sanitation Practices
Penalty
Summary
The facility failed to utilize safe food practices and provide a safe and sanitary kitchen for food storage, preparation, and service, affecting 90 residents. During observation of the tray line, the ambient room temperature was over 100 degrees Fahrenheit, three of four employees were observed with soaked perspired uniforms and facial masks, and one employee was seen perspiring profusely and stating, "I need some air in here." At the same time, a large clear container of raw chicken was stored on the counter for approximately 20 minutes, and the kitchen air conditioning units were observed off or not working. Additional observations showed a colander of diced turkey cubes thawing in the first sink of the three-compartment sink, and later 6-7 rolls of ground beef thawing in standing water in the cook's sink. A dietary aide could not correctly identify the immersion time frame for sanitizing pot and pans in the sink. A local vendor delivered 21 assorted boxes of frozen and staple food supplies that were stored on the floor without a pallet, and the dietary manager later labeled and put away the items, stating there was no stock person and one position was not filled. Employee personal clothing, including a hat and coat, was also observed hanging in the kitchen from a storage rack among food supplies. The administrator, DON, and RD stated the dietary department was in the process of changing and addressing concerns, and the facility policy titled Dietary Cleaning and Sanitation did not specifically address the cited deficiencies.
Failure to Ensure Dignified, Respectful Care and Appropriate Staff Assignment After Resident Complaint
Penalty
Summary
The deficiency involves a failure to honor a resident’s right to dignity and respect during incontinence and ADL care. A cognitively intact resident with Parkinson’s disease, vascular dementia, hemiplegia, cerebral infarction, generalized anxiety disorder, major depressive disorder, and other psychiatric diagnoses reported that a CNA became upset when the resident needed to be changed. The resident stated that while in the bathroom on the toilet, the CNA questioned why the resident had waited so long to be changed, said the resident was “always doing this,” and then tossed a brief at the resident. The resident reported feeling hurt by this interaction and responded by cursing at the CNA. The resident later told Social Services about the incident, describing that a CNA had thrown a “pamper” at her and expressing uncertainty about what would happen and a desire not to be around that CNA anymore. Despite this reported incident and the resident’s expressed discomfort, facility records showed that the CNA continued to be assigned to the resident’s room on multiple subsequent dates. The resident reported that although the CNA apologized and the resident accepted the apology, the resident no longer felt good about what had happened and felt that the trust was gone. The resident stated that the CNA would come into the room, walk past without speaking, and provide care only to the roommate, prompting the resident to leave the room whenever the CNA entered. The Nursing Home Administrator later stated that the Abuse Coordinator was responsible for ensuring the CNA’s assignment was away from the resident and acknowledged being unaware that the CNA continued to have contact with the resident, stating that the aide should have been removed from the unit and that the resident had the right to feel comfortable in the bedroom. The facility’s Resident Rights policy states that the facility protects and promotes each resident’s right to a dignified existence, self-determination, and communication, and that residents have freedom of choice about how they wish to live their everyday lives and receive care.
Failure to Report and Investigate Suspected STD
Penalty
Summary
The facility failed to implement policies and procedures for timely reporting and investigation of a suspected sexually transmitted disease for a vulnerable resident with severe cognitive impairment. The resident was admitted with diagnoses including vascular dementia with agitation, depressive disorder, and chronic obstructive pulmonary disease, and had a BIMS score of 00. Her record did not show a herpes virus diagnosis or review of prior records from another facility. On 8/15/25, an RN documented white bumps on the resident’s vaginal labia, swelling of the labia, and no complaints of pain or itching, and later that day the physician ordered acyclovir for 7 days. A laboratory order created on 8/19/25 showed STD testing, and results later revealed positive Herpes Simplex Virus type 1 and type 2. During interviews, the DON and Nurse Manager stated they did not report the STD incident to the Abuse Coordinator, and the NHA/Abuse Coordinator stated it was not a case of abuse and there was no reason to report it to the State Agency. The Abuse Coordinator also stated the labs proved the resident had herpes antibodies and therefore there was no need to report or investigate, but could not explain why the suspicious incident was not reported at the time it occurred and followed by an investigation.
