Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hannah B G Shaw Home during CMS and state inspections, most recent first.
Food Thermometers Not Cleaned Between Food Items: Dietary staff handled ready-to-eat food on a unit using thermometers that were not cleaned and sanitized between food items. One dietary staff member used the same thermometers on multiple items without cleaning them, and another rinsed probes under running water between items but did not sanitize them until after all temperatures were taken. The FSD stated thermometers should have been cleaned and sanitized between each food item to prevent cross contamination.
Broda Chair Used as a Mobility Restriction Without Restraint Assessment: A resident with Alzheimer’s disease, dementia, impulsive behavior, and prior falls was moved from a standard wheelchair to a Broda chair after a serious fall with facial fractures. The chair prevented self-propelling, and the record did not show a restraint assessment, ongoing review, or a care plan reflecting the mobility restriction. Staff and the DON acknowledged the device could be considered a restraint, while the resident representative said no alternative options were offered.
Failure to care plan for trauma triggers: A resident with anxiety, depression, Alzheimer’s disease, TBI, and PTSD had behavioral symptoms, rejection of care, and wandering, but the care plan did not include the family-reported history of prior assault or the related startle trigger. The resident’s Kardex and CNA care card also lacked this trauma information, and staff interviews confirmed the trigger was not clearly communicated to direct care staff.
Infection Prevention and Control Failure with Respiratory Equipment: A resident with COPD who used O2 and BiPAP had tubing and mask equipment found improperly maintained and stored. The O2 tubing was labeled with an outdated change date despite documentation that it had been changed, and the BiPAP mask and corrugated tubing were left exposed on top of the machine, not dated, and not stored in a plastic bag as required.
The facility failed to implement a water management program to prevent Legionella growth, as required by their infection control policy. During a survey, the facility could not provide evidence of such a program, and interviews with staff confirmed the absence of a risk assessment, water diagram, or testing protocols.
The facility failed to provide a meaningful activity program for residents on the Memory Care Unit. Despite having a detailed activity calendar, observations showed that residents were often left without engagement, with many sitting in the day room with only the television on. Staff interviews confirmed that activities were not consistently provided, with activities mainly occurring in the late afternoon. The Therapeutic Activity Director noted insufficient help to meet residents' needs, and family members expressed concerns about the lack of specialized activities for those not participating in off-unit activities.
The facility failed to maintain a safe environment in the Dementia Special Care Unit by leaving a three-tiered cart with hazardous items accessible to residents. The cart contained personal care products and razors, which should have been stored in a locked closet. A nurse confirmed the items were hazardous and should not have been accessible.
The Memory Care unit in the facility was inadequately staffed, with only one nurse and one CNA per shift, despite the need for more staff to safely care for residents. Observations revealed multiple residents exhibiting unsafe behaviors, with staff unable to respond promptly due to insufficient numbers. Interviews with staff and family members highlighted ongoing concerns about safety and the lack of response from administration to address these issues.
The facility failed to securely store medications for three residents, as observed during a survey. A resident had an Albuterol inhaler on their bedside table, while another had Calcium Carbonate and eye drops on a windowsill, both against facility policy. A third resident kept a Ventolin inhaler on their bedside table for urgent use, which should have been locked up when not in use. The DON and nursing staff confirmed these medications should have been stored securely.
The facility failed to follow professional standards for food safety and sanitation, risking foodborne illness spread. Surveyors found improperly stored, labeled, and dated food in the main kitchen and unit kitchenettes. Interviews revealed a lack of adherence to facility policies on food storage and dating.
Two residents' representatives raised concerns about low staffing and safety issues in the Memory Care Unit, including a malfunctioning doorbell that delayed access for visitors. Despite multiple reports to the Administrator, these grievances were not documented or addressed, violating the facility's grievance policy.
A resident with severe cognitive impairment and a behavior of eating non-food items did not have an individualized care plan addressing this behavior. Despite documented instances and staff awareness, the care plan lacked measurable objectives and timeframes. The resident's physician was not informed, and temporary staff were unaware of the behavior due to inadequate documentation.
