Inspection Reports for
Sheffield Care Center
100 Bennett Drive, Sheffield, IA, 504750400
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
5.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
32% worse than Iowa average
Iowa average: 4.4 deficiencies/year
Deficiencies per year
16
12
8
4
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.
Occupancy over time
Inspection Report
Plan of Correction
Deficiencies: 0
Date: 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
Routine
Census: 37
Deficiencies: 9
Date: Aug 21, 2025
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with care plan development, fall prevention, catheter care, medication storage, staffing, infection control, and staff training requirements.
Findings
The facility was found deficient in multiple areas including failure to implement and update resident care plans, inadequate fall prevention and root cause analysis, improper catheter care, failure to maintain required RN staffing hours, unlocked medication cart, ineffective infection control practices including hand hygiene and reuse of gowns, and failure to provide timely dependent adult abuse training for staff.
Deficiencies (9)
Failed to implement care plan interventions related to locking smoking materials for Resident #27.
Failed to update care plans to reflect resident needs for Residents #8 and #32.
Failed to provide adequate nursing supervision and root cause analysis to prevent falls for Resident #13.
Failed to provide adequate catheter care for Resident #32; catheter bag found on floor.
Failed to ensure RN coverage for at least 8 consecutive hours on 2/1/25 and 8/1/25.
Medication cart left unlocked and unsupervised for over 7 minutes.
Failed to correct repeated deficiencies related to abuse training and infection control.
Failed to follow infection control practices including hand hygiene between glove changes and reuse of gowns for Resident #32.
Failed to provide dependent adult abuse certification training within 6 months of hire for 2 staff members.
Report Facts
Census: 37
Fall Risk Assessment Scores: 27
Fall Risk Assessment Scores: 20
Fall Risk Assessment Scores: 13
Injury measurements: 3
Injury measurements: 2.1
Injury measurements: 4
Alarm pad life: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Licensed Practical Nurse (LPN) | Observed medication cart unlocked and provided catheter and g-tube care |
| Staff A | Registered Nurse (RN) | Observed failing to perform hand hygiene between glove changes during wound care |
| Staff E | Certified Nursing Assistant (CNA) | Observed providing catheter and perineal care without proper hand hygiene |
| Staff F | Certified Nursing Assistant (CNA) | Observed providing catheter and perineal care and reusing gowns |
| Staff G | Certified Nurse Aide (CNA) | Reported Resident #27 kept lighter and cigarettes on him |
| Staff H | Certified Nursing Assistant (CNA) | Reported Resident #13's alarm use and maintenance |
| Director of Nursing | Director of Nursing (DON) | Acknowledged missed care plan updates, fall documentation, and infection control issues |
| Administrator | Facility Administrator | Reported expectations for RN coverage and fall prevention policies |
| Business Office Manager | Business Office Manager (BOM) | Verified staff abuse training deficiencies |
| Staff C | Dietary Aide | Lacked dependent adult abuse training within 6 months of hire |
| Staff D | Housekeeper | Completed dependent adult abuse training late |
Inspection Report
Annual Inspection
Census: 37
Deficiencies: 7
Date: 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.
Deficiencies (7)
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.
Facility failed to provide adequate nursing supervision to prevent accidents for 1 of 3 residents reviewed for falls.
Facility failed to ensure resident with urinary catheter received appropriate care; catheter bag was lying on the floor without dignity bag.
Facility failed to ensure a Registered Nurse worked 8 consecutive hours a day, 7 days a week as required.
Facility failed to keep medication cart locked and unattended for a minimum of 7 minutes in an area accessible to residents.
Facility failed to ensure infection control practices including hand hygiene and use of protective gowns were followed consistently.
Facility failed to provide dependent adult abuse certification training to staff within 6 months of hire.
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
Date: 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
Census: 56
Deficiencies: 3
Date: Sep 26, 2024
Visit Reason
The inspection was conducted to review the facility's compliance with CMS Payroll Based Journal (PBJ) Staffing Data Report submission requirements, infection prevention and control program implementation, and staff training on mandatory adult abuse reporting.
Findings
The facility failed to submit required staffing data for three quarters in 2024, lacked knowledge and implementation of Enhanced Barrier Precautions for infection control, and did not ensure two employees completed mandatory adult abuse training. The facility reported minimal harm or potential for actual harm with some residents affected.
Deficiencies (3)
Failed to submit staffing data for Fiscal Year 2024 Quarters 1, 2, and 3, resulting in a One Star Staffing Rating and lack of licensed nursing coverage 24 hours/day.
