Complete Care at Shrewsbury LLC

In the surveyor’s words

From the most serious findings on record at Complete Care at Shrewsbury LLC, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600May 30, 2024

  Based on observation, record review, interviews, and review of facility policy, the facility failed to ensure adequate supervision of residents by specifically failing to prevent Resident (R) #60 from wandering into other residents' rooms leading to physical altercations with other residents. Due to the vulnerable nature of the nursing home population, a potential for serious injury or serious physical or psychosocial impairment from being hit by R #60, or R #60 being hit, existed, and the likeliness of R #60 hitting another resident or being hit by another resident in the facility was high and required immediate action to prevent further events of physical abuse by or to R #60. […]

• No harm, potential for more than minimal, patternF550Sep 25, 2025

  Based on observation, interview, record review, and policy review, the facility failed to ensure one resident of three (Resident (R)53) of 33 sampled residents were treated with dignity in toileting. This failure had the potential to negatively impact the quality of life and self-esteem for the affected resident.Findings include: Review of R53's admission Record located in the resident's EMR section titled Profile revealed the resident was admitted to the facility on [DATE] with diagnoses that included benign prostatic hyperplasia with lower urinary tract symptoms. […]

• No harm, potential for more than minimal, patternF641Sep 25, 2025

  Based on observations, interviews, record review, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure the Minimum Data Set (MDS) was coded accurately for five residents (Residents (R)44, R9, R133, R6, and R80 in a total sample of 33 residents. This failure placed residents at risk of unmet care needs.Findings include: 1. Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed R44 was admitted to the facility on [DATE] with a diagnosis of chronic respiratory failure with hypoxia (an inadequate oxygen supply to the body). […]

• No harm, potential for more than minimal, patternF656Sep 25, 2025

  Based on observations, record review, interviews, and review of facility policy, the facility failed to ensure care plans were developed and/or implemented for five residents (Residents (R) R1, R7, R14, R36, and R104) from a total sample of 33 residents. This failure had the potential that residents would not receive all necessary care and services.Findings include: 1. Review of R1's admission Record located in the electronic medical record (EMR) tab titled Profile revealed the resident was admitted to the facility initially on 03/28/21 and readmitted [DATE] with diagnoses that included Asperger's syndrome (developmental disorder to effectively socialize and communicate. […]

• No harm, potential for more than minimal, patternF883Sep 25, 2025

  Based on record review, interview, and policy review, the facility failed to ensure four of five residents (Resident (R)12, R82, R89, and R129) reviewed for immunizations out of a total sample of 33 residents had been offered and/or provided a pneumococcal immunization This failure increased the risk of residents contracting pneumonia.Findings include: 1. Review of R12's electronic medical record (EMR), located under the Census tab revealed R12 was admitted to the facility on [DATE] with diagnoses found under the Medical Diagnosis tab included encounter for surgical aftercare following surgery of the digestive system, colostomy, and an incisional site infection. Review of R12's paper medical record revealed no documentation that the resident had been offered a pneumococcal immunization. 2. […]