A resident with multiple medical conditions experienced significant weight loss, which the facility failed to address in a timely manner. Despite policies requiring monitoring and intervention, there was a lack of comprehensive nutritional assessment and action between mid-July and mid-August. The delay in addressing the resident's weight loss was a deficiency in the facility's care processes.
A resident with multiple health conditions was not seen by a physician within the first 90 days of admission, as required. Instead, all assessments were conducted by a Nurse Practitioner. The Medical Director was not contacted to provide coverage when the attending physician was unavailable.
Food Thermometers Not Cleaned Between Food Items
Penalty
Summary
The facility failed to follow professional standards of practice for food safety and sanitation when dietary staff handled ready-to-eat food temperatures without properly cleaning and sanitizing thermometers between food items. On 9/10/25, Dietary Staff #1 delivered lunch to the [NAME] unit and used two thermometers to check temperatures of food in covered holding containers that would be plated on the unit. He inserted each thermometer into a food item and then immediately used the same thermometers to check the rest of the food without cleaning or sanitizing them between uses. He stated this was his usual process and said he was unaware whether any residents on the unit had food allergies. On 9/11/25, Dietary Staff #2 was observed delivering food to the [NAME] unit and taking temperatures with two thermometers. She rinsed the thermometer probes under running sink water between each food item but did not wipe or sanitize the probes between items, and she sanitized them only after completing all temperature checks. During an interview later that day, the Food Service Director stated staff should have cleaned and sanitized the thermometers between each food item to prevent cross contamination.
Broda Chair Used as a Mobility Restriction Without Restraint Assessment
Penalty
Summary
The facility failed to ensure that one resident was free from the use of a physical restraint when the resident’s standard wheelchair was replaced with a Broda positioning wheelchair that no longer allowed the resident to self-propel around the unit. The resident had diagnoses including Alzheimer’s disease, impulse disorder, dementia, muscle weakness, osteoporosis, and a history of traumatic brain injury, and was dependent on staff for activities of daily living and locomotion. The facility’s own restraint policy stated that practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted, including placing a resident in a chair that prevents the resident from rising. The resident’s record showed repeated behaviors of self-propelling around the unit, entering other residents’ rooms, pushing furniture, attempting to self-transfer, and becoming agitated and restless. After a fall in which the resident leaned too far forward in the wheelchair and sustained facial injuries, including a laceration near the eye, forehead hematoma, abrasions, nasal fracture, and orbital laceration, the physician documented that the resident could not safely self-propel and that the wheelchair could not be allowed any longer. The physician also documented discussion with the health care proxy about the resident’s lack of safety awareness and the need for a different approach because staff could not provide continuous one-to-one supervision. The resident was then placed in a Broda chair with lateral supports, footrests, and a chair alarm. The care plan did not identify a restraint or potential restraint, and the medical record did not show a pre-restraint assessment or regular review for restraint reduction, less restrictive methods, or elimination. Staff and the DON acknowledged that removing the resident’s ability to self-propel could be considered a restraint, and the DON stated that no restraint assessment was completed and the care plan was not reflective of the resident’s current status or use of the Broda chair. The resident representative said no alternative options were offered, and the resident was observed by surveyors sitting in the Broda chair on multiple occasions.
Failure to Care Plan for Trauma Triggers
Penalty
Summary
The facility failed to develop a care plan that accounted for one resident’s experiences and preferences to help eliminate or reduce triggers that could cause re-traumatization. The resident was admitted with diagnoses including anxiety, depression, Alzheimer’s disease, traumatic brain injury, and PTSD. The MDS assessment dated 6/18/25 indicated the resident was unable to complete the BIMS and had PTSD, and also showed physical behavioral symptoms, verbal behavioral symptoms, other behavioral symptoms, rejection of care, and wandering. The social service admission assessment dated 7/5/23 documented that the resident was in the process of divorcing a spouse, had difficulty adjusting to the new environment, had mood swings, was irritable and easily angered, and could be combative with care. It also noted the resident appeared comfortable in a quiet environment but could become anxious in loud settings. The trauma/PTSD assessment dated 7/5/23 stated the resident could not participate, but family reported a history of prior assault that could make the resident prone to startle easily. The comprehensive care plan addressed behavioral issues, anxiety, resistance to care, calm communication, diversion, alternate location, and minimizing physical touch, but the resident’s Kardex and CNA Care Card did not include the family-reported trauma trigger. During interviews, a CNA stated she was not aware of any resident on the unit with PTSD or specific trauma triggers and said the information could be communicated better between departments and direct care staff. The social worker stated she had not care planned any resident for a history of trauma and did not see anything specific to this resident’s history of trauma and potential triggers in the care plan.
