Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Shrewsbury Rehabilitation And Nursing At Southgate during CMS and state inspections, most recent first.
The facility failed to keep the dumpster area clean and sanitary near the main kitchen. The surveyor observed two dumpsters in a fenced area with 10 to 15 cardboard boxes, four worn mattresses, disposable gloves, cups, trash bags, and other debris scattered on the ground around them. The FSD said she was not aware of the amount of trash present, the Maintenance Director said it could breed insects and rodents, and the IP said the area was a breeding ground for infestation and that all trash should have been contained inside the dumpsters.
Missing Signatures on Controlled Medication Count Log: The facility failed to maintain accurate controlled substance records when a Control Medication Log for one medication cart had no signatures or evidence that the required shift-change counts were documented. An LPN and other nurses stated they completed the counts and found them correct, but each said they forgot to sign the log, and the DON confirmed the expectation was for two nurses to count and sign together at every shift change.
Expired Multi-Dose Tuberculin Vial Stored in Medication Refrigerator A surveyor found an open multi-dose vial of Tuberculin, Purified Protein in a Unit One med refrigerator after the manufacturer’s 30-day discard timeframe had passed. The vial had been opened and dated, but staff did not discard it as required by the facility policy and package insert. Nurse #1, the SDC, and the DON all acknowledged the vial should have been discarded after 30 days.
A resident with a history of urinary retention did not receive a physician-ordered post void residual (PVR) bladder scan on one shift, and there was no documentation to confirm the procedure was performed or the results recorded. The nurse preceptor supervising a new graduate was unaware if the PVR was completed, and facility policy requiring documentation of treatments was not followed.
A facility failed to conduct required cognitive and mood assessments for a resident with dementia, anxiety disorder, and hallucinations. Despite the resident's ability to communicate, the BIMS and mood assessments were not completed within the required timeframe. Staff interviews revealed a lack of training for nursing staff on conducting BIMS, with the responsibility placed on social workers. The assessments were conducted after the ARD, leading to their exclusion from the comprehensive assessment.
A resident with dementia and anxiety received Ativan incorrectly due to a transcription error on the MAR, leading to twice-daily administration instead of the prescribed once-daily PRN. The facility failed to follow the five rights of medication administration, resulting in a deficiency in care.
A resident with paraplegia and a Stage IV pressure ulcer did not receive wound care as ordered by the physician. The nurse applied Santyl around the wound instead of to the wound base, contrary to the physician's instructions. This failure to adhere to the prescribed treatment placed the resident at risk for delayed healing.
A facility failed to assess and manage a resident's wandering and elopement risk, leading to increased risk for unsafe wandering. The resident, with Parkinson's Disease and Dementia, exhibited exit-seeking behaviors not present at admission. The facility did not reassess the risk or develop a care plan, even after hospital transfers and escalating behaviors. An elopement risk assessment and care plan were delayed until the resident required hospital transfer due to these behaviors.
The facility failed to remove expired Ferrous Gluconate liquid from a medication cart, as observed by a surveyor. The medications had expiration dates of 5/2024 and 10/2024. Nurse #2 confirmed that these expired medications should not have been administered and should have been removed. The facility's policy requires expired medications to be identified and reported for removal, but this was not adhered to.
A facility failed to accurately document a behavioral incident involving a resident with dementia, expressive aphasia, and generalized anxiety disorder. The resident was reported to have had two episodes of behavioral issues, including yelling and attempting to strike a roommate. However, interviews revealed discrepancies, with staff indicating that the resident did not make contact with the roommate. The DON acknowledged the inaccuracy in the nurse's progress note, which did not accurately reflect the incident.
A facility failed to accurately complete an MDS Assessment for a resident with Dementia with Behavioral Disturbance. The resident had an order for Ativan, an antianxiety medication, but the Medication Administration Record showed no administration during the observation period. Despite this, the MDS Assessment incorrectly indicated the resident received the medication. The MDS Nurse confirmed this was a coding error.
A facility failed to promptly notify the State mental health authority after a resident exhibited new symptoms of paranoia, delusions, and hallucinations, requiring antipsychotic medication. The resident's condition changed significantly, but the facility delayed submitting a resident review for a Level Two PASRR Evaluation, leading to a deficiency.
