Sanford Senior Care Sheldon

Inspectors wroteBased on observation, infection control policy and staff interview the facility failed perform proper hand hygiene during toileting for 1 of 3 residents observed (Resident #2) The facility reported a total census of 42 residents.

Inspectors wroteBased on clinical record review, facility record review, staff interviews and facility policy review the facility failed to report an allegation of abuse within 2 hours of an allegation of abuse for 1 of 5 residents reviewed for abuse (Resident #1). The facility staff removed the deficiency prior to the surveyor entering the facility on March 4, 2026 through the following actions:On 12/18/25 the facility placed education related to no cell phones in resident care areas, and if staff see or hear anything that could be suspected abuse or neglect or an infringement of resident dignity on the scheduling app for all staff. On 12/19/25 the facility implemented all staff receive education on resident dignity, photography, abuse or suspected abuse reporting, abuse definitions and follow up quiz for understanding. The facility reported a census of 41 residents.

Inspectors wroteBased on observations, clinical record reviews, staff interviews and policy review the facility failed to prepare and serve food in a form designed to meet individual needs and according to their assessments and care plans for 5 of 9 residents (Resident #4, #9, #30, #117 and #217) reviewed. The facility failed to prepare and serve 5 meals according to the residents' prescribed diet orders. The facility reported a census of 46 residents.

Inspectors wroteBased on observation, staff interview, and policy review the facility failed to prepare, serve and distribute food in accordance with professional standards by not practicing accepted hygiene practices. The facility reported a census of 46 residents.

Inspectors wroteBased on record review and staff interview, the facility failed to notify the physician and the resident's representative of a significant weight loss for 1 of 3 residents reviewed (Resident #11). The facility reported a census of 46 residents.

Inspectors wroteBased on record review and staff interview, the facility failed to update a resident's care plan with an intervention to prevent further falls for 1 of 2 residents reviewed with falls (Resident #4). The facility reported a census of 46 residents.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure a resident received services to maintain or improve Range of Motion (ROM) for 1 of 3 residents reviewed (Resident #4). The facility reported a census of 46 residents.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a resident received dietary supplements as planned to maintain or increase weight for 1 of 3 residents reviewed (Resident #11). The facility reported a census of 46 residents.

Inspectors wroteBased on observations, record review, staff and family interviews, the facility failed to complete accurate assessments and implement interventions for a resident to prevent the development of a Stage 4 pressure sore for 1 of 3 residents reviewed (Resident #1). Certified Nursing Assistant (CNA) staff identified a reddened area on a resident's coccyx in [DATE] and reported it to nursing staff. The record lacked assessments of the area, notification to the physician and treatment orders. On [DATE] an open area on the coccyx was identified and measured 1cm x1 cm. The facility failed to assess the area, implement interventions, implement treatments and notify the physician and family. On [DATE] the open area to the coccyx measured 1cm x 0.8 cm. The facility failed to assess the area, implement interventions, implement treatments and notify the physician and family. [...]

Inspectors wroteBased on record review, staff and physician interview, the facility failed to notify the physician and family of significant weight loss for 2 of 3 residents reviewed (Resident #14 and #27) and for 1 resident with a choking incident (Resident #27). The facility reported a census of 49 residents.

Inspectors wroteBased on record review and staff interview, the facility failed to notify the long term care (LTC) Ombudsman of resident hospitalizations for 2 residents reviewed (Resident #4 and #8). The facility reported a census of 49 residents.

Inspectors wroteBased on record review and staff interview, the facility failed to assure the Minimum Data Set (MDS) assessment accurately reflected the resident's status for 1 of 17 residents reviewed (Resident #4). The facility reported a census of 49 residents.

Inspectors wroteBased on record review and staff interviews the facility failed to provide professional standards of care by not repositioning a resident with spinal cord dysfunction per provider orders for 1 of 17 residents reviewed (Resident #49). The facility reported a census of 49 residents.

