Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Mary, Queen And Mother Center during CMS and state inspections, most recent first.
The facility did not maintain its call light system in working order and failed to enforce the use of pagers by direct care staff as required by a state exception. A resident with multiple health conditions was left without assistance for several hours due to a malfunctioning call light, and staff interviews confirmed that pagers had not been used for months and that system monitoring was lacking.
A resident with multiple medical conditions experienced a surgical wound dehiscence and was started on new antibiotic and wound care orders. While the physician and nurse manager were notified, the resident's representative was not informed of the change in condition or new treatment until several days later, contrary to facility policy. Staff interviews confirmed the lapse in timely family notification.
A resident who underwent a left breast lumpectomy was not kept NPO as ordered prior to surgery, resulting in a delayed procedure. After returning from surgery, the facility did not obtain or follow physician orders for wound care, and wound treatments were performed without orders. Additionally, weekly skin assessments failed to document the surgical wound, despite ongoing issues including dehiscence and infection.
Failure to Maintain Call Light System and Enforce Pager Use
Penalty
Summary
The facility failed to maintain its call light system in working order and did not adhere to the stipulations outlined in the state exception granted for the use of its wireless call light system. Observations, interviews, and record reviews revealed that the call light system was not consistently operational, and direct care staff were not carrying pagers as required by both facility policy and the state exception. The exception specifically required all direct care staff to carry pagers to compensate for the lack of corridor indicator lights and audible signals, but multiple staff members, including CNAs, LPNs, and CMTs, confirmed that pagers had not been used for several months and that the requirement was no longer enforced or monitored by administration. A resident with a history of renal failure, depression, heart failure, and bipolar disorder experienced a significant event when their call light failed to function during a time of need. The resident reported severe foot pain and attempted to use the call light system for assistance, but no staff responded until a hospice nurse arrived several hours later. The resident stated that this was not the first time the call light system had failed and that the issue had persisted for months, with only temporary fixes applied by staff and maintenance. The resident was unable to call out for help due to their condition, further highlighting the impact of the malfunctioning system. Interviews with staff and the maintenance director confirmed that there was no internal audit or monitoring system in place to ensure the call light system was functioning properly. The maintenance director acknowledged that the system was monitored by an outside agency, but no alerts were sent to the facility in the event of a malfunction. The administrator was aware of the stipulations in the exception but was not aware that staff were not carrying pagers. The lack of enforcement and monitoring of both the call light system and pager usage directly contributed to the deficiency, affecting the ability of residents to request and receive timely assistance.
Failure to Notify Responsible Party After Change in Condition
Penalty
Summary
The facility failed to notify a resident's responsible party after a significant change in the resident's condition that required an alteration in the treatment plan. Specifically, a resident with a history of stroke, hemiplegia, hemiparesis, an open wound from a left breast biopsy, and seizures experienced dehiscence of the surgical area on the left breast. The physician and nurse manager were notified, and new orders for antibiotics and wound care were implemented. However, there was no documentation that the resident's representative was informed of this change in condition or the new treatment until several days later. Interviews with facility staff confirmed that the nurse on duty contacted the physician but did not notify the family as required by facility policy. The resident's family only became aware of the situation after being informed by the resident, at which point they contacted the facility and requested hospital follow-up. Facility leadership stated that staff are expected to notify family members as soon as possible after a change in condition, and definitely before the end of their shift, but this did not occur in this instance.
Failure to Follow Physician Orders and Provide Proper Post-Surgical Wound Care
Penalty
Summary
The facility failed to provide care and treatment in accordance with physician orders and accepted standards of practice for a resident who underwent a left breast lumpectomy. The resident was not maintained on NPO (nothing by mouth) status after midnight prior to surgery, despite a clear physician order, and was given a bowl of cereal for breakfast on the morning of the scheduled procedure. This resulted in a delay of the surgery, as documented in the surgeon's assessment and plan. The facility's own policies require strict adherence to physician orders, including those related to pre-operative care. Following the resident's return from surgery, the facility did not obtain or follow physician orders for wound care to the surgical site. There was no documentation of wound care orders or treatments for the surgical incision for an extended period, and wound care, including the application of steri-strips and dressings, was performed without a physician order. The resident reported that a dressing was left unchanged for three weeks, and when it was finally removed, there was thick yellow drainage present. The facility's policies state that wound treatments must be provided according to physician orders and that, in the absence of such orders, the physician should be notified to obtain them. Additionally, the facility failed to perform and document accurate weekly head-to-toe skin assessments, as required by the resident's care plan and facility policy. Multiple weekly skin assessments did not include any mention of the left breast surgical wound, despite its presence and subsequent complications, including dehiscence and infection. Interviews with staff and administration confirmed that there was an expectation for thorough assessment and documentation of all open areas, including surgical incisions, and that these expectations were not met in this case.
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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) |
|---|---|---|---|---|
| Lutheran Convalescent Home | 1.7 mi | ★★★★★ | 0 | 0 |
| Bethesda Dilworth | 2.8 mi | ★★★★★ | 2 | 0 |
| Lansdowne Village | 3.1 mi | ★★★★★ | 18 | 0 |
| Sherbrooke Village | 3.3 mi | ★★★★★ | 6 | 0 |
| Pine Grove Manor | 3.4 mi | ★★★★★ | 20 | 1 |
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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.