Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Care One At Millbury during CMS and state inspections, most recent first.
Improper Storage of Refrigerated Injectable Medication: A resident with osteoporosis and other significant diagnoses had a Teriparatide pen brought in by family for daily injections, but an LPN placed it in the med cart instead of refrigerating it per manufacturer instructions. The medication remained unrefrigerated for several days, was later found warm, and the resident declined the dose after missing several days of therapy.
A resident with severe cognitive impairment and multiple serious medical conditions was admitted with a documented hospital MOLST/POLST indicating DNR/DNI status, but facility staff did not obtain corresponding DNR orders, complete a MOLST, or incorporate code status into the care plan or care conference documentation. The admitting nurse did not act on the hospital discharge information to secure appropriate physician orders, and the social worker did not review or document the resident’s advance directives during admission or subsequent care conferences. Later, when the resident was found unresponsive and pulseless, nurses could not locate any DNR order or MOLST in the electronic or paper chart and, in the absence of such documentation, initiated a Code Blue and CPR, after which the resident was transported to the hospital and expired.
Unsafe Transfer After Refusal of Required Assistive Device: A resident with a high fall risk and a care plan requiring a stand aid with 2-person assist for transfers was moved by two CNAs after refusing the stand aid, gait belt, and Hoyer lift. The CNAs did not wait for RN or rehab intervention, and the resident fell, hit his/her head, and was sent to the ED with a C7 fracture. Interviews confirmed staff were not notified before the transfer and there was no documentation that the refusal or related education had been communicated to nursing or rehab staff.
Two residents experienced significant lapses in care when staff failed to notify the physician or NP about missed pain medication doses and the unavailability of critical medications, despite ongoing symptoms and documented need. One resident endured unmanaged pain during catheter care due to missed Lidocaine gel applications, while another did not receive essential antiviral, immunosuppressant, and artificial saliva medications, resulting in persistent symptoms. In both cases, the responsible medical providers were not informed in a timely manner, contrary to facility policy.
A resident with a genital wound and indwelling urinary catheter experienced ongoing severe pain during catheter care due to staff failing to adequately assess and manage pain, including not administering prescribed lidocaine gel when it was unavailable and not offering alternative interventions. Staff were aware of the resident's pain but did not consistently assess or address it during care, and did not communicate medication unavailability or pain issues to the medical team.
Three residents did not receive critical medications as ordered due to the facility's failure to procure and administer them, with repeated documentation errors, lack of follow-up, and ongoing pharmacy delivery issues. Staff and the DON were often unaware of the medication shortages, and there was no effective system to ensure medications were received or to document omissions.
The facility failed to maintain an effective QAPI program for pharmaceutical services, resulting in several residents not receiving ordered medications over an extended period due to ongoing issues with the contracted pharmacy. Despite repeated reports and communication from nursing staff and administration, there was no improvement in medication availability, and no performance improvement plan was implemented to address the persistent problem.
A resident with moderate cognitive impairment and significant ADL needs was not assisted to get out of bed and dressed before breakfast, despite expressing this preference and having it documented in their care plan. Staff were unaware of the resident's wishes and did not offer or provide the necessary assistance, resulting in the resident repeatedly eating breakfast in bed while dressed in a hospital gown.
Two residents did not receive accurate MDS assessments: one did not have a BIMS assessment conducted in their primary language despite available translation services, and another was admitted with a surgical wound that was not properly coded on the MDS, even though documentation and staff confirmed its presence.
A resident with physical limitations and a need for assistance with personal hygiene did not receive help with facial grooming, resulting in unwanted facial hair despite repeated requests. Staff interviews confirmed awareness of the resident's needs, but the required ADL support was not provided as outlined in the care plan.
A resident admitted with a post-operative cervical surgical wound did not receive care in accordance with professional standards, as staff failed to assess the wound, obtain physician orders based on hospital discharge instructions, or document wound characteristics. Nursing and clinical staff did not consistently evaluate the incision site, and the required admission skin assessment was not completed, resulting in inadequate monitoring and care of the surgical wound.