Dumpster Area Not Kept Clean and Sanitary
Penalty
Summary
The facility failed to ensure that the dumpster area was maintained in a clean and sanitary manner to prevent the harborage and feeding of pests. During observation with the Food Service Director, the surveyor found two dumpsters inside a fenced area near the main kitchen, one for general refuse and one for recyclable cardboard, with trash and debris scattered on the ground around them. The items observed on the ground included 10 to 15 cardboard boxes, four old worn mattresses, disposable gloves in multiple colors, a worn Coca-Cola box, multiple disposable clear cups, clear trash bags, and various other trash debris. During interviews, the Food Service Director said she was not aware there was so much trash around the dumpsters, the Maintenance Director stated the amount of trash and debris could breed insects and rodents, and the Infection Preventionist said the dumpster area was a breeding ground for infestation and that all trash should have been contained inside the dumpsters.
Missing Signatures on Controlled Medication Count Log
Penalty
Summary
The facility failed to maintain accurate records of controlled substances for one Control Medication Log on Unit One Side A. During review of the log and observation of the medication cart, the surveyor found no signatures or other evidence that the controlled medication count had been completed on 3/10/26 at 11:00 P.M. or 3/11/26 at 7:00 A.M. The facility policy titled Controlled Substances required nursing staff to count controlled medication inventory at the end of each shift and for the nurse coming on duty and the nurse going off duty to make the count together and document it. During interviews, Nurse #1 stated she counted the controlled medications with Nurse #2 at 7:00 A.M. and that the count was correct, but she had forgotten to sign the log. Nurse #2 stated she had counted the controlled medications with Nurse #3 at 11:00 P.M. and with Nurse #1 at 7:00 A.M., and that both counts were correct, but she also forgot to sign the log. Nurse #3 stated she had counted the controlled medications with Nurse #2 at 11:00 P.M. and forgot to sign the log. The DON stated the expectation was for two nurses to count the controlled medications at every shift change and both sign the Control Medication Log together, but the log reviewed had no entries for those counts.
Expired Multi-Dose Tuberculin Vial Left in Medication Refrigerator
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in accordance with State and Federal laws in one medication storage room on Unit One. During observation and record review, a surveyor found an open multi-dose vial of Tuberculin, Purified Protein in the refrigerator. The box holding the vial was labeled as opened on 1/24/26, and the manufacturer’s instructions on the box and package insert stated that once opened, the vial should be discarded after 30 days. The facility policy also stated that multi-dose vials that have been opened or accessed are to be dated and discarded within 28 days unless the manufacturer specifies a different timeframe. During interview, Nurse #1 stated the open Tuberculin, Purified Protein vial should have been discarded the prior month but had not been discarded. The Staff Development Coordinator stated nurses were expected to discard multi-dose vials of Tuberculin, Purified Protein 30 days after opening, but they had not done so. The DON also stated the expectation was that the vial should be labeled when opened and discarded per the instructions after 30 days.
Failure to Perform and Document Physician-Ordered Urinary Retention Monitoring
Penalty
Summary
A deficiency occurred when a resident with a history of urinary retention and diagnoses of obstructive and reflux uropathy did not receive a physician-ordered treatment for monitoring and managing urinary retention. The resident had an order for post void residual (PVR) bladder scans every shift, with instructions for straight catheterization if the residual exceeded 500 ml. On one night shift, there was no documentation in the medical record or Medication Administration Record (MAR) to indicate that the PVR was performed, nor was the amount of urine retained recorded, as required by the physician's order and facility policy. Interviews revealed that the nurse preceptor on duty was supervising a new graduate nurse on orientation. The preceptor was unaware if the PVR was completed and acknowledged that if it had been done, it would have been documented accordingly. The Staff Development Coordinator confirmed that the preceptor was responsible for ensuring all treatments and documentation were completed as ordered. The Director of Nurses also stated that proper documentation would have been present if the PVR had been performed. The lack of documentation and uncertainty about whether the ordered treatment was provided constituted a failure to meet professional standards of practice.
