The nursing home failed to keep the area free of hazards and provide enough supervision to prevent accidents. Cited November 2025 — isolated incident, actual harm.
View the original federal record
F-Tag 689 — 42 CFR §483.25(d) — S/S: G
Nursing home report
CARE ONE AT MILLBURY
MILLBURY, MA · Medicare-certified · 154 beds
Needs attention
For-profitChain member
Data as of July 1, 2026
1 of 5 overall
CARE ONE AT MILLBURY has a 1-star overall rating, with a 1-star health inspection rating and 2-star staffing rating; reported nurse staffing is 3.64 hours per resident per day, below the 4.1 federal benchmark. It also has $84,611 in fines over the last 24 months and a recent federal penalty, while its quality measures rating is 4 stars.
Facility ratings
Health inspections
Staffing
3.6409 hrs/resident/day
Quality measures
Last inspection: May 14, 2026Penalties, last 24 months: $84,611recent federal penalty
Federal guidance recommends at least 4.1 nursing hours per resident each day. This facility reports 3.6409.
Staffing detail
- Registered nurses
- 0.53
- Licensed practical nurses
- 1.01
- Nurse aides
- 2.10
- Weekend nursing
- 3.34
Hours per resident per day.
Total staff turnover: 46%
Registered nurse turnover: 45%
Resident outcomes
Each measure compares a year ago with the most recent quarter. Green means the facility moved the right way; red means the wrong way.
Negative outcomes
Lower is better — fewer affected residents. A decrease is good (green); an increase is concerning (red).
Long-stay residents on antipsychotic medication
8.2%13.3%Worsening
Residents with a fall causing major injury
2.9%0.9%Improving
Residents with pressure ulcers (bedsores)
1.3%1.4%No change
Residents with a urinary tract infection
1%0%Improving
Residents who lost too much weight
6.1%5.7%No change
Residents who were physically restrained
0%0%No change
Residents needing more help with daily activities
20.2%19.4%Improving
Residents whose ability to walk got worse
12.4%18.7%Worsening
Long-stay residents on antianxiety or sleep medication
18.6%22.3%Worsening
Short-stay residents newly given an antipsychotic
0%1.1%Worsening
Residents with a long-term catheter
1%0%Improving
Residents with new or worsening incontinence
37.9%19.1%Improving
Residents with depressive symptoms
12.2%30.6%Worsening
Positive outcomes
Higher is better — e.g. vaccinations. An increase is good (green); a decrease is concerning (red).
Long-stay residents given the seasonal flu vaccine
—90.3%—
Long-stay residents given the pneumonia vaccine
100%100%No change
Short-stay residents given the seasonal flu vaccine
—84.8%—
Short-stay residents given the pneumonia vaccine
98.5%98.3%No change
What the inspectors found
The home failed to promptly tell the resident, doctor, and family about changes or problems affecting the resident. Cited April 2025 — isolated incident, actual harm.
View the original federal record
F-Tag 580 — 42 CFR §483.10(g)(14) — S/S: G
The home failed to provide safe, appropriate pain management for a resident who needed it. Cited April 2025 — isolated incident, actual harm.
View the original federal record
F-Tag 697 — 42 CFR §483.25(k) — S/S: G
The nursing home failed to ensure residents were free from significant medication errors. Cited April 2024 — isolated incident, actual harm.
View the original federal record
F-Tag 760 — 42 CFR §483.45(f)(2) — S/S: G
The home failed to provide safe, appropriate dialysis care for a resident who needed it. Cited August 2022 — isolated incident, actual harm.
View the original federal record
F-Tag 698 — 42 CFR §483.25(l) — S/S: G
Recent history
- STAFFING
Reported nurse staffing was below the federal recommendation of 4.1 hours per resident per day.
- INSPECTION
Health inspection found 1 health deficiency.
See what inspectors found
- STAFFING
Reported nurse staffing was below the federal recommendation of 4.1 hours per resident per day.
- INSPECTION
Health inspection found 1 health deficiency.
See what inspectors found
- PENALTY
A federal fine of $12,438 was recorded.
- PENALTY
A federal fine of $19,135 was recorded.
- INSPECTION
Health inspection found 1 health deficiency.
See what inspectors found
- PENALTY
A federal fine of $72,173 was recorded.
- INSPECTION
Health inspection found 15 health deficiencies.
See what inspectors found
Penalties & enforcement
On record with Medicare: 3 fines · $95,138 in total fines.
- $12,438
Federal fine
Nov 19, 2025
- $72,173
Federal fine
Apr 25, 2025
- $10,527
Federal fine
Feb 2, 2024
Operator & ownership
- Ownership
- For profit - Limited Liability company
- Chain
- Part of CAREONE · 37 homes · 3.4 stars avg
- Occupancy
- 144 residents on an average day (94% of 154 beds)
- Resident voice
- Resident council
- Medicare history
- Certified for 29 years
Things at a nursing home change — inspections, staffing, ownership, news.
Source: Centers for Medicare & Medicaid Services — public records, updated monthly. GoodStanding presents official records with plain-language summaries. Always visit a facility in person.