3
Findings
below the state median of 6
0
Repeat findings
June 11, 2024
Last state review

Massachusetts inspects every assisted living residence at least once every two years. At its most recent compliance review on June 11, 2024, the state cited 3 findings at Southgate at Shrewsbury - Hampton Suites. Across the 145 Massachusetts residences with a published report, the median is 6.

This page covers one review, not a history, and it is not a score or a ranking. A finding means the state identified something the residence has to correct; it does not on its own mean a resident was harmed. The state does not publish what happened after this review, so a finding listed here may since have been fixed.

Facility details

Owner
Southgate Operations, LLC
Action taken
Plan of correction required
Initial certification
8/1/1996
Current certification
5/1/2024 – 8/1/2024
Previous compliance review
8/11/22

What the state found

3 findings
Emergency call response · Food and dietary servicesIn the month of May 2024 there were 117 e-call response times over the eight (8) minutes required by Residence policy.▼

Emergency call response: How quickly staff answer a resident's emergency call button.

Food and dietary services: Meals, dietary review and how the kitchen is run.

The state cited these together under one finding.

What the inspector found

EOEA reviewed the Personalized Emergency Response procedures developed to provide timely assistance to a Resident in the event of an emergency needs situation.

In the month of May 2024 there were 117 e-call response times over the eight (8) minutes required by Residence policy.

EOEA reviewed the Residence’s dietary plan to confirm consistency with the most recent edition of the Dietary Guidelines.

Menus lacked the inclusion of the required language designating that the meal selections meet the minimum dietary standards of the daily recommended allowances of sodium, sugar and fat content as established by the Food and Nutrition Board of the National Research Council of the National Academy of Sciences.

EOEA observed two (2) Personal Care (PC) staff nurses providing medication assistance to six (6) Residents to ensure the Residence has developed and implemented systems that support and promote safe SAMM.

EOEA observed two (2) Residents with family filled medication containers which lacked a label noting the Resident’s name as required by policy.

EOEA observed two (2) Resident’s individual medications were stored in one medication cabinet.

EOEA observed one (1) Resident’s medication storage cabinet contained three opened medication packets with medications still present after being refused by the Resident on previous days. The Residence does not have a policy for disposal of medications.

EOEA observed two (2) PC staff did not perform proper hand hygiene prior to providing SAMM assistance.

General Requirements for an ALR: Emergency Response Dietary Reviews
651 CMR 12.04(2)(b) (3)(b),(4)

Quality assurance programMissing or incomplete components of the Quality Assurance and Performance Improvement requirements.▼

The residence's own program for auditing and improving the care it gives.

General Requirements for an ALR-Service and Service Coordination: Quality Assurance and Performance Improvement
651 CMR 12.04(10)(c)

Controlled medication handlingControlled Substance policy is not being followed. Missing disposal policy▼

How tightly the residence tracks medications that are subject to abuse.

What the inspector found

EOEA reviewed the Controlled Substance (CS) policy and procedure to provide safeguards to prevent theft and dispose of controlled substances prescribed to Residents who participate in SAMM.

The Residence policy does not include steps regarding the disposal of controlled substances.

EOEA observed documentation which did not meet the policy requirements intended to prevent the theft or diversion of controlled substances.

General Requirements for an ALR: Controlled Substances
651 CMR 12.04(14)(a)(b)

Glossary

Abbreviations the state uses without explaining them
EOEAExecutive Office of Elder Affairs — the former name of AGE, used in older reports.
SAMMSelf-administered medication management — the resident manages their own medication with oversight.
e-callThe emergency call system a resident uses to summon staff.
PC staffPersonal care staff — the aides who help residents with daily activities.
CSControlled substances — medications tracked under stricter rules.
What the residence must doThe residence must send the state a plan to correct each finding, what it will do to keep it from happening again, who is responsible and by when.▼

The residence must send the state a plan to correct each finding, what it will do to keep it from happening again, who is responsible and by when.