A resident with an indwelling urinary catheter and a genital wound did not receive physician-ordered elevation of the genital area following a catheter-associated complication. Staff failed to implement or document the intervention in a timely manner, and interviews revealed a lack of awareness and understanding among nursing staff regarding how to provide the required elevation, despite ongoing skin breakdown and wound care needs.
Two residents did not receive IV therapy care according to professional standards, including failure to flush a PICC line as ordered and lack of proper care and timely removal of a PIV. Staff did not correctly transcribe or follow physician orders, and required documentation and monitoring were not performed, resulting in lapses in IV therapy administration and maintenance.
The facility did not ensure that food and beverages were served at a palatable and appetizing temperature, as residents reported receiving lukewarm or cold meals and hot drinks. Surveyor observations confirmed significant delays in meal tray distribution, especially for residents needing assistance, with some waiting up to an hour after meal trucks arrived. Test trays and resident council feedback further supported that hot foods, such as eggs, were often served below the expected temperature.
A resident with dysphagia and a history of aspiration did not consistently receive meals in accordance with their documented food preferences and physician-ordered diet. The resident was repeatedly served disliked items such as dried toast and was not provided with the prescribed fortified cereal, despite clear documentation and staff expectations to verify meal trays before delivery. Interviews and observations confirmed that the resident's dietary needs and preferences were not honored.
Staff failed to follow infection control protocols by not wearing required PPE during care of three residents on contact, droplet, or enhanced barrier precautions. In each case, staff either did not recognize the need for PPE, did not observe posted precaution signs, or misunderstood when precautions applied, resulting in direct care being provided without appropriate gowns, gloves, or masks.
A resident with a history of delusional disorder and stroke, whose Health Care Proxy had provided consent, did not receive a Pneumococcal Conjugate Vaccine as required by facility policy and CDC guidelines. Despite proper documentation of consent and eligibility, the vaccine was not administered, and this omission was confirmed by facility staff.
A resident with a history of delusional disorder and stroke, whose Health Care Proxy was activated, did not have proper documentation indicating that COVID-19 vaccine education was provided or that consent or declination was obtained. The consent form was incomplete, with key acknowledgment sections left blank, and staff confirmed the lack of documentation regarding education and decision-making by the HCP.
A resident received two different anticoagulant medications for five days due to a transcription error by a nurse who failed to discontinue the previous medication order. This led to a critical low hemoglobin level and rectal bleeding, requiring hospital admission for further treatment. The Facility's policy for transcribing physician orders was not followed.
Improper Storage of Refrigerated Injectable Medication
Penalty
Summary
The facility failed to store Teriparatide in accordance with manufacturer instructions for one newly admitted resident whose physician orders included daily Teriparatide subcutaneous injections for osteoporosis. The resident had diagnoses including gastrointestinal bleed, anemia, acute kidney failure, psoriatic arthritis, and osteoporosis. Facility policy stated medications must be administered safely and in accordance with manufacturer specifications, and the product information for Teriparatide indicated the pen should be refrigerated immediately after every use. The resident’s family member brought the Teriparatide pen to the facility and gave it to Nurse #1, who said she did not read the storage instructions and placed the medication in the medication cart instead of refrigerating it. The pen remained unrefrigerated for approximately 72 to 96 hours, and the resident later reported that it felt warm and declined the dose. The facility pharmacist stated the medication required refrigeration at 36 to 46 degrees Fahrenheit and could be left out only up to 36 hours. The NP progress note documented that the facility notified the provider the medication had not been refrigerated for an extended period, rendering it unusable, and the resident missed approximately three days of therapy.