Failure to Conduct Required Cognitive and Mood Assessments
Penalty
Summary
The facility failed to complete an accurate comprehensive assessment for a resident, as required by the Resident Assessment Instrument (RAI) process in the Minimum Data Set (MDS) assessment. Specifically, the staff did not assess the resident's cognitive and mood status through the required resident interview process, despite the resident having adequate hearing, clear speech, and the ability to sometimes make themselves understood and understand others. The resident was admitted with diagnoses including dementia with agitation, anxiety disorder, and hallucinations, yet the Brief Interview for Mental Status (BIMS) and mood assessments were not conducted as required. Interviews with facility staff revealed that the nursing staff on the floor were not trained to assess BIMS upon admission, and it was the responsibility of the social worker to conduct these assessments. The MDS Nurse confirmed that the BIMS should have been assessed within the 14-day assessment reference period but was not completed. The Director of Nursing acknowledged that the BIMS and mood assessments were conducted after the comprehensive assessment's Assessment Reference Date (ARD), resulting in their exclusion from the comprehensive assessment.
Medication Administration Deficiency Due to Incorrect Transcription
Penalty
Summary
The facility failed to adhere to professional standards of practice for medication administration for a resident diagnosed with dementia and anxiety. The resident was prescribed Ativan to manage anxiety, with specific orders for administration both regularly and as needed (PRN). However, the facility staff did not administer the medication according to the physician's order, leading to a deficiency in care. The deficiency occurred when the PRN Ativan was administered twice within a short period, contrary to the physician's order for once daily administration. The Unit Manager acknowledged that the medication was given at 1:44 A.M. and 5:51 A.M., which was not in line with the prescribed frequency. This error was attributed to an incorrect transcription of the medication order on the Medication Administration Record (MAR), where the frequency was omitted. Interviews with the Unit Manager and the Director of Nursing revealed that the facility's process for transcribing medication orders was not followed correctly. The Director of Nursing confirmed that the transcription should include the five rights of medication administration, which were not adhered to in this case. The omission of the frequency in the MAR led to the improper administration of Ativan, highlighting a lapse in the facility's medication management practices.
Failure to Follow Physician's Orders for Pressure Ulcer Treatment
Penalty
Summary
The facility failed to ensure that its staff adhered to professional standards of practice in the prevention and treatment of pressure ulcers for a resident. Specifically, the staff did not perform a wound treatment as ordered by the physician, which was necessary for the healing of a Stage IV pressure ulcer. The facility's policy on wound treatment management, revised in May 2024, mandates that wound treatments be provided according to physician orders, including the method of cleansing, type of dressing, and frequency of dressing changes. However, during an observation, it was noted that the prescribed treatment was not followed. The resident, who was admitted with paraplegia and a deep tissue injury, had developed a Stage IV pressure ulcer. The physician's order required the application of Santyl to the wound base, followed by a damp to dry dressing and a border foam dressing. During a surveyor's observation, a nurse applied Santyl around the wound instead of directly to the wound base as ordered. Both the unit manager and the nurse acknowledged the discrepancy between the physician's order and the treatment provided. This failure to follow the physician's order placed the resident at risk for delayed wound healing.
Failure to Assess and Manage Wandering and Elopement Risk
Penalty
Summary
The facility failed to adequately assess and manage the wandering and elopement risk for a resident, identified as Resident #83, which increased the resident's risk for unsafe wandering and elopement. Upon admission, the resident was diagnosed with Parkinson's Disease, Dementia with Behavioral Disturbance, and a Right Femur Fracture. The initial Wandering Risk Scale Assessment was not accurately completed, as it failed to acknowledge the resident's diagnosis of Dementia and the impact on mobility. Additionally, sections of the assessment meant to be completed at 72 hours post-admission and one month later were left incomplete, resulting in an inaccurate low-risk score. The resident exhibited changes in behavior, including exit-seeking and wandering into other residents' rooms, which were not present at admission. Despite these behaviors, the facility did not reassess the resident's wandering and elopement risk or develop a resident-centered care plan to address these behaviors. The resident's clinical record lacked evidence of any assessment or care plan initiation for wandering and elopement risk, even after the resident was transferred to the hospital and readmitted to the facility. The facility's failure to reassess the resident's risk and implement a care plan continued even as the resident's behaviors escalated, including attempts to exit the unit and expressing delusions and paranoia. It was not until the resident's behavior necessitated a hospital transfer on 9/30/24 that an elopement risk assessment was completed, and a wander guard was placed on the resident's wheelchair. The care plan for elopement was not initiated until the same day, and the behavior care plan was not revised until 10/8/24, indicating a significant delay in addressing the resident's needs.
