Care One at Millbury
312 Millbury Avenue, Millbury, MA 01527
Care One at Millbury is a nursing home in Millbury, Massachusetts. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
CMS star ratings
- 2 of 5CMS overall star rating
- 1 of 5CMS health inspection star rating
- 3 of 5CMS staffing star rating
- 5 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (978) 870-3397
- Last standard health inspection
- April 25, 2025 (1 year ago)
- Certified beds
- 154
- Residents per day, on average
- 140.2
- Ownership type
- For profit - Limited Liability company
- Legal business name
- 312 Millbury Avenue Operating Company, LLC
- Chain
- Careone
- Takes part in
- Medicare and Medicaid
More health citations than the Massachusetts average (37 vs 28).
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS overall star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS staffing star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5.
CMS update of October 8, 2026
Fine
CMS changed the fine from November 19, 2025 from $12,438 to $12,628.
CMS update of July 29, 2026
Star rating
The CMS overall star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS quality measures star rating changed from 5 of 5 to 4 of 5.
Fine
CMS changed the fine from November 19, 2025 from $19,135 to $12,438.
CMS update of May 27, 2026
Star rating
The CMS overall star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 1 of 5.
1 citation
Health inspection on May 14, 2026
CMS lists this as a complaint inspection.
Citation F0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
CMS lists it as corrected on May 29, 2026.
CMS update of April 29, 2026
Star rating
The CMS overall star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS staffing star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5.
1 citation
Health inspection on March 17, 2026
CMS lists this as a complaint inspection.
Citation F0578. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on March 7, 2026.
CMS has cited this home for F0578 2 times since 2022.
CMS update of February 25, 2026
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5.
1 citation
Health inspection on November 19, 2025
CMS lists this as a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
51 of 341 Massachusetts homes (15%) got a citation at the actual harm level in 2025.
Citation F0689. Severity G: actual harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on December 17, 2025.
Fine
November 19, 2025 (11 months ago)
CMS fine of $12,628 on November 19, 2025.
CMS update of July 30, 2025
Star rating
The CMS overall star rating changed from 3 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS health inspection star rating changed from 3 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.
15 citations
Health inspection on April 25, 2025
CMS lists this as a standard inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
51 of 341 Massachusetts homes (15%) got a citation at the actual harm level in 2025.
Citation F0580. Severity G: actual harm, isolated.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on June 2, 2025.
Citation F0697. Severity G: actual harm, isolated.
The rule CMS cited:
Provide safe, appropriate pain management for a resident who requires such services.
CMS lists it as corrected on June 2, 2025.
Citation F0755. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on June 2, 2025.
Citation F0865. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have a plan that describes the process for conducting QAPI and QAA activities.
CMS lists it as corrected on June 2, 2025.
Citation F0561. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
CMS lists it as corrected on June 2, 2025.
Citation F0641. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives an accurate assessment.
CMS lists it as corrected on June 2, 2025.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on June 2, 2025.
CMS has cited this home for F0677 2 times since 2024.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on June 2, 2025.
Citation F0690. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS lists it as corrected on June 2, 2025.
Citation F0694. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
CMS lists it as corrected on June 2, 2025.
Citation F0804. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
CMS lists it as corrected on June 2, 2025.
Citation F0808. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on June 2, 2025.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on June 2, 2025.
CMS has cited this home for F0880 2 times since 2022.
Citation F0883. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement policies and procedures for flu and pneumonia vaccinations.
CMS lists it as corrected on June 2, 2025.
Citation F0887. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on June 2, 2025.
12 citations
Fire safety inspection on April 25, 2025
CMS lists this as a standard inspection.
Citation E0020. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Establish policies and procedures including evacuation.
CMS lists it as corrected on June 9, 2025.
Citation E0022. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Establish policies and procedures for sheltering.
CMS lists it as corrected on June 9, 2025.
Citation K0222. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
CMS lists it as corrected on June 9, 2025.
Citation K0311. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have an enclosure around a vertical opening shaft.
CMS lists it as corrected on June 9, 2025.
Citation K0324. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on June 9, 2025.
Citation K0711. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide a written emergency evacuation plan.
CMS lists it as corrected on June 9, 2025.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on June 9, 2025.
CMS has cited this home for K0918 2 times since 2022.
Citation K0920. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on June 9, 2025.
CMS has cited this home for K0920 2 times since 2022.
Citation K0321. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on June 9, 2025.
Citation K0712. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on June 9, 2025.