Inspectors wroteBased on clinical record review, staff interviews, and policy the facility failed to complete assessments as ordered by the physician for the necessary care and services. Clinical record review revealed the nursing staff failed to complete all required skin assessments for 1 out of 17 residents reviewed (Resident #49) and failed to follow physican orders for administration of oxygen for 1 of 1 resident reviewed, (Resident #6). The facility reported a census of 49 residents.

Inspectors wroteBased on record review and staff interview, the facility failed to assure the physician evaluated for a dose reduction of a psychotropic medication for 1 of 5 residents reviewed (Resident #8). The facility reported a census of 49 residents.

Inspectors wroteBased on observation, clinical record review, resident and staff interviews, the facility failed to appropriately perform assessments and interventions for the necessary care and services to maintain the residents' highest practical physical well- being for 5 out of 45 residents reviewed with signs and symptoms of COVID-19 (Residents #2, #3, #4,#5 and #6). Records showed 3 residents required hospitalization after emergency room (ER) visits, (Residents #2, #4 and #5). The failure to assess and test for COVID when signs and symptoms presented resulted in immediate jeopardy to resident health and safety. The facility identified a census of 45 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of [DATE] on [DATE] at 4:49 PM. The Facility Staff removed the Immediate Jeopardy on [DATE] through the following actions: A. [...]

Inspectors wroteBased on observations, interviews and record review the facility failed to implement adequate infection control strategies and practices to mitigate the transfer of viruses by failure to test and isolate residents with respiratory signs and symptoms for 5 out of 45 residents reviewed (Residents #2, #3, #4, #5 and #6). Records showed three residents required hospitalization after emergency room (ER) visits, ( Residents #2, #4 and #5). The failure to test for COVID and isolate when signs and symptoms presented resulted in immediate jeopardy to resident health and safety. The facility identified a census of 45 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of [DATE] on [DATE] at 5:09 PM. The Facility Staff removed the Immediate Jeopardy on [DATE] through the following actions: A. [...]

Inspectors wroteBased on clinical record review, staff interviews, facility record review and facility policy review, the facility failed to ensure residents at risk for elopement were unable to exit the facility unattended for 1 of 1 residents reviewed for elopement (Resident #18). The facility failure resulted in an Immediate Jeopardy to the health, safety, and security of the residents. The facility reported a total census of 49 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of [DATE] on [DATE] at 9:30 a.m The Facility Staff removed the Immediate Jeopardy on [DATE] through the following actions: A staff member is to monitor the door at all times until the Wanderguard servicing agent arrives to assess the system. Maintenance also increased the distance for alarm to activate to 8 feet instead of 6 1/2 feet that it was previously set at. [...]

Inspectors wroteBased on clinical record, facility policy, and staff interview, the facility failed to include side effects of high risk medications and psychotropic medications and revise a care plan to include a non-pressure related wound on care plans for 4 of 16 residents reviewed (Residents #15, #22, #25, #40). The facility reported a census of 49 residents.

Inspectors wroteBased on clinical record, Resident Assessment Instrument (RAI) Version 3.0 Manual, and staff interview, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 1 of 16 residents reviewed (Resident #36). The facility reported a census of 49 residents.

Inspectors wroteBased on clinical record review and interview, the facility lacked a discharge summary including a recapitulation of a resident's stay for 1 of 2 residents reviewed in the closed record sample (Resident #48). The facility reported a census of 49 residents. Findings Include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident # 48 documented diagnoses of peripheral vascular disease, depression, and hyperlipidemia. The MDS showed the Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. Review of Resident #48 ' s Census Tab revealed Resident #48 was discharged on 5/30/23 at 9:16 a.m. discharge. Review of Resident #48 ' s Progress Notes revealed on 5/22/23 at 9:32 a.m., resident discharged . Review of Resident #48 ' s medical record lacked a completed discharge summary including a recapitulation of the resident ' s stay. [...]