Failure to Investigate Suspected Sexual Abuse Related to Genital Lesions and HSV Testing
Penalty
Summary
The facility failed to investigate a suspected sexually transmitted disease for a vulnerable resident with severe cognitive impairment. R64 was admitted with diagnoses including vascular dementia with agitation, depressive disorder, and COPD, and had a BIMS score of 00. The resident was also documented as unable to ambulate and requiring a geri chair for locomotion. The facility’s abuse prohibition policy stated that allegations of resident abuse, exploitation, neglect, adverse event, or mistreatment shall be thoroughly investigated and documented by the Administrator and reported to the appropriate state agencies. On 8/15/2025, RN H documented white bumps on R64’s vaginal labia, multiple whitish raised bumps, and swollen labia, with no complaint of pain or itching. That same day, Doctor K ordered acyclovir for 7 days. On 8/19/2025, Nurse Manager M entered laboratory orders for an STD panel that included HSV-1, HSV-2, HIV antibody, syphilis antibody, chlamydia, and gonorrhea testing. The labs were collected by an outside agency on 8/29/2025, and results later showed R64 positive for HSV type 1 and type 2. During interviews, the DON and Nurse Manager M stated they did not remember the incident and did not consider sexual abuse when the genital lesions and STD testing occurred. Nurse Manager M stated she did not question the reason for the STD labs and did not discuss the condition with the DON or the Abuse Coordinator. The NHA stated the facility did not investigate because the HSV antibodies showed R64 had herpes before and said there was no reason to investigate. The DON later stated the situation should have been investigated and was unsure how it was missed.
Hazardous Material Stored at Resident Bedside
Penalty
Summary
The facility failed to ensure that a bottle of hydrogen peroxide was not stored at the bedside for one resident. On 2/24/2026, surveyors observed a bottle of hydrogen peroxide on the resident’s bedside table in view from the doorway, positioned in front of a container with the resident’s name on it. The resident stated the bottle was hers but could not explain why she had it. The resident was observed in a wheelchair, able to self-propel, and able to reach items on the bedside table. She was alert and oriented times two and was difficult to understand. The hydrogen peroxide was again observed on the resident’s bedside table on 2/25/2026. An RN was observed entering the room and making the resident’s bed, and later an LPN stated the resident should not have hydrogen peroxide at bedside and described it as a potential accident due to her behaviors. The LPN reported the resident had a history of spitting and hitting other residents and staff. The DON stated the hydrogen peroxide should not have been at bedside because it was a hazardous material and said the resident had a history of behaviors and lived on the lockdown unit for increased supervision. Record review showed diagnoses of schizophrenia, adjustment disorder with mixed anxiety and depressed mood, dysphagia, and violent behavior, with no order allowing self-administration of medications or hydrogen peroxide, no interdisciplinary self-administration assessment, and no care plan interventions for self-administration. The facility policy stated self-administration requires physician authorization, evaluation, and care plan reflection.
Insufficient dietary staffing to maintain kitchen sanitation
Penalty
Summary
The facility failed to ensure adequate supportive personnel were available to consistently maintain kitchen sanitation and carry out food and nutrition service functions. During observation of the kitchen sanitation, the Dietary Manager stated the department was budgeted for 9 employees a day Monday through Friday, including fine dining for lunch, and that no overtime could be used. The Dietary Manager also stated that about three weeks earlier a stock person had been let go, and that this employee had helped clean kitchen equipment, rotate stock, and ensure the floors were cleaned and other kitchen tasks were completed. Since that vacancy, all staff, including the Dietary Manager, had been pitching in to complete the stock person’s duties. During interview, the Administrator, DON, and Registered Dietitian confirmed the department was currently allocated 9 budgeted employees but did not provide the exact budgeted hours or the basis used to determine staffing for those 9 employees. The staffing schedule showed an A.M. shift with 1 cook, 3 aides, and 1 porter seven days a week, and a P.M. shift with 1 cook, 2 aides, and 1 porter seven days a week. The Administrator stated the Dietary Manager was a working supervisor and that the allotted hours should be sufficient, but no actual numbers or other details were provided concerning the department’s lack of personnel to perform and maintain sanitation.
Failure to Track and Investigate Resident HSV Infection
Penalty
Summary
The facility failed to implement and operationalize a comprehensive infection prevention and control program, including outcome and process surveillance, accurate data collection, documentation, analysis, and tracking for one resident with an infection-related event. The resident had an admission diagnosis of vascular dementia with agitation, depressive disorder, and chronic obstructive pulmonary disease, and a BIMS score of 00 indicating severe cognitive impairment. The resident’s care plan directed staff to observe skin during showers and care and to notify the nurse immediately of any new skin breakdown, redness, blisters, bruises, or discoloration. Progress notes documented that the resident was found with white bumps on the vaginal labia, with multiple whitish raised bumps and swollen labia, and no complaints of pain or itching. A physician ordered acyclovir the same day, and a nurse manager later entered laboratory orders for STD testing, including HSV-1, HSV-2, HIV antibody, syphilis antibody, chlamydia, and gonorrhea. The laboratory results later showed positive HSV type 1 and type 2. During interviews, the DON and nurse manager stated they did not remember the incident, and the nurse manager said she did not think anything of the STD labs, did not question why they were ordered, and did not discuss the vaginal blisters, acyclovir, or STD labs with the DON or abuse coordinator. The infection preventionist stated she received the resident being started on acyclovir on her dashboard, but said the physician ordered the antiviral and that was it, and that the resident did not need to be monitored. The NHA, who was also the abuse coordinator, stated the lab results proved the resident had herpes antibodies and there was no need to report or investigate. The DON later stated the unexplained positive HSV type 1 and type 2 should have been reported and investigated, and that the care plan and diagnosis list should have been updated. The facility’s infection prevention policy stated resident infection cases are monitored by the infection preventionist, who completes the infection surveillance tracking tool, reports to the infection prevention committee, provides feedback to staff, reports notifiable diseases to the local health department as directed, and monitors and documents compliance through surveillance and observation.