Infection Prevention and Control Failure with Respiratory Equipment
Penalty
Summary
The facility failed to maintain an infection prevention and control program for one resident who had diagnoses including chronic obstructive pulmonary disease and received oxygen therapy. The resident’s physician ordered weekly changes of oxygen tubing and nightly use of a BiPAP mask with supplemental oxygen. The facility policy stated that respiratory therapy equipment, including oxygen tubing and corrugated tubing, must be changed weekly and as needed, and equipment should be dated when changed. During observations, the resident’s oxygen tubing was found attached to the concentrator and connected to the BiPAP machine, with the tubing labeled as last changed on 8/27/25 even though it had been documented as changed on 9/7/25. The BiPAP mask was connected to corrugated tubing, resting exposed on top of the BiPAP machine, not dated, and not covered with a plastic bag. A nurse stated the tubing should have been changed weekly, the hose should have been removed and cleaned every morning, and the mask should have been stored in a plastic bag when not in use. The DON also stated the oxygen tubing should have been changed as ordered, the hose removed and cleaned, and the mask placed in a plastic bag rather than left uncovered on top of the BiPAP unit.
Failure to Implement Water Management Program
Penalty
Summary
The facility failed to maintain an infection prevention and control program specifically related to a water management program aimed at preventing the growth of Legionella and other waterborne pathogens. The facility's policy, revised in September 2022, outlined the need for a comprehensive water management program, including an interdisciplinary team, a detailed water system description, identification of risk areas, and specific control measures. However, during the recertification survey, the facility could not provide evidence of such a program. Interviews conducted during the survey revealed that the facility's administration and maintenance staff were unaware of any existing water management program. The Administrator admitted there was no assessment of the building or evidence of a water management program. Similarly, the Director of Maintenance and Maintenance Staff confirmed the absence of a risk assessment, water diagram, or testing protocols, indicating a significant oversight in the facility's infection control measures.
Inadequate Activity Program in Memory Care Unit
Penalty
Summary
The facility failed to provide a meaningful and engaging activity program for residents on the Memory Care Unit, as observed during a survey. The facility's policies outlined various activities designed to engage residents mentally, physically, and emotionally, such as arts and crafts, music sessions, and cognitive stimulation activities. However, the survey revealed that these activities were not being implemented effectively. The activity calendar indicated scheduled activities, but observations showed that residents were often left without meaningful engagement, with many sitting in the day room with only the television on. Interviews with staff, including a Certified Nursing Assistant (CNA) and the Therapeutic Activity Director (TAD), confirmed that activities were not consistently provided on the Memory Care Unit. The CNA mentioned that activities were only conducted from 3:00 P.M. to 6:00 P.M. or 7:00 P.M., and that activities listed in bold on the calendar were held off the unit, with only a few residents attending. The TAD, who worked part-time and had other responsibilities, stated that there was insufficient help on the unit to meet residents' needs, and that her time was mostly spent on paperwork rather than conducting activities. Family members and nursing staff also expressed concerns about the lack of specialized activities for residents who did not participate in off-unit activities. The absence of daytime activities, especially during the afternoons when residents are prone to sundowning, was highlighted as a significant issue. The facility's failure to implement its activity program as per its policies resulted in residents not receiving the necessary physical, mental, and psychosocial stimulation, leading to the deficiency noted in the survey.
Hazardous Items Accessible to Residents in Dementia Unit
Penalty
Summary
The facility failed to ensure an environment free from accident hazards on the Memory Care Unit, specifically the Dementia Special Care Unit. During an observation, a surveyor noted a three-tiered cart with hazardous items was easily accessible to residents who were independently ambulating in the hallway. The cart contained various personal care products and disposable razors, which were stored in a clear plastic bin on the bottom shelf. During an interview, a nurse confirmed that these items were hazardous and should have been kept in a locked closet, inaccessible to residents.
