Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sanford Senior Care Sheldon during CMS and state inspections, most recent first.
Staff failed to timely report an allegation of abuse after a CNA took and shared a photo of a cognitively impaired resident lying on the floor after a fall, with the resident’s brief down and the CNA visible in the background. Another CNA viewed the photo on the CNA’s phone and, despite recognizing it was inappropriate, waited about a week before informing administration. Two CNAs discussed the photo with a third CNA, who then immediately reported it to the DON. Facility policy required that any alleged or suspected abuse be reported to administration and appropriate agencies immediately and no later than 2 hours after the allegation was made.
A resident at risk for pressure ulcers developed a stage 4 sacral ulcer after staff failed to assess, document, and intervene despite repeated reports of skin breakdown. CNAs observed and reported worsening skin issues, but licensed nurses did not consistently assess, notify the physician or family, or initiate treatment. The resident was eventually hospitalized with a severe pressure wound and died from MRSA cellulitis related to the ulcer.
The facility failed to notify the physician and family of significant weight loss for two residents and a choking incident for one resident. A resident with no cognitive impairment experienced significant weight loss without physician or family notification, contrary to facility policy. Another resident with moderate cognitive impairment also had significant weight loss and a choking incident, yet the facility did not inform the physician or family. The DON did not see the need for notification, although the resident's physician expected to be informed.
The facility failed to notify the LTC Ombudsman of hospitalizations for two residents. Hospital transfers were omitted from the monthly notification forms, as the Social Worker was not instructed to include them. The facility's policy requires such notifications to ensure the ombudsman can advocate effectively for residents.
A facility failed to ensure an accurate MDS assessment for a resident with severe cognitive impairment and mental illness. The resident's MDS inaccurately documented their PASRR status, despite having a Level 2 PASRR indicating the need for specialized behavioral health services. The MDS Coordinator did not correctly answer the PASRR-related question, leading to the deficiency.
A facility failed to reposition a resident with spinal cord dysfunction as per provider orders, which required repositioning every hour in a chair and every two hours in bed. The care plan did not reflect the updated orders, and records showed non-compliance on multiple dates. Staff interviews revealed a lack of documentation for refusals and absences, and the DON acknowledged the need for improved compliance.
The facility failed to complete daily skin assessments for a resident with a spinal cord injury and pressure ulcer risk, and did not follow physician orders for oxygen administration for a resident with cognitive impairment and coronary artery disease. Documentation was lacking for both skin assessments and oxygen therapy adjustments, contrary to the facility's policies.
A facility failed to ensure a physician evaluated a gradual dose reduction (GDR) for a resident's psychotropic medication. The resident, diagnosed with Alzheimer's and dementia with psychotic disturbance, was prescribed Amitriptyline 50 mg at bedtime. Despite a consultant pharmacist's recommendation for a GDR in May, there was no documented physician response. The DON confirmed the absence of a GDR evaluation during the survey.
Failure to Timely Report Allegation of Abuse Involving Inappropriate Resident Photograph
Penalty
Summary
Facility staff failed to timely report an allegation of abuse involving a cognitively impaired resident. The resident had diagnoses including depression, hypertension, and psychomotor defect following cerebral infarction, with a BIMS score of 8 indicating severe cognitive impairment. After the resident experienced a fall and was on the floor wearing a brief and T‑shirt, a CNA (Staff B) took a photo showing the resident on the floor with the brief down to the ankles and a pillow under the resident’s head, with Staff B visible in the background. Staff B then shared this photo in a staff work group chat. Another CNA (Staff A) later viewed the photo on Staff B’s phone in the hallway and questioned why Staff B had the photo; Staff B responded that it was in their work group chat. Staff A did not immediately report the incident to administration, instead “sitting on it” for approximately a week before deciding to turn it in, acknowledging she knew it was not right for Staff B to have the photo. During this period, Staff A and another CNA (Staff D) discussed the photo with a third CNA (Staff C), describing the image but not showing it to her. Staff C, upon learning of the photo, immediately reported the matter to the DON. The DON confirmed that Staff A, Staff C, and Staff D informed her that about a week earlier Staff B had shown them the photo of the resident on the floor after the fall. The facility’s abuse and neglect policy required that alleged or suspected violations involving mistreatment, neglect, exploitation, or abuse be reported immediately to the administrator and to designated agencies not later than 2 hours after the allegation is made. The DON stated that staff should have reported the allegation to administration right away.