Expired Medications Found on Medication Cart
Penalty
Summary
The facility failed to remove expired medications from one of the medication carts, specifically two bottles of Ferrous Gluconate liquid, which is an iron supplement. These medications had expiration dates of 5/2024 and 10/2024 and were still present on the medication cart during the surveyor's observation. Nurse #2 acknowledged that the expired medications should not have been administered to residents and should have been removed from the cart upon expiration. The facility's policy on medication storage and administration requires that all drugs and biologicals be stored in locked compartments and that expired medications be identified and reported to the nurse manager for removal. However, these procedures were not followed, leading to the presence of expired medications on the cart.
Inaccurate Documentation of Resident Behavioral Incident
Penalty
Summary
The facility failed to maintain an accurate medical record for a resident, specifically regarding a behavioral incident that occurred. The resident, who was admitted with diagnoses including dementia, expressive aphasia, and generalized anxiety disorder, was involved in an incident with their roommate. The Minimum Data Set (MDS) assessment indicated that the resident was severely cognitively impaired and did not exhibit any behaviors. However, a nurse's note documented that the resident had two episodes of behavioral issues, including yelling, pointing, and attempting to strike the roommate with a wheelchair, while using foul language. Interviews with family members and staff revealed discrepancies in the documentation. A family member reported an incident over the weekend where the resident became angry with the roommate. A witness statement by a nurse indicated that the resident was yelling from their bed, using foul language, but did not make contact with the roommate. The Director of Nurses acknowledged that the nurse's progress note was inaccurate based on the witness statement, and the note would be corrected. The inaccurate documentation failed to accurately represent the resident's behavior and the incident's nature.
MDS Assessment Coding Error for Antianxiety Medication
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) Assessment for a resident, leading to a deficiency. The resident, admitted in June 2024 with a diagnosis of Dementia with Behavioral Disturbance, had an active physician order for Ativan, an antianxiety medication, to be administered as needed for anxiety or agitation. However, during the MDS Assessment observation period from November 2 to November 8, 2024, the Medication Administration Record showed no administration of Ativan to the resident. Despite this, the MDS Assessment dated November 8, 2024, incorrectly indicated that the resident received antianxiety medication during the observation period. The MDS Nurse confirmed in an interview that this was a coding error, as the resident did not receive any antianxiety medication during the specified period.
Failure to Notify State Mental Health Authority of Resident's Condition Change
Penalty
Summary
The facility failed to notify the State mental health authority promptly after a significant change in the mental condition of a resident, which increased the risk of the resident not receiving specialized services in a timely manner. The resident, who was admitted with a diagnosis of Dementia with Behavioral Disturbance, began exhibiting new symptoms of paranoia, delusions, and visual hallucinations. These symptoms were not present during the initial Preadmission Screening and Resident Review (PASRR) Level One Screening, and the resident had not been diagnosed with any serious mental illness at that time. The resident's condition changed significantly, as noted in various progress notes and evaluations. The resident was observed to be alert with delusions and hallucinations, and required treatment with an antipsychotic medication, Seroquel, which had not been previously prescribed. Despite these changes, there was no evidence in the clinical record that the facility staff notified the State mental health authority of the resident's newly indicated serious mental illness and decline in condition until several days after the resident returned from a hospital visit. Interviews with facility staff revealed that the Unit Manager responsible for completing PASRR screenings was not made aware of the resident's new diagnoses and use of antipsychotic medication until informed by a Consultant Social Worker. The Consultant Social Worker confirmed that the facility was required to promptly submit a resident review to the State mental health authorities for a Level Two PASRR Evaluation, which was not done in a timely manner. This delay in notification and submission of the resident review contributed to the deficiency identified in the report.
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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 Shrewsbury
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Beaumont Rehab & Skilled Nursing Ctr - Northboro | 2.8 mi | ★★★★★ | 0 | 0 |
| Notre Dame Long Term Care Center | 3 mi | ★★★★★ | 0 | 0 |
| Alliance Health At Coleman | 3.3 mi | ★★★★★ | 10 | 0 |
| Regalcare At Worcester | 3.3 mi | ★★★★★ | 0 | 0 |
| Knollwood Nursing Center | 4 mi | ★★★★★ | 9 | 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 July 2026) and official state health department websites.