Inadequate Staffing in Memory Care Unit
Penalty
Summary
The facility failed to maintain sufficient staffing levels to meet the needs of residents in the Memory Care unit, as observed during a survey. The unit, which has a census of 12 residents, was consistently staffed with only one nurse and one CNA per shift, despite the facility's assessment indicating a need for two CNAs during the day and evening shifts. This staffing inadequacy was evident on multiple days, where only one CNA was present for the entire shift, with minimal additional support from a float CNA who was only available for a short period in the morning. During the surveyor's observation, several residents exhibited unsafe behaviors, such as attempting to stand unassisted or propelling themselves in wheelchairs unsafely, which required immediate attention. The limited staff struggled to manage these situations, as they were occupied with other residents' care needs. The surveyor noted that alarms were frequently triggered, indicating potential falls, but the staff was unable to respond promptly due to the insufficient number of caregivers available. Interviews with staff and family members highlighted ongoing concerns about the inadequate staffing levels. Staff members expressed that the current staffing was insufficient to ensure resident safety, particularly given the high number of residents with behavioral issues and the need for one-to-one supervision. Family members also reported multiple falls and expressed dissatisfaction with the facility's response to their concerns about staffing. Despite these issues being raised with the administration, no changes had been made to address the staffing deficiencies.
Failure to Securely Store Medications
Penalty
Summary
The facility failed to ensure the safe storage of medications and biologicals for three residents, as observed during a survey. Resident #57 was found with an Albuterol inhaler on their bedside table, despite having physician's orders allowing self-administration. The Director of Nursing (DON) acknowledged that the inhaler should have been stored securely. Similarly, Resident #270 had a bottle of Calcium Carbonate and eye drops on their windowsill, which were also supposed to be secured according to the facility's policy. Nurse #9 and the DON confirmed that these medications should have been stored in a secure location. Resident #6 was observed with a Ventolin inhaler on their bedside table on multiple occasions. The resident stated they kept the inhaler accessible for urgent use, but Nurse #7 and the DON confirmed that it should have been locked up when not in use. These observations indicate a failure to adhere to the facility's policy on the secure storage of self-administered medications, as outlined in their policy last revised in February 2021.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards of practice for food safety and sanitation, which could potentially lead to the spread of foodborne illness among residents. The surveyor observed multiple instances of improperly stored, labeled, and dated food items in both the main kitchen and various unit kitchenettes. In the main kitchen, items such as croutons, bologna, frozen ravioli, and cheese-stuffed shells were found without proper dating. Additionally, several opened containers of thickened liquids and other food items were not labeled with the date they were opened, contrary to the facility's policy. The facility's policies, including those for Refrigerators and Freezers, Food Receiving and Storage, and Resident Food Storage and Heating, require that all food items be appropriately dated to ensure proper rotation and safe consumption. However, the surveyor found numerous violations of these policies, including undated opened containers of Lactaid milk, thickened juices, and various other food items. The lack of proper labeling and dating was consistent across different areas of the facility, indicating a systemic issue with food safety practices. Interviews with dietary staff and the dietitian revealed a lack of documentation and adherence to the facility's policies regarding the storage and dating of food items. Dietary Staff #1 and the dietitian both acknowledged that all food and beverage items should be labeled with the date received, a use-by date, and the date the product is opened. Despite these expectations, the facility failed to maintain proper records and oversight, leading to the observed deficiencies in food safety and sanitation practices.
Failure to Document and Address Grievances in Memory Care Unit
Penalty
Summary
The facility failed to honor the residents' right to voice grievances without discrimination or reprisal, as evidenced by the lack of documentation and follow-up on grievances voiced by two residents' representatives. The facility's grievance policy, last revised in April 2017, requires that all grievances be investigated and documented in a Resident Grievance Complaint Log. However, the grievances raised by the representatives of two residents regarding low staffing and safety concerns on the Memory Care Unit were not documented or addressed. The first resident's representative expressed concerns about resident safety due to low staffing and a malfunctioning doorbell on the Memory Care Unit. The representative reported that the doorbell, which alerts staff to unlock the door for visitors, frequently did not work, causing delays in accessing the unit. Despite raising these concerns with the Administrator and the property management company multiple times, no changes were made, and the grievances were not documented in the facility's Grievance Book. Similarly, the second resident's representative voiced concerns about low staffing and the safety of residents on the Memory Care Unit, noting that the staff was insufficient to meet the residents' needs. The representative reported these concerns to the Administrator several times, but there was no response or documentation of the grievances. The Administrator, who is also the Grievance Official, admitted that verbal complaints from resident representatives were not documented, contrary to the facility's policy.
