Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
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 Sheffield Manor Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with multiple neurologic and psychiatric conditions, who was cognitively intact and required extensive one-person assistance with most ADLs, reported that a CNA became upset during incontinence care, criticized the resident for needing to be changed, and tossed a brief at the resident while the resident was on the toilet, causing emotional distress. The resident later told Social Services about the incident and expressed not wanting to be around that CNA. Despite this, assignment records showed the CNA continued to be assigned to the resident’s room on several later dates, and the resident reported that the CNA would enter the room, ignore the resident, and provide care only to the roommate, leading the resident to leave the room whenever the CNA appeared. The NHA stated they were unaware the CNA continued to have contact with the resident and that the aide should have been removed from the unit, in contrast to the facility’s Resident Rights policy requiring protection of each resident’s dignity and right to a comfortable living environment.
The facility failed to maintain an effective Antibiotic Stewardship program, leading to inappropriate antibiotic administration for three residents. One resident was prescribed Cipro without meeting infection criteria, another received Keflex without documented symptoms, and a third was incorrectly listed for Gentamycin ointment for a respiratory infection. The facility's protocols, based on McGeer's Criteria, were not followed, and there was a lack of necessary documentation in the residents' records.
A facility failed to implement Enhanced Barrier Precautions (EBP) during medication administration via a gastric tube for a resident. Despite signage indicating the need for EBP, an LPN did not wear a gown while administering medications. The resident required substantial assistance and had a medical device, necessitating EBP to prevent infection spread. The facility's policy required EBP for residents with medical devices.
A resident with severe cognitive impairment fell from a geri-chair due to inadequate positioning and lack of appropriate interventions, resulting in a laceration and emergency room visit. The care plan did not address the use of the geri-chair or fall prevention measures, and interventions were only implemented after the incident.
Failure to Ensure Dignified, Respectful Care and Appropriate Staff Assignment After Resident Complaint
Penalty
Summary
The deficiency involves a failure to honor a resident’s right to dignity and respect during incontinence and ADL care. A cognitively intact resident with Parkinson’s disease, vascular dementia, hemiplegia, cerebral infarction, generalized anxiety disorder, major depressive disorder, and other psychiatric diagnoses reported that a CNA became upset when the resident needed to be changed. The resident stated that while in the bathroom on the toilet, the CNA questioned why the resident had waited so long to be changed, said the resident was “always doing this,” and then tossed a brief at the resident. The resident reported feeling hurt by this interaction and responded by cursing at the CNA. The resident later told Social Services about the incident, describing that a CNA had thrown a “pamper” at her and expressing uncertainty about what would happen and a desire not to be around that CNA anymore. Despite this reported incident and the resident’s expressed discomfort, facility records showed that the CNA continued to be assigned to the resident’s room on multiple subsequent dates. The resident reported that although the CNA apologized and the resident accepted the apology, the resident no longer felt good about what had happened and felt that the trust was gone. The resident stated that the CNA would come into the room, walk past without speaking, and provide care only to the roommate, prompting the resident to leave the room whenever the CNA entered. The Nursing Home Administrator later stated that the Abuse Coordinator was responsible for ensuring the CNA’s assignment was away from the resident and acknowledged being unaware that the CNA continued to have contact with the resident, stating that the aide should have been removed from the unit and that the resident had the right to feel comfortable in the bedroom. The facility’s Resident Rights policy states that the facility protects and promotes each resident’s right to a dignified existence, self-determination, and communication, and that residents have freedom of choice about how they wish to live their everyday lives and receive care.
Inadequate Antibiotic Stewardship in LTC Facility
Penalty
Summary
The facility failed to maintain an effective Antibiotic Stewardship program, as evidenced by the inappropriate administration of antibiotics to three residents. The Director of Nursing (DON) acknowledged that the facility's protocols for antibiotic administration were not followed, and infection criteria were not met. The facility's Infection Prevention Program, which follows McGeer's Criteria, was not properly implemented, leading to the prescription of antibiotics without sufficient justification. For one resident, Cipro was prescribed without a start or stop date, and there was no Infection Report or McGeer Criteria for Infection Surveillance Checklist (MCISC) available. The resident's Electronic Health Record (EHR) indicated a diagnosis of bladder cancer with frequent pain, but the criteria for a urinary tract infection were not met. Another resident was prescribed Keflex for a skin infection without documented signs and symptoms, and the EHR lacked the necessary MCISC form. A progress note indicated no drainage from the surgical site, suggesting the prescription did not follow McGeer's protocol. A third resident was incorrectly listed as receiving Gentamycin ointment for a respiratory infection, which was a mistake. The resident's EHR showed prescriptions for three antibiotics, including Gentamycin for a heel skin infection and two others for pneumonia. The facility had experienced turnover in the Infection Control Nurse position, which may have contributed to the oversight. The facility's Antibiotic Stewardship program emphasizes the importance of appropriate prescribing to prevent unnecessary treatment and antibiotic resistance, but these protocols were not adhered to in these cases.
Failure to Implement Enhanced Barrier Precautions During Medication Administration
Penalty
Summary
The facility failed to ensure that Enhanced Barrier Precautions (EBP) were followed during the administration of medications via a gastric tube for a resident. On the specified date, signage was observed on the resident's door indicating that EBP should be worn when providing care. However, an LPN entered the resident's room and administered medications without applying a gown, which is part of the required EBP. The resident had a pertinent diagnosis of gastrostomy status and required substantial/maximal assistance with most Activities of Daily Living (ADLs). The resident's electronic medical record and care plan documented the need for EBP due to the presence of a medical device. During an interview, the LPN acknowledged that a gown and gloves should be worn when administering medications to residents with a gastric tube. The Director of Nursing confirmed that the LPN should have applied EBP to prevent the spread of infections. The facility's policy on EBP, dated prior to the incident, outlined the necessity of these precautions for residents with medical devices to prevent the transmission of multidrug-resistant organisms.
Failure to Prevent Fall from Geri-Chair
Penalty
Summary
The facility failed to ensure the safe positioning of a resident in a geri-chair, implement appropriate interventions to prevent falls, and provide adequate post-fall interventions. A resident, identified as R303, who had severe cognitive impairment and required substantial assistance for daily activities, was observed in a geri-chair with thick, slippery cushions. The resident's care plan did not include the use of a geri-chair or any interventions for falls, despite being at risk. On a specific date, the resident was found on the floor with a laceration above their right eye after sliding out of the geri-chair, which led to an emergency room visit. The facility's incident report and post-fall evaluation noted the use of extra padding on the geri-chair as a factor in the fall. However, the care plan for falls was only implemented the day after the incident, and it did not address the use of the geri-chair or the cushions. Interviews with the facility's Director of Nursing revealed an acknowledgment of the inappropriate care plan interventions in place at the time of the fall. The facility's policy on fall management required the review and revision of care plans following a fall, but this was not adequately executed prior to the incident.
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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 Detroit
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Westwood Nursing Center | 0.7 mi | — | 19 | 0 |
| The Orchards At Northwest | 0.7 mi | — | 2 | 0 |
| Hartford Nursing & Rehabilitation Center | 1.4 mi | — | 23 | 0 |
| Oakpointe Senior Care And Rehab Center | 1.9 mi | — | 0 | 0 |
| The Villa At Great Lakes Crossing | 3.1 mi | — | 8 | 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.