Failure to Assess and Intervene for Pressure Ulcer Leads to Resident Death
Penalty
Summary
A resident with diagnoses including non-Alzheimer's dementia, diabetes mellitus, and hypertension, and who was assessed as having no cognitive impairment, was identified as being at risk for pressure ulcers but did not have any at baseline. The resident required partial to moderate assistance with activities of daily living and had a pressure-reducing device in bed. Over a period of time, certified nursing assistants (CNAs) observed and reported reddened and open areas on the resident's coccyx and buttocks to nursing staff. Documentation in bath sheets and progress notes indicated repeated observations of skin issues, including redness, open areas, and bleeding, but there was a lack of consistent and thorough assessment, documentation, and follow-up by licensed nursing staff. Despite multiple reports from CNAs about the resident's deteriorating skin condition, including descriptions of the area as "very red and sore," "openish," and "looked like hamburger," nursing staff failed to perform timely and accurate assessments, did not notify the physician or the resident's family, and did not initiate appropriate treatment interventions. Several nurses admitted in interviews that they either did not assess the area, did not document their findings, or assumed another nurse would handle the situation. There was also a lack of communication and follow-through between shifts, resulting in the resident's worsening condition going unaddressed. The resident's condition progressed to a stage 4 sacral decubitus ulcer, which was only identified after the resident was admitted to the emergency room with altered mentation and hypotension. Hospital records documented a large sacral pressure wound with purulent drainage, and the resident was diagnosed with sepsis likely originating from the ulcer. The resident subsequently died, with the death certificate listing MRSA cellulitis of the buttock due to a stage 4 sacral ulcer as the immediate cause of death. The facility's own policies required prompt assessment, documentation, and notification for pressure ulcers, but these procedures were not followed in this case.
Removal Plan
- All residents receive a full body skin review by RN Nurse Supervisor.
- All nursing staff are reminded of the importance of skin observations and following process.
- Additional education is provided to staff, including notifications to physicians and family, and this information is included in skin checklist packets.
- Skin processes and status are reviewed at each huddle using the huddle checklist.
- All care plans are reviewed and updated as appropriate by RN supervisors, Social Worker, and Activity Director.
- A tracking tool is initiated to show all ulcers and surgical wounds, and is reviewed at the Risk meeting.
- A Risk meeting is established including Administrator, Director of Nursing, RN Supervisors, Social Services, Activity Director, Quality Director, and Infection Preventionist to review residents with skin impairments and update care plans as needed.
- Reviews for each resident with ulcers and/or surgical wounds are conducted for signs and symptoms of pain and infection, noted on the residents treatment sheet.
- The Director of Nursing and/or RN Supervisors review the Matrix Even to review tasks and assessments that were completed as necessary.
- Audits to ensure skin observations are complete are conducted by the Director of Nursing or designee.
- The tracking tool is completed to track measurements, treatment and care plan updates by an RN supervisor or designee.
Failure to Notify Physician and Family of Significant Events
Penalty
Summary
The facility failed to notify the physician and family of significant weight loss for two residents and a choking incident for one resident. Resident #14, who had no cognitive impairment and was self-feeding, experienced a significant weight loss of 5% or more in the last month or 10% or more in the last six months. Despite the facility's policy requiring immediate notification of the physician and family in such cases, there was no documentation that this was done. The Director of Nursing (DON) could not confirm whether the physician or family were informed, although a meeting with the dietician for recommendations was held. Resident #27, with moderate cognitive impairment and requiring assistance with eating, also experienced significant weight loss. The clinical record lacked documentation of physician or family notification. Additionally, Resident #27 had a choking incident where the resident struggled to breathe due to aspiration, but the facility did not notify the physician or family. The DON did not believe notification was necessary as the nurses managed the situation, and the resident was fine afterward. However, the resident's physician expected to be informed of both the weight loss and the choking incident. The facility's policy mandates immediate notification of significant changes in a resident's status to the physician and family.