Failed to initiate Enhanced Barrier Precautions (EBP) for a resident with an indwelling catheter and failed to wear appropriate PPE when handling isolation laundry.
Failed to assure 2 of 5 employees completed the required Mandatory Adult Abuse Training within six months of hire.
Report Facts
Census: 56
Census: 35
Deficiencies cited: 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
Annual Inspection
Census: 35
Deficiencies: 3
Date: 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.
Deficiencies (3)
Failure to submit complete and accurate direct care staffing information to CMS Payroll Based Journal for Fiscal Year Quarters 1, 2, and 3, 2024.
Failure to initiate Enhanced Barrier Precautions (EBP) for a resident with an indwelling catheter and failure to handle isolation laundry with appropriate PPE.
Failure to ensure 2 of 5 employees completed mandatory Adult Abuse Training within required timeframe.
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
Date: Jun 26, 2024
Visit Reason
Investigation of complaint #119258-C at Sheffield Care Center.
Complaint Details
Complaint #119258-C was investigated and found not substantiated.
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.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: 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
Routine
Census: 33
Deficiencies: 1
Date: Nov 16, 2023
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control practices, specifically related to wound care for Resident #28.
Findings
The facility failed to follow standard infection prevention protocols during wound care for Resident #28, including not establishing a clean field, not sanitizing surfaces, and not changing gloves appropriately, which raised concerns for infection control.
Deficiencies (1)
Failure to follow standard infection prevention practices during wound care for Resident #28, including lack of clean field, improper glove use, and unsanitized surfaces.
Report Facts
Residents Affected: 1
Census: 33
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Contracted Registered Nurse (RN) | Named in infection prevention deficiency related to wound care |
| Director of Nursing | Director of Nursing (DON) | Present during wound care observation and acknowledged concerns with Staff A's wound care practices |
Inspection Report
Annual Inspection
Census: 33
Deficiencies: 1
Date: 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.
Deficiencies (1)
Failure to establish and maintain an infection prevention and control program, including failure to follow infection prevention during wound care.
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
Date: 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
Date: Sep 5, 2023
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to ensure assessments before and after outpatient hemodialysis treatments for a resident requiring such services.
Complaint Details
The complaint investigation found that pre and post dialysis assessments were not completed for Resident #4 as required. The Director of Nursing acknowledged the deficiency and committed to starting the assessments immediately.
Findings
The facility failed to complete pre and post hemodialysis assessments for Resident #4 during August 2023, including monitoring vital signs and dialysis port status. Staff interviews and policy review confirmed the lack of required assessments and documentation.
Deficiencies (1)
Failure to ensure assessments before and after outpatient hemodialysis treatments were completed for Resident #4.
Report Facts
Residents affected: 1
Census: 30
Dialysis dates missed: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Reported lack of assessment form and incomplete post dialysis assessments for Resident #4 |
| Director of Nursing | Director of Nursing (DON) | Acknowledged and verified pre and post dialysis assessments were not completed and committed to starting them |
Inspection Report
Complaint Investigation
Census: 30
Deficiencies: 1
Date: 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.
Complaint Details
Complaints #108966-C and #114498-C were investigated and found to be unsubstantiated.
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.
Deficiencies (1)
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
Date: 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
Date: Oct 12, 2021
Visit Reason
Investigation of facility complaint #99971-C conducted from 10/8/21 to 10/12/21.
Complaint Details
Complaint #99971 was not substantiated.
Findings
The complaint investigation resulted in no deficiencies and the complaint was not substantiated.
Inspection Report
Annual Inspection
Census: 27
Deficiencies: 9
Date: 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.
Deficiencies (9)
Failure to address pain in the comprehensive care plan for Resident #23.
Failure to document weekly progress of care for a pressure ulcer for Resident #23.
Failure to provide respiratory care consistent with professional standards; oxygen administered continuously without physician's order for Resident #23.
Failure to ensure 24-hour CPR certified nursing staff coverage.
Failure to prepare food in a form meeting individual needs; Resident #11 served regular goulash with corn instead of mechanical soft diet.
Failure to accommodate resident allergies and preferences; Residents #18 and #26 served foods containing corn and tomato respectively, contrary to dietary restrictions.
Failure to maintain sanitary food procurement, storage, preparation, and serving areas; broken floor tile, sticky cupboards, and calcium buildup on ice machine.
Failure to hold quarterly Quality Assurance meetings with required minimum members including Medical Director or designee.
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.
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
Date: 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
Date: 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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