Inadequate Antibiotic Stewardship in LTC Facility
Penalty
Summary
The facility failed to maintain an effective Antibiotic Stewardship program, as evidenced by the inappropriate administration of antibiotics to three residents. The Director of Nursing (DON) acknowledged that the facility's protocols for antibiotic administration were not followed, and infection criteria were not met. The facility's Infection Prevention Program, which follows McGeer's Criteria, was not properly implemented, leading to the prescription of antibiotics without sufficient justification. For one resident, Cipro was prescribed without a start or stop date, and there was no Infection Report or McGeer Criteria for Infection Surveillance Checklist (MCISC) available. The resident's Electronic Health Record (EHR) indicated a diagnosis of bladder cancer with frequent pain, but the criteria for a urinary tract infection were not met. Another resident was prescribed Keflex for a skin infection without documented signs and symptoms, and the EHR lacked the necessary MCISC form. A progress note indicated no drainage from the surgical site, suggesting the prescription did not follow McGeer's protocol. A third resident was incorrectly listed as receiving Gentamycin ointment for a respiratory infection, which was a mistake. The resident's EHR showed prescriptions for three antibiotics, including Gentamycin for a heel skin infection and two others for pneumonia. The facility had experienced turnover in the Infection Control Nurse position, which may have contributed to the oversight. The facility's Antibiotic Stewardship program emphasizes the importance of appropriate prescribing to prevent unnecessary treatment and antibiotic resistance, but these protocols were not adhered to in these cases.
Failure to Implement Enhanced Barrier Precautions During Medication Administration
Penalty
Summary
The facility failed to ensure that Enhanced Barrier Precautions (EBP) were followed during the administration of medications via a gastric tube for a resident. On the specified date, signage was observed on the resident's door indicating that EBP should be worn when providing care. However, an LPN entered the resident's room and administered medications without applying a gown, which is part of the required EBP. The resident had a pertinent diagnosis of gastrostomy status and required substantial/maximal assistance with most Activities of Daily Living (ADLs). The resident's electronic medical record and care plan documented the need for EBP due to the presence of a medical device. During an interview, the LPN acknowledged that a gown and gloves should be worn when administering medications to residents with a gastric tube. The Director of Nursing confirmed that the LPN should have applied EBP to prevent the spread of infections. The facility's policy on EBP, dated prior to the incident, outlined the necessity of these precautions for residents with medical devices to prevent the transmission of multidrug-resistant organisms.
Failure to Prevent Fall from Geri-Chair
Penalty
Summary
The facility failed to ensure the safe positioning of a resident in a geri-chair, implement appropriate interventions to prevent falls, and provide adequate post-fall interventions. A resident, identified as R303, who had severe cognitive impairment and required substantial assistance for daily activities, was observed in a geri-chair with thick, slippery cushions. The resident's care plan did not include the use of a geri-chair or any interventions for falls, despite being at risk. On a specific date, the resident was found on the floor with a laceration above their right eye after sliding out of the geri-chair, which led to an emergency room visit. The facility's incident report and post-fall evaluation noted the use of extra padding on the geri-chair as a factor in the fall. However, the care plan for falls was only implemented the day after the incident, and it did not address the use of the geri-chair or the cushions. Interviews with the facility's Director of Nursing revealed an acknowledgment of the inappropriate care plan interventions in place at the time of the fall. The facility's policy on fall management required the review and revision of care plans following a fall, but this was not adequately executed prior to the incident.
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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 Detroit
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Westwood Nursing Center | 0.7 mi | ★★★★★ | 21 | 0 |
| The Orchards At Northwest | 0.7 mi | ★★★★★ | 22 | 0 |
| Hartford Nursing & Rehabilitation Center | 1.4 mi | ★★★★★ | 23 | 0 |
| Oakpointe Senior Care And Rehab Center | 1.9 mi | ★★★★★ | 0 | 0 |
| The Villa At Great Lakes Crossing | 3.1 mi | ★★★★★ | 8 | 0 |
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