Failure to Implement Care Plan for Resident with Pica
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan for a resident with severe cognitive impairment and a behavior of eating non-food items, known as Pica. Despite multiple documented instances of the resident placing non-food items in their mouth, the care plan did not include measurable objectives and timeframes to address this behavior. The facility's policies require the interdisciplinary team to create comprehensive care plans that reflect the resident's needs, but this was not done for the resident in question. The resident, who was admitted with diagnoses including Alzheimer's disease, anxiety, and major depression, exhibited behaviors of chewing on non-food items on several occasions. Nursing notes and social service notes documented these behaviors, yet the care plan meetings failed to consistently identify and address the behavior. Although a care plan meeting on one occasion noted the need for monitoring due to Pica, no changes were made to the care plan to address this concern. Interviews with staff revealed that while regular staff were aware of the resident's behavior, it was not documented in the care plan or CNA care card, leaving temporary or agency staff unaware. The resident's physician was also not informed of the behavior, indicating a lack of communication and documentation. This oversight in care planning and communication could lead to inadequate supervision and potential harm to the resident.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to implement timely interventions after identifying significant weight loss in a resident, leading to further weight loss over a two-week period. The facility's policies required the nursing staff to monitor and document residents' weight and dietary intake, report significant weight changes, and conduct nutritional assessments when necessary. However, the facility did not adhere to these policies for one resident who experienced a 9.8% weight loss over a month, which was not promptly addressed by the interdisciplinary team. The resident, who had multiple medical conditions including dysphagia, chronic renal insufficiency, and Parkinson's disease, was admitted to the facility with a history of significant weight loss. Despite the resident's complex medical history and the facility's policy requirements, there was a lack of comprehensive nutritional assessment and intervention between mid-July and mid-August. The dietitian acknowledged the absence of documentation and intervention during this period, which should have been addressed sooner given the resident's significant weight loss. Interviews with the dietitian and the Director of Nurses revealed that the facility's weight monitoring process was not effectively coordinated among nursing, dietitians, and physicians. The Director of Nurses expected the interdisciplinary team to identify and act upon significant weight changes, but this did not occur in a timely manner for the resident in question. The delay in addressing the resident's weight loss was a clear deficiency in the facility's care processes.
Failure to Ensure Physician Visits for New Admission
Penalty
Summary
The facility failed to ensure that a resident was seen by a physician within the first 90 days of admission, as required by federal and state regulations. The resident, who was admitted in June 2024, had multiple diagnoses including dysphagia, anemia, chronic renal insufficiency, thyroid disorder, Parkinson's disease, and major depressive disorder. Despite these conditions, the resident's medical record indicated that all assessments and visits were conducted by a Nurse Practitioner, with no documented visit by a physician. Interviews conducted during the investigation revealed that the Director of Nursing confirmed the Nurse Practitioner was responsible for the resident's initial assessment and ongoing care. The Medical Director stated that newly admitted residents should be assessed by a physician within the first 30 days and that if the attending physician is unavailable, alternative arrangements should be made. However, in this case, the Medical Director was not contacted to provide coverage, and the resident was not seen by a physician 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 Middleboro
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Nemasket Rehabilitation And Healthcare Center | 2.8 mi | ★★★★★ | 0 | 0 |
| Oakhill Healthcare | 3 mi | ★★★★★ | 13 | 0 |
| Life Care Center Of Raynham | 8.6 mi | ★★★★★ | 0 | 0 |
| Oaks, The | 9.7 mi | ★★★★★ | 3 | 0 |
| Tremont Rehabilitation & Skilled Care Center | 10.2 mi | ★★★★★ | 5 | 0 |
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