Deficiency Records for Sheffield Manor Nursing and Rehab Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Sheffield Manor Nursing and Rehab Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-02-07 | 2024-03-04 | Y |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-11-29 | 2024-01-12 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-11-29 | 2024-01-05 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-11-29 | 2024-01-05 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-11-29 | 2024-01-05 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-11-29 | 2024-01-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-29 | 2024-01-05 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-11-29 | 2024-01-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-11-29 | 2024-01-05 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-11-29 | 2024-01-05 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-11-29 | 2024-01-05 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-11-30 | 2023-12-29 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-11-30 | 2023-12-29 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-11-30 | 2023-12-29 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-11-30 | 2023-12-29 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-01-05 | 2023-01-23 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-01-05 | 2023-01-23 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-10-21 | 2022-11-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-21 | 2022-11-16 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-10-21 | 2022-11-16 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-10-21 | 2022-11-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-10-21 | 2022-11-16 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-10-21 | 2022-11-16 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-21 | 2022-11-16 | Y |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-10-24 | 2022-11-16 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-10-24 | 2022-11-16 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-10-24 | 2022-11-16 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-10-24 | 2022-11-16 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-10-24 | 2022-11-16 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-10-24 | 2022-11-16 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2022-10-24 | 2022-11-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-10-24 | 2022-11-16 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-10-24 | 2022-11-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-10-24 | 2022-11-16 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-10-24 | 2022-11-16 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-10-24 | 2022-11-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-21 | 2022-07-21 | Y |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-08-03 | 2021-09-03 | N |
| Construct fire resistant interior walls. | Fire Safety | 2021-08-03 | 2021-09-02 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-08-03 | 2021-09-02 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-08-05 | 2021-09-01 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-08-05 | 2021-09-01 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-08-05 | 2021-09-01 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-08-05 | 2021-09-01 | N |
| Dispose of garbage and refuse properly. | Health | 2021-08-05 | 2021-09-01 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2021-08-05 | 2021-09-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-05 | 2021-09-01 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-08-05 | 2021-09-01 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-08-05 | 2021-09-01 | N |
| Respond appropriately to all alleged violations. | Health | 2021-08-05 | 2021-09-01 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-08-05 | 2021-09-01 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2021-08-05 | 2021-09-01 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-08-03 | 2021-09-01 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2021-08-03 | 2021-09-01 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2021-08-03 | 2021-09-01 | N |
| Install proper backup exit lighting. | Fire Safety | 2021-08-03 | 2021-09-01 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-08-03 | 2021-09-01 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-08-03 | 2021-09-01 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2021-08-03 | 2021-09-01 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2021-08-03 | 2021-09-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-08-03 | 2021-09-01 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-08-03 | 2021-09-01 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2021-08-03 | 2021-09-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-08-03 | 2021-09-01 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-08-03 | 2021-09-01 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-08-03 | 2021-09-01 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-08-03 | 2021-09-01 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-08-03 | 2021-09-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-08-03 | 2021-09-01 | N |
