Inspection Reports for Sheffield Care Center
100 Bennett Drive, IA, 504750400
Back to Facility ProfileInspection Report Summary
The most recent inspection on November 4, 2025, did not identify any deficiencies and resulted in certification of compliance. Prior inspections showed a pattern of deficiencies related mainly to care planning, infection control, nursing staffing, medication security, and staff training on abuse prevention. Complaint investigations were generally unsubstantiated, with one substantiated issue involving incomplete assessments before and after outpatient dialysis that was addressed. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility’s record suggests some improvement over time, with recent inspections showing fewer and less extensive deficiencies compared to earlier years.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
3.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
20% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
37 residents
Based on a August 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Plan of Correction
Deficiencies: 0
Nov 4, 2025
Visit Reason
The document is a statement of deficiencies and plan of correction related to the facility's compliance status.
Findings
The facility submitted a credible allegation of compliance and plan of correction, resulting in certification of compliance effective August 27, 2025. No specific deficiencies are detailed in this document.
Inspection Report
Annual Inspection
Census: 37
Deficiencies: 7
Aug 21, 2025
Visit Reason
The inspection was an annual recertification survey conducted from August 18 to August 21, 2025, to assess compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.
Findings
The facility was found not in compliance with multiple requirements including comprehensive care plan development and implementation, free of accident hazards, nursing care staffing, medication cart security, infection control, and abuse prevention training. Deficiencies were identified related to care planning, fall prevention, catheter care, nursing staffing, medication storage, infection control practices, and staff training on abuse prevention.
Severity Breakdown
SS = D: 5
SS = F: 2
SS = E: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Facility failed to develop and implement a comprehensive person-centered care plan including smoking interventions and care plan updates for residents with indwelling catheters and falls. | SS = D |
| Facility failed to provide adequate nursing supervision to prevent accidents for 1 of 3 residents reviewed for falls. | SS = D |
| Facility failed to ensure resident with urinary catheter received appropriate care; catheter bag was lying on the floor without dignity bag. | SS = D |
| Facility failed to ensure a Registered Nurse worked 8 consecutive hours a day, 7 days a week as required. | SS = F |
| Facility failed to keep medication cart locked and unattended for a minimum of 7 minutes in an area accessible to residents. | SS = D |
| Facility failed to ensure infection control practices including hand hygiene and use of protective gowns were followed consistently. | SS = D |
| Facility failed to provide dependent adult abuse certification training to staff within 6 months of hire. | SS = E |
Report Facts
Deficiencies cited: 8
Census: 37
Fall Risk Assessment Scores: 13
Fall Risk Assessment Scores: 27
Fall Risk Assessment Scores: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Acknowledged missed updates to Resident #27's and Resident #32's care plans and fall documentation for Resident #13. |
| Staff G | Certified Nurse Aide (CNA) | Reported Resident #27 kept lighter and cigarettes on him. |
| Staff F | Certified Nurse Assistant (CNA) | Observed Resident #32 perineal care and catheter care; failed hand hygiene between changing gloves during catheter care. |
| Staff H | Certified Nursing Assistant (CNA) | Reported Resident #13's alarm went off and transferred Resident #13. |
| Administrator | Administrator | Reported facility lacked alarm policy and discussed fall interventions and staff training. |
| Staff A | Registered Nurse (RN) | Failed to disinfect hands between changing gloves during wound treatments. |
| Staff C | Personnel file | Personnel file lacked documentation of Dependent Adult Abuse Mandatory Reporter Training. |
| Staff D | Personnel file | Personnel file lacked documentation of Dependent Adult Abuse Mandatory Reporter Training. |
Inspection Report
Plan of Correction
Deficiencies: 0
Nov 5, 2024
Visit Reason
The document is a Plan of Correction related to Sheffield Care Center's compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities following a credible allegation of substantial compliance.
Findings
Sheffield Care Center is in compliance with the regulatory requirements based on acceptance of the credible allegation of substantial compliance and the submitted Plan of Correction. The facility will be certified in compliance effective October 2, 2024.
Inspection Report
Annual Inspection
Census: 35
Deficiencies: 3
Sep 26, 2024
Visit Reason
The inspection was conducted as the facility's annual recertification survey from September 23 to September 26, 2024.
Findings
The facility was found non-compliant with requirements including failure to submit Payroll Based Journal staffing data, lack of Enhanced Barrier Precautions for infection control, and failure to ensure mandatory adult abuse training for some staff. The facility had appropriate nursing staffing but failed in data submission and infection prevention protocols.
Severity Breakdown
Level E: 1
Level D: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to submit complete and accurate direct care staffing information to CMS Payroll Based Journal for Fiscal Year Quarters 1, 2, and 3, 2024. | Level E |
| Failure to initiate Enhanced Barrier Precautions (EBP) for a resident with an indwelling catheter and failure to handle isolation laundry with appropriate PPE. | Level D |
| Failure to ensure 2 of 5 employees completed mandatory Adult Abuse Training within required timeframe. | Level D |
Report Facts
Resident census: 35
Resident census: 56
Deficiency count: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Dietary Aide | Failed to complete mandatory Adult Abuse Training |
| Staff B | Dietary Aide | Failed to complete mandatory Adult Abuse Training |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 26, 2024
Visit Reason
Investigation of complaint #119258-C at Sheffield Care Center.
Findings
The facility was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities. The complaint #119258-C was not substantiated.
Complaint Details
Complaint #119258-C was investigated and found not substantiated.
Inspection Report
Plan of Correction
Deficiencies: 0
Dec 6, 2023
Visit Reason
The document is a Plan of Correction submitted following a prior inspection, indicating acceptance of credible allegation of substantial compliance and certification of the facility in compliance effective December 6, 2023.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction submitted, resulting in certification of compliance effective December 6, 2023.
