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
2 of 5 overall
Care One at Millbury has a 2-star overall rating, with a 1-star health inspection rating and 2-star staffing rating, though its quality measures are 5 stars. It has had $91,308 in fines in the last 24 months, a recent federal penalty, and reported nurse staffing of 3.58 hours per resident per day versus the 4.1-hour federal benchmark.
Facility ratings
Health inspections
Staffing
3.5814 hrs/resident/day
Quality measures
Last inspection: March 17, 2026Penalties, last 24 months: $91,308recent federal penalty
Federal guidance recommends at least 4.1 nursing hours per resident each day. This facility reports 3.5814.
Staffing detail
- Registered nurses
- 0.43
- Licensed practical nurses
- 1.11
- Nurse aides
- 2.04
- Weekend nursing
- 3.30
Hours per resident per day.
Total staff turnover: 39%
Registered nurse turnover: 44%
Resident outcomes
How often residents experience these outcomes, with the direction over the past year.
Long-stay residents on antipsychotic medication
9%Worsening
Residents with a fall causing major injury
1.9%Improving
Residents with pressure ulcers (bedsores)
1.2%Improving
Residents with a urinary tract infection
1.3%Improving
Residents who lost too much weight
7.4%Worsening
Residents who were physically restrained
0%Steady
Residents needing more help with daily activities
14.7%Improving
Residents whose ability to walk got worse
16.3%Improving
Show all measures
Long-stay residents on antianxiety or sleep medication
17.8%Worsening
Short-stay residents newly given an antipsychotic
0.2%Worsening
Residents with a long-term catheter
0.5%Improving
Residents with new or worsening incontinence
29.2%Worsening
Residents with depressive symptoms
11.5%Improving
Long-stay residents given the seasonal flu vaccine
90.3%Steady
Long-stay residents given the pneumonia vaccine
99.8%Improving
Short-stay residents given the seasonal flu vaccine
84.8%Steady
Short-stay residents given the pneumonia vaccine
97.3%Improving
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
- 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 · $101,835 in total fines.
- $19,135
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
- 144.1 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.