Failure to Notify Ombudsman of Resident Hospitalizations
Penalty
Summary
The facility failed to notify the long-term care (LTC) Ombudsman of resident hospitalizations for two residents. Resident #4 was hospitalized on multiple occasions and returned to the facility on specific dates, yet the monthly Transfers/Discharges forms provided by the facility for ombudsman notification did not include these hospital transfers. Similarly, Resident #8 was hospitalized and returned on a specific date, but their transfer was also omitted from the notification forms. The Social Worker at the facility stated that she did not include hospital transfers in the monthly notifications to the ombudsman because she was not instructed to do so. The facility's Ombudsman policy emphasizes the role of the ombudsman as an advocate for residents, promoting the highest quality of life by serving as a communication bridge. According to federal regulations, copies of notices for emergency transfers must be sent to the ombudsman when practicable, such as in a monthly list, which the facility failed to do.
Inaccurate MDS Assessment for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the status of a resident, specifically for one resident out of the 17 reviewed. The resident in question had a diagnosis of non-Alzheimer's dementia and bipolar disorder, and was identified as having severe cognitive impairment with a score of 5 on the Brief Interview for Mental Status (BIMS). Despite this, the MDS inaccurately documented that the resident was not considered to have a serious mental illness by the state Level 2 Preadmission Screening and Record Review (PASRR), even though the resident had a PASRR Notice indicating the need for specialized behavioral health services. The discrepancy arose because the MDS Coordinator, a Registered Nurse, did not correctly answer the PASRR-related question on the MDS. The facility's policy required each discipline to complete its section of the MDS, with the MDS Coordinator responsible for submission. However, the coordinator acknowledged the resident had a Level 2 PASRR, which should have been reflected in the MDS assessment.
Failure to Reposition Resident as Ordered
Penalty
Summary
The facility failed to adhere to professional standards of care by not repositioning a resident with spinal cord dysfunction according to the provider's orders. The resident, who had a diagnosis of traumatic spinal cord dysfunction and an unhealed pressure ulcer, was supposed to be repositioned every hour while in a chair and every two hours while in bed, as per the provider's order dated 9/4/24. However, the care plan did not reflect the updated repositioning schedule, and the facility's repositioning records showed non-compliance with these orders on multiple dates between 9/4/24 and 9/30/24. Additionally, there was a lack of documentation for several days within this period. Interviews with staff revealed that there was a failure to document the resident's refusals to reposition and absences from the facility for medical appointments and family outings. The Director of Nursing acknowledged the need for improvement in compliance with repositioning orders and documentation. The facility's policy on provider orders, last revised on 2/14/24, did not include instructions for care, treatments, and services beyond medications, which may have contributed to the oversight.
Deficiencies in Skin Assessments and Oxygen Administration
Penalty
Summary
The facility failed to complete required skin assessments for a resident diagnosed with traumatic spinal cord dysfunction and an unhealed pressure ulcer. The resident's care plan required daily skin inspections due to immobility, but the facility's records showed multiple days where these assessments were not completed. The Director of Nursing acknowledged the oversight in skin assessment documentation and noted that follow-up with the nursing staff had occurred. Additionally, the facility did not adhere to physician orders for oxygen administration for another resident with moderate cognitive impairment and coronary artery disease. The resident's care plan required oxygen therapy adjustments to maintain saturation levels above 90%. However, documentation was lacking for the administration of increased oxygen levels, assessments of the resident's respiratory status, and follow-up on low oxygen saturation levels. The facility's policy required oxygen administration to be carried out with a medical provider order and regular assessments, which were not consistently documented.
Failure to Evaluate Gradual Dose Reduction for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a physician evaluated a gradual dose reduction (GDR) for a psychotropic medication for one of the residents reviewed. The resident, diagnosed with Alzheimer's disease with late onset and dementia with psychotic disturbance, was prescribed Amitriptyline 50 mg at bedtime starting from November 20, 2023. The facility's records indicated that the resident was due for a dose evaluation in May 2024, but there was no documented response from the physician regarding the GDR recommendation made by the consultant pharmacist on May 30, 2024. During the survey, the Director of Nursing (DON) was unable to confirm whether a GDR had been conducted for the resident's Amitriptyline. The lack of a physician's response to the consultant pharmacist's recommendation was confirmed during the exit conference with facility staff. This oversight indicates a failure in the facility's process to ensure appropriate medication management and evaluation for dose reduction as required.
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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 Sheldon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Prairie View Home | 10.2 mi | — | 0 | 0 |
| Good Samaritan - George | 13.5 mi | — | 0 | 0 |
| Pleasant Acres Care Center | 15 mi | — | 14 | 0 |
| Sibley Specialty Care | 15.3 mi | — | 1 | 0 |
| Prairie Ridge Care Center | 15.6 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.