Inspection Report
Annual Inspection
Census: 33
Deficiencies: 1
Nov 16, 2023
Visit Reason
The inspection was conducted as the facility's annual recertification survey from November 13, 2023 to November 16, 2023.
Findings
The facility failed to follow standard infection prevention and control practices during wound care for one of two residents reviewed, specifically Resident #28. The wound care nurse did not maintain a clean field or change gloves appropriately, which was a concern for infection control.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to establish and maintain an infection prevention and control program, including failure to follow infection prevention during wound care. | SS=D |
Report Facts
Resident census: 33
Deficiency correction date: Correction date set as 12-16-23
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN) | Conducted wound care on Resident #28 and failed to maintain infection control procedures |
| Director of Nursing | DON | Present during wound care observation and acknowledged infection control concerns |
Inspection Report
Plan of Correction
Deficiencies: 0
Sep 6, 2023
Visit Reason
The document is a Plan of Correction submitted following a prior inspection, indicating acceptance of a credible allegation of substantial compliance.
Findings
The facility was found to be in substantial compliance based on the accepted Plan of Correction, resulting in certification of compliance effective September 6, 2023.
Inspection Report
Complaint Investigation
Census: 30
Deficiencies: 1
Sep 5, 2023
Visit Reason
The inspection was conducted as a result of investigation of complaints #108966-C and #114498-C from August 30, 2023 to September 5, 2023.
Findings
The facility failed to ensure assessments before and after outpatient hemodialysis treatments were completed for one resident requiring dialysis. Documentation was lacking for pre and post dialysis assessments, dialysis evaluations on non-dialysis days, and vital signs monitoring. The Director of Nursing acknowledged the assessments had not been completed and planned to start them immediately.
Complaint Details
Complaints #108966-C and #114498-C were investigated and found to be unsubstantiated.
Deficiencies (1)
| Description |
|---|
| Failure to ensure assessments before and after outpatient hemodialysis treatments were completed for one resident requiring dialysis. |
Report Facts
Resident reviewed for dialysis: 1
Census: 30
Dates resident should have attended hemodialysis: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Staff A, LPN, reported Resident #4 had a port for dialysis and did not complete vital signs or assessments after dialysis. | |
| Director of Nursing (DON) | Acknowledged and verified pre and post dialysis assessments had not been completed and stated assessments would start immediately. |
Inspection Report
Annual Inspection
Deficiencies: 0
Oct 27, 2022
Visit Reason
An annual recertification survey was conducted from October 24, 2022 to October 27, 2022.
Findings
The facility was found to be in substantial compliance with no deficiencies cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 12, 2021
Visit Reason
Investigation of facility complaint #99971-C conducted from 10/8/21 to 10/12/21.
Findings
The complaint investigation resulted in no deficiencies and the complaint was not substantiated.
Complaint Details
Complaint #99971 was not substantiated.
Inspection Report
Annual Inspection
Census: 27
Deficiencies: 9
May 25, 2021
Visit Reason
The inspection was conducted as the facility's annual survey to assess compliance with federal regulations.
Findings
The facility was found deficient in multiple areas including failure to develop and implement comprehensive care plans addressing pain, inadequate documentation and treatment of pressure ulcers, improper respiratory care including oxygen administration without proper orders, insufficient CPR certified staff coverage, failure to prepare food according to residents' dietary needs and allergies, unsanitary kitchen conditions, incomplete quality assurance committee meetings, and lapses in infection prevention and control practices.
Severity Breakdown
SS=D: 7
SS=E: 1
SS=B: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Failure to address pain in the comprehensive care plan for Resident #23. | SS=D |
| Failure to document weekly progress of care for a pressure ulcer for Resident #23. | SS=D |
| Failure to provide respiratory care consistent with professional standards; oxygen administered continuously without physician's order for Resident #23. | SS=D |
| Failure to ensure 24-hour CPR certified nursing staff coverage. | SS=D |
| Failure to prepare food in a form meeting individual needs; Resident #11 served regular goulash with corn instead of mechanical soft diet. | SS=D |
| Failure to accommodate resident allergies and preferences; Residents #18 and #26 served foods containing corn and tomato respectively, contrary to dietary restrictions. | SS=D |
| Failure to maintain sanitary food procurement, storage, preparation, and serving areas; broken floor tile, sticky cupboards, and calcium buildup on ice machine. | SS=E |
| Failure to hold quarterly Quality Assurance meetings with required minimum members including Medical Director or designee. | SS=B |
| Failure to conduct annual review of infection prevention and control policies and failure to follow infection control standards including improper linen transport and failure to change oxygen tubing as per protocol. | SS=D |
Report Facts
Census: 27
Deficiency count: 9
CPR certified nurses: 3
Dates missing pressure ulcer assessments: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Involved in review and acknowledgement of care plan deficiencies and oxygen order issues for Resident #23 | |
| MDS Nurse | Involved in review and acknowledgement of care plan deficiencies and oxygen order issues for Resident #23 | |
| Dietitian | Acknowledged dietary errors related to Resident #11, #18, and #26 | |
| Dietary Manager | Acknowledged dietary errors and kitchen sanitation issues | |
| Nursing Home Administrator | Involved in QA meeting attendance and infection control policy review | |
| Housekeeping and Laundry Services Supervisor | Observed transporting linens without covering | |
| Housekeeping and Laundry Staff | Observed transporting residents' clothing without covering |
Inspection Report
Routine
Census: 30
Deficiencies: 0
Jul 28, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals on 7/27/20 - 7/28/20 to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total residents: 30
Inspection Report
Abbreviated Survey
Census: 32
Deficiencies: 0
Jun 22, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total residents: 32
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