Failure to Implement and Communicate Resident DNR/DNI and MOLST on Admission
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s advance directives and properly address code status upon admission. The facility’s own Advance Directives policy required the Social Services Director or designee, prior to or upon admission, to inquire about any written advance directives, communicate the resident’s wishes to direct care staff and the physician, and place advance directive documents in a prominent, accessible location in the medical record. The Orders for Life Sustaining Treatment policy required the admitting nurse to determine whether a MOLST form existed, notify the physician if the patient wished to discuss MOLST, and for the Social Worker to provide advance directive information and identify any existing directives at admission. Despite these policies, the facility did not ensure that the resident’s existing DNR/DNI status and MOLST/POLST from the hospital were recognized and implemented. The resident was admitted with multiple serious diagnoses, including unspecified dementia with severe cognitive impairment, CHF, acute respiratory failure with hypoxia, dysphagia, right-sided hemiplegia/hemiparesis following CVA, pneumonia, and a right humerus fracture. The hospital discharge summary documented that the resident had completed a Massachusetts MOLST/POLST and was DNR/DNI. However, review of the facility’s physician orders for the month showed only that the resident had an invoked HCP, with no physician order indicating DNR status. Nursing progress notes contained no documentation that staff had discussed advanced directives or resuscitation preferences with the resident’s HCA. The resident’s care plan did not address advanced directives, and care conference notes, including those attended by the resident’s daughter and son, lacked any documentation that advanced directives, resuscitation status, or MOLST were reviewed or discussed. When the resident was later found unresponsive and pulseless, nurses searched the electronic medical record and physical chart but could not locate a DNR order or MOLST form. In the absence of such documentation, a Code Blue was paged and CPR was initiated and continued until EMS arrived and transported the resident to the hospital, where the resident expired. In interviews, the physician stated the resident had been DNR/DNI at the hospital and should have been DNR/DNI at the facility, and that she had not been notified that the resident lacked a MOLST and was considered full code. The Director of Social Services indicated the admitting social worker should have reviewed and documented the resident’s advanced directives and MOLST during admission and care conferences, and the DON stated the admitting nurse should have identified the hospital DNR order, notified the physician, and obtained a MOLST and DNR order, but this had not occurred.
Unsafe Transfer After Refusal of Required Assistive Device
Penalty
Summary
The facility failed to provide adequate supervision and use of assistive devices during a transfer for a resident who was assessed as high risk for falls and whose care plan required a stand aid with two-person assist for bed-to-wheelchair transfers. The resident had diagnoses including COPD, morbid obesity, and generalized muscle weakness, and his/her care plan directed staff to use a stand aid with two-person assist. The facility’s policy on mechanical lifting indicated that at least two trained, competent staff members are needed to safely move a resident with a mechanical lift. On the day of the incident, two CNAs attempted to transfer the resident from bed to wheelchair after the resident reportedly refused the stand aid, gait belt, and Hoyer lift. CNA #1 stated she left the room to notify Nurse #1 and OT #1 that the resident was refusing the stand aid, but both later stated they were not notified before the fall. CNA #1 said she understood the resident had a right to refuse and believed she needed to transfer the resident without the stand aid, while CNA #2 said they proceeded with the transfer because the resident refused the devices and said he/she could get up on his/her own. The CNAs did not wait for supervisory or rehabilitation staff intervention before proceeding. During the transfer, the resident fell and hit his/her head on the wall. The resident was sent to the hospital emergency department and was diagnosed with a nondisplaced C7 fracture and discharged back to the facility with a hard collar to be worn at all times. Interviews with Nurse #1, OT #1, the SDC, the Director of Rehabilitation, and the DON confirmed that if the resident refused the required transfer device, staff should have notified supervision or rehab staff, and that the resident should not have been transferred unsafely. The medical record contained no documentation that nursing or rehab staff were made aware of the refusals before the fall or that education about the risks of not using the stand aid had been provided.