Citation K0923. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have proper medical gas storage and administration areas.
CMS lists it as corrected on June 9, 2025.
Citation K0363. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on June 9, 2025.
Fine
April 25, 2025 (1 year ago)
CMS fine of $72,173 on April 25, 2025.
CMS update of February 26, 2025
Star rating
The CMS staffing star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.
CMS update of August 29, 2024
Fine
CMS changed the fine from February 2, 2024 from $16,195 to $10,527.
1 citation
Health inspection on April 3, 2024
CMS lists this as a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
69 of 341 Massachusetts homes (20%) got a citation at the actual harm level in 2024.
Citation F0760. Severity G: actual harm, isolated.
The rule CMS cited:
Ensure that residents are free from significant medication errors.
CMS lists it as corrected on January 30, 2024.
8 citations
Health inspection on February 2, 2024
CMS lists this as a standard inspection.
Citation F0644. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
CMS lists it as corrected on March 18, 2024.
Citation F0655. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
CMS lists it as corrected on March 18, 2024.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on March 18, 2024.
CMS has cited this home for F0656 2 times since 2022.
Citation F0657. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on March 18, 2024.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on March 18, 2024.
Citation F0685. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Assist a resident in gaining access to vision and hearing services.
CMS lists it as corrected on March 18, 2024.
Citation F0758. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on March 18, 2024.
Citation F0842. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on March 18, 2024.
Fine
February 2, 2024 (2 years ago)
CMS fine of $10,527 on February 2, 2024.
10 citations
Health inspection on August 16, 2022
CMS lists this as a standard inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
9 of 341 Massachusetts homes (3%) got a citation at the actual harm level in 2022.
Citation F0698. Severity G: actual harm, isolated.
The rule CMS cited:
Provide safe, appropriate dialysis care/services for a resident who requires such services.
CMS lists it as corrected on September 19, 2022.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on September 19, 2022.
Citation F0886. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Perform COVID19 testing on residents and staff.
CMS lists it as corrected on September 19, 2022.
Citation F0578. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on September 19, 2022.
Citation F0623. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
CMS lists it as corrected on September 19, 2022.
Citation F0625. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
CMS lists it as corrected on September 19, 2022.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on September 19, 2022.
Citation F0695. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on September 19, 2022.
Citation F0756. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
CMS lists it as corrected on September 19, 2022.
Citation F0812. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on September 19, 2022.
9 citations
Fire safety inspection on August 16, 2022
CMS lists this as a standard inspection.
Citation K0300. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Meet other general requirements that are deficient.
CMS lists it as corrected on October 6, 2022.
Citation K0293. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have properly located and lighted "Exit" signs.
CMS lists it as corrected on October 6, 2022.
Citation K0351. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install an approved automatic sprinkler system.
CMS lists it as corrected on October 6, 2022.
Citation K0781. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have restrictions on the use of portable space heaters.
CMS lists it as corrected on October 6, 2022.
Citation K0911. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Meet requirements for the installation and maintenance of electrical systems.
CMS lists it as corrected on October 6, 2022.
Citation K0918. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on October 6, 2022.
Citation K0211. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Keep aisles, corridors, and exits free of obstruction in case of emergency.
CMS lists it as corrected on October 6, 2022.
Citation K0372. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
CMS lists it as corrected on October 6, 2022.
Citation K0920. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on October 6, 2022.
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- THCI OF MASSACHUSETTS, LLC5% or greater direct ownership interest · no percentage provided · since 07/01/2003
- CARE REALTY, LLC5% or greater indirect ownership interest · no percentage provided · since 04/30/2002
- DES-I 2016 GRAT5% or greater indirect ownership interest · no percentage provided · since 12/01/2021
- STRAUS, DANIEL5% or greater indirect ownership interest · no percentage provided · since 07/01/2003
- STRAUS, MOSHAEL5% or greater indirect ownership interest · no percentage provided · since 07/01/2003
- HEALTHBRIDGE MANAGEMENT LLCOperational/managerial control · not applicable · since 07/01/2003
Questions
When was Care One at Millbury last inspected?
CMS lists April 25, 2025 as the date of its most recent standard health inspection.
How many citations (violations) does Care One at Millbury have?
CMS lists 37 health citations since August 16, 2022. CMS also calls these deficiencies.
Has Care One at Millbury been fined?
CMS lists 3 fines in the past three years, $95,328 in total.
What is the CMS star rating of Care One at Millbury?
Its CMS overall star rating is 2 of 5.
Is Care One at Millbury a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.