Care One at Millbury
312 Millbury Avenue · Millbury, MA · 01527 · 9788703397
154 certified beds For profit - Limited Liability company Chain: Careone
Why this verdict
- Inspection record is far worse than the national median (deficiency count and severity).
- Federal penalties on record: $91,308 in fines in the last 24 months.
- Inspection results are getting worse cycle over cycle, not better.
- 5 citations involved actual harm to residents.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
3 actual-harm citations in the most recent cycle
Inspectors found deficiencies that caused real harm to residents, beyond potential-harm paperwork findings.
$91,308 in federal fines in the last 24 months
2 fines — CMS fines are reserved for verified, serious non-compliance.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 2 of 5 Inspections: 1 of 5 Staffing: 2 of 5 Quality measures: 5 of 5
| Total nurse hours / resident-day | 3.58 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.43 | 0.55–0.75 |
| Weekend hours / resident-day | 3.30 | ≈ weekday level |
| Nursing turnover / year | 39% | median 45% |
| Fines (3-yr window) | 3 · $101,835 |
Inspection citations (36 in the current record)
-
Potential for harm · D March 17, 2026 · found via complaint
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected March 7, 2026 · Resident Rights
-
Actual harm · G November 19, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected December 17, 2025 · Quality of Life and Care
-
Actual harm · G April 25, 2025
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected June 2, 2025 · Resident Rights
-
Actual harm · G April 25, 2025
Provide safe, appropriate pain management for a resident who requires such services.
Corrected June 2, 2025 · Quality of Life and Care
-
Potential for harm · D April 25, 2025
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected June 2, 2025 · Resident Rights
-
Potential for harm · D April 25, 2025
Ensure each resident receives an accurate assessment.
Corrected June 2, 2025 · Resident Assessment and Care Planning
-
Potential for harm · D April 25, 2025
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected June 2, 2025 · Quality of Life and Care
-
Potential for harm · D April 25, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected June 2, 2025 · Quality of Life and Care
-
Potential for harm · D April 25, 2025
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected June 2, 2025 · Quality of Life and Care
-
Potential for harm · D April 25, 2025
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected June 2, 2025 · Quality of Life and Care
-
Potential for harm · E April 25, 2025
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected June 2, 2025 · Pharmacy Service
-
Potential for harm · D April 25, 2025
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected June 2, 2025 · Nutrition and Dietary
-
Potential for harm · D April 25, 2025
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected June 2, 2025 · Nutrition and Dietary
-
Potential for harm · E April 25, 2025
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected June 2, 2025 · Administration
-
Potential for harm · D April 25, 2025
Provide and implement an infection prevention and control program.
Corrected June 2, 2025 · Infection Control
-
Potential for harm · D April 25, 2025
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected June 2, 2025 · Infection Control
-
Potential for harm · D April 25, 2025
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected June 2, 2025 · Infection Control
-
Actual harm · G April 3, 2024 · found via complaint
Ensure that residents are free from significant medication errors.
Corrected January 30, 2024 · Pharmacy Service
-
Potential for harm · D February 2, 2024
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected March 18, 2024 · Resident Assessment and Care Planning
-
Potential for harm · D February 2, 2024
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected March 18, 2024 · Resident Assessment and Care Planning
-
Potential for harm · D February 2, 2024
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected March 18, 2024 · Resident Assessment and Care Planning
-
Potential for harm · D February 2, 2024
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected March 18, 2024 · Resident Assessment and Care Planning
-
Potential for harm · D February 2, 2024
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected March 18, 2024 · Quality of Life and Care
-
Potential for harm · D February 2, 2024
Assist a resident in gaining access to vision and hearing services.
Corrected March 18, 2024 · Quality of Life and Care
-
Potential for harm · D February 2, 2024
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected March 18, 2024 · Pharmacy Service
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| November 19, 2025 | Fine | $19,135 |
| April 25, 2025 | Fine | $72,173 |
| February 2, 2024 | Fine | $10,527 |
Family & resident reviews — a separate signal, never mixed into the score
No approved reviews yet. If your family has experience with this facility, yours could be the review that helps the next family decide.
Sign in to share your family's experience — reviews are moderated and never affect the Safety Score.
Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 225720 · certified since January 23, 1997. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.