Failure to Notify Physician/NP of Missed Treatments and Medication Unavailability
Penalty
Summary
The facility failed to notify the physician or nurse practitioner (NP) of significant changes in the treatment needs of two residents, resulting in ineffective management of pain and medication administration. For one resident with a history of urinary tract infection, urinary retention, and urethral erosion, staff did not inform the NP about the resident's uncontrolled pain during indwelling urinary catheter care or about 34 missed doses of prescribed Lidocaine gel for genital pain. Despite the resident frequently expressing pain during catheter care and the medication being unavailable for an extended period, there was no documentation or evidence that the NP was notified of the missed doses or the resident's ongoing pain. The NP confirmed she was unaware of the situation and would have reassessed the pain management plan if informed. Another resident, admitted with multiple complex diagnoses including myasthenia gravis, malignant melanoma, and chronic respiratory failure, did not receive several critical medications, including an antiviral, an immunosuppressant, and an artificial saliva product, due to pharmacy supply issues. The resident reported persistent symptoms related to the lack of these medications, such as dry mouth and double vision. Facility staff documented the medications as "not available" over an extended period but did not consistently notify the NP or the prescribing oncologist about the ongoing unavailability. The NP stated she was only made aware of the issue after surveyor inquiries and had not been kept informed of the continued lack of medication administration. The facility's own policy required timely notification of the physician or NP when there is a need to significantly alter a resident's medical treatment or when a resident's condition changes. In both cases, staff failed to follow this policy, resulting in prolonged periods where residents did not receive necessary pain management or essential medications, and the responsible medical providers were not given the opportunity to intervene or adjust care as needed.
Failure to Provide Effective Pain Management During Catheter Care
Penalty
Summary
Facility staff failed to provide effective, person-centered pain management for a resident with a genital wound and an indwelling urinary catheter. The resident, who was cognitively intact and dependent on staff for activities of daily living, consistently reported severe pain (8 out of 10) during catheter care and manipulation. Despite the resident's clear verbal and nonverbal expressions of pain, staff did not adequately assess or address pain during these procedures. Staff acknowledged the resident's discomfort but proceeded with care without implementing pain management interventions at the time of care, and did not consistently assess for pain specific to the genital area during catheter care. The resident had physician orders for pain management, including scheduled acetaminophen, as-needed tramadol, and topical lidocaine gel for the genital wound. However, the lidocaine gel, specifically ordered for pain related to the genital wound, was not administered for the majority of scheduled doses due to unavailability. Staff did not notify the nurse practitioner or physician about the lack of lidocaine gel, nor did they offer alternative pain interventions when the medication was unavailable. The nurse practitioner and director of nursing were unaware that the lidocaine gel was not being administered and that the resident continued to experience pain during catheter care. Interviews with staff revealed that they were aware of the resident's pain during catheter care but did not consistently assess or intervene for pain at the time of care. Staff relied on post-care notification to nursing staff rather than proactive pain management. The resident reported that staff did not ask about genital pain during care and that pain was only present during catheter manipulation. Documentation showed frequent reports of pain, but interventions were not adjusted or communicated to the medical team when current pain management was ineffective or unavailable.
Failure to Provide Timely Pharmaceutical Services for Multiple Residents
Penalty
Summary
The facility failed to provide necessary pharmaceutical services to meet the needs of three residents, resulting in multiple missed doses of critical medications. For one resident with a history of hypertension, the facility did not procure or administer a prescribed antihypertensive medication, Amlodipine Besylate-Valsartan, for several days. Documentation errors were noted, as the medication was marked as administered on days when it was not available in the facility. The Director of Nursing (DON) confirmed that the medication had never been delivered, and there was no system in place to confirm receipt of ordered medications or to document incidents of omitted medication. Staff interviews revealed ongoing issues with pharmacy delivery and communication, with repeated but ineffective attempts to resolve the problem. Another resident, who suffered from severe pain due to a foot ulcer, traumatic amputation, and urethral erosion, did not receive prescribed topical pain medications (Lidocaine Gel and Biofreeze) for the majority of scheduled doses. The medications were not available from the pharmacy, and there was a lack of clear communication and follow-up between nursing staff and the DON regarding the unavailability. The resident continued to experience pain during care, and staff acknowledged the absence of the medications but could not specify when the last request for them had been made. A third resident, with complex medical conditions including myasthenia gravis and undergoing chemotherapy, did not receive several essential medications, including an immunosuppressant, an antiviral, and an artificial saliva product, over an extended period. Medication administration records repeatedly documented these medications as "not available." The DON was unaware of the ongoing issue until it was brought to her attention during the survey, and there was no evidence of consistent follow-up with the prescribing provider or pharmacy. The lack of a reliable system for tracking and ensuring the delivery of ordered medications contributed to the ongoing deficiencies in pharmaceutical services for these residents.
Failure to Implement Effective QAPI for Pharmaceutical Services
Penalty
Summary
The facility failed to maintain an effective, comprehensive, data-driven Quality Assurance and Performance Improvement (QAPI) program specifically related to pharmaceutical services, resulting in ordered medications not being administered to multiple residents. The QAPI plan, last revised in 2014, was intended to monitor and improve the quality and safety of resident care, but the facility did not implement a performance improvement plan when ongoing issues with medication procurement from the contracted pharmacy persisted for at least five months. The Director of Nursing (DON) and other staff acknowledged that there was no improvement in obtaining medications despite repeated communications with the pharmacy, and no system was in place to confirm receipt of ordered medications. One resident with a history of diabetes, foot ulcer, traumatic amputation, and urethral erosion did not receive prescribed pain management medications (Biofreeze and Lidocaine gel) for the majority of scheduled doses over several weeks. The resident reported ongoing pain during catheter care and frequent lower extremity pain. Staff interviews confirmed that these medications had not been available from the pharmacy for an extended period, and the process for reporting unavailable medications did not result in resolution or improvement. Another resident with complex medical conditions, including myasthenia gravis, cancer, and chronic respiratory failure, did not receive critical medications such as an immunosuppressant, an antiprotozoal agent, and a dry mouth treatment for extended periods, as documented in the medication administration records. The resident reported that staff consistently informed them that medications were on back order. A third resident with hypertension did not receive a prescribed antihypertensive medication for multiple consecutive days after admission, with staff confirming that the medication had never been available in the facility. Despite repeated orders and communications with the pharmacy, the facility did not initiate a performance improvement project or develop an alternative solution to address the ongoing pharmaceutical service failures.
Failure to Honor Resident's Preference for Morning Routine
Penalty
Summary
The facility failed to honor a resident's right to make choices about their daily preferences, specifically regarding the desire to be out of bed and dressed before breakfast. The resident, who was moderately cognitively impaired and required substantial to maximum assistance with activities of daily living, consistently expressed a preference to be up, dressed, and seated in a chair for breakfast. Despite this, multiple observations over several days showed the resident remained in bed, dressed in a hospital gown, and ate breakfast in bed. The resident reported that staff did not offer or assist with getting up and dressed before breakfast, contrary to their stated preference. Review of the resident's care plan (Kardex) indicated that staff were to encourage the resident to be out of bed daily and offer to get them up before breakfast. However, interviews with staff revealed a lack of awareness of the resident's preferences, and staff did not consistently offer or provide the assistance needed to fulfill the resident's wishes. Nursing staff confirmed that the resident should have been offered the option to get up and dressed prior to breakfast, and that this was not being done as required.
Inaccurate MDS Assessments Due to Language and Documentation Failures
Penalty
Summary
The facility failed to accurately complete comprehensive Minimum Data Set (MDS) assessments for two residents out of a sample of 29. For one resident, who was admitted with diagnoses including benign neoplasm of the meninges and diabetes, the facility did not conduct the Brief Interview for Mental Status (BIMS) assessment in the resident's primary language. Although the resident's care plan and clinical record indicated a language barrier and the need for translation services, the social worker responsible for the assessment did not utilize available translation resources, such as bilingual staff, family members, or telephone translation services. Interviews confirmed that translation services were available and that the resident was able to communicate effectively in their primary language when such services were used, but the assessment was not attempted in the appropriate language, leading to an inaccurate evaluation of the resident's mental status. For the second resident, who was admitted with cervical spinal stenosis and had recently undergone a cervical discectomy and fusion, the facility failed to accurately code the presence of a surgical wound on the MDS assessment. Hospital discharge documentation and care instructions clearly indicated the presence of a surgical incision and dressing on the anterior neck. Observations and interviews with facility staff confirmed that the resident was admitted with a surgical wound, but the MDS assessment did not reflect this, as the surgical wound box was not checked and no skin issues were identified in the initial evaluation. These deficiencies were identified through record review, staff interviews, and direct observation, demonstrating that the facility did not follow established protocols and policies for accurate resident assessment, particularly in relation to language needs and the documentation of surgical wounds. The failures resulted in inaccurate MDS assessments for both residents.
Failure to Provide Assistance with Facial Grooming for Resident Requiring ADL Support
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs), specifically facial grooming, for one resident who required help due to physical limitations. The resident, who was cognitively intact and had diagnoses including generalized anxiety disorder, depression, and muscle weakness, was assessed as needing assistance with personal hygiene and grooming. The care plan indicated the resident should be clean, dressed, and well-groomed daily. Despite this, multiple observations over two days showed the resident with 1.5 inches of facial hair on the chin and upper lip, which the resident did not want and repeatedly requested to have removed. Interviews with the resident, CNAs, and nursing staff revealed that the resident had been asking for assistance with shaving but did not receive it. The CNA assigned to the resident acknowledged awareness of the need for assistance with all ADLs, including facial grooming, but had not provided the care. The DON confirmed that CNAs are expected to offer facial hair removal to residents and that this should have been addressed during daily ADL care, but it was not done for this resident.
Failure to Assess and Implement Post-Operative Wound Care Orders
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for a resident admitted with a post-operative surgical wound on the neck following an anterior cervical discectomy and fusion (ACDF) procedure. Upon admission, the resident had a dressing in place with instructions from the hospital to leave the dressing until a specified date, then either leave the incision open to air or cover with sterile gauze for comfort, and to monitor daily for signs of infection. However, the facility did not obtain or implement specific physician orders for the surgical wound care as outlined in the hospital discharge instructions. Multiple staff members, including nurses and the wound nurse, did not assess the surgical incision site as required. The admitting nurse did not complete the required Nursing Advantage Clinical Admission Assessment, which included a skin assessment, and did not extract or submit the hospital's wound care instructions for physician orders. Nursing documentation over several days failed to consistently assess or document the condition of the surgical wound, and the wound was not examined by the physician or nurse practitioner during their assessments. Some staff reported not removing the resident's soft collar or dressing to assess the wound, citing either lack of permission or misunderstanding of instructions. Interviews with staff revealed a lack of clarity and communication regarding the care and assessment of the surgical wound. The wound nurse was not alerted to drainage from the incision, and the staff relied on verbal reports rather than reviewing the clinical record for wound care instructions. The resident's surgical wound was not properly assessed for characteristics such as size, drainage, or signs of infection, and the required documentation and physician orders for wound care were not obtained or implemented, resulting in a failure to follow professional standards and the facility's own protocols.
Failure to Implement Physician-Ordered Genital Elevation for Catheter-Associated Complication
Penalty
Summary
The facility failed to provide care and services consistent with professional standards and the resident's person-centered care plan regarding the management of an indwelling urinary catheter. Specifically, the facility did not adhere to a physician's order to elevate a resident's genital area after the resident developed a slit and swelling in the genital region, which was associated with the indwelling catheter. The care plan and physician's orders required elevation of the genital area to address the complication, but this intervention was not implemented in a timely manner. The resident, who had a history of urinary tract infection, urine retention, and obstructive uropathy, was dependent on staff for activities of daily living and positioning in bed. Documentation showed that the order to elevate the genital area was not transcribed or carried out until several weeks after it was given, despite ongoing skin breakdown and wound care needs. Observations confirmed that the resident's genital area was not elevated during care, and staff interviews revealed a lack of awareness and understanding of how to provide the required elevation. Nursing staff, including a CNA and a nurse, indicated they were either unaware of the intervention or believed that the use of an air mattress was sufficient, which was contradicted by the Director of Nursing. The DON clarified that an air mattress does not provide elevation to the genital area and that pillows or rolled towels should be used. The deficiency was further evidenced by the lack of documentation and implementation of the elevation order, as well as staff's lack of knowledge regarding the intervention.
Failure to Provide Safe and Appropriate IV Therapy Administration and Maintenance
Penalty
Summary
The facility failed to provide care and maintenance of intravenous (IV) therapy consistent with professional standards of practice for two residents. For one resident admitted with a non-valved, double lumen peripherally inserted central catheter (PICC) line, nursing staff did not correctly transcribe and administer physician orders for flushing the PICC line. The resident's medical record and medication administration record (MAR) showed no evidence that required saline and heparin flushes had been administered since admission, despite clear physician orders and facility protocols mandating regular flushing to maintain catheter patency. Observations and interviews confirmed that the MAR was not set up correctly, and staff were unaware of the need to flush the PICC line as ordered, resulting in the line not being flushed until the surveyor's intervention. For another resident with a peripheral intravenous catheter (PIV) placed for antibiotic administration, the facility did not obtain or follow orders for essential aspects of PIV care, including flushing, site rotation, dressing changes, and monitoring for infection or infiltration. The resident's PIV remained in place beyond the recommended 72-hour period, and the dressing was observed to be partially lifted and frayed. Nursing notes and interviews revealed that batch orders for PIV care, which were available in the electronic charting system, were not obtained or implemented. The PIV was only discontinued after the surveyor's observation and subsequent notification of the nurse practitioner. Both deficiencies were confirmed through review of facility policies, resident records, direct observation, and staff interviews. The failures included not following established protocols for IV care, not ensuring accurate transcription of physician orders into the MAR, and not performing required documentation and monitoring. These lapses resulted in residents not receiving appropriate IV care as ordered and as required by professional standards.
Failure to Serve Palatable and Hot Meals to Residents
Penalty
Summary
The facility failed to ensure that food and beverages were served at a palatable and appetizing temperature on one unit, as evidenced by multiple resident complaints and direct observations. Residents reported that by the time meal trays arrived in their rooms, hot foods and beverages were often lukewarm or cold. Resident Council meeting minutes from two separate months documented ongoing concerns about cold breakfast items, particularly eggs. During surveyor observations, significant delays were noted between the arrival of meal trucks and the distribution of trays, with some residents waiting up to an hour to receive their meals. Residents requiring assistance with meals consistently received their trays at the end of the meal pass, regardless of when their trays arrived on the unit. Further observations revealed that meal truck doors were left open during the meal pass, potentially contributing to the loss of food temperature. A test tray conducted with a nurse showed scrambled eggs at 113.1°F, which was described as lukewarm. The Food Service Director (FSD) acknowledged that hot food should be at least 140°F and palatable, but was unaware that residents needing assistance were served last, resulting in extended wait times and cold food. The FSD also stated that she had not observed the meal pass process on the affected unit and was therefore unaware of the inefficiencies impacting food temperature.
Failure to Honor Resident Food Preferences and Dietary Orders
Penalty
Summary
The facility failed to honor a resident's documented food preferences and dietary needs as identified on the meal tray card and care plan. Despite the resident being cognitively intact and having specific dietary restrictions and preferences due to medical conditions such as Myasthenia Gravis, dysphagia, and a history of aspiration, the resident consistently received food items that were either disliked or not suitable for their condition. Observations revealed that the resident was repeatedly served dried toast, which was listed as a disliked item, and was not provided with the prescribed fortified cereal, even though these preferences and requirements were clearly documented in the care plan and physician orders. Interviews with the resident, nursing staff, and the registered dietician confirmed that the resident's preferences were not being followed, and that staff were expected to verify meal trays against the meal tickets before delivery but failed to do so. The resident reported having to request preferred food items regularly and often received meals that could not be safely chewed or swallowed. The registered dietician also acknowledged that the resident should not have been receiving bread items and confirmed the absence of the fortified cereal as ordered. These failures occurred despite facility policies requiring the identification and honoring of resident food preferences.
Failure to Adhere to Infection Control Standards and PPE Use
Penalty
Summary
The facility failed to adhere to infection prevention and control standards for three residents, resulting in deficiencies related to the use of Personal Protective Equipment (PPE) and compliance with established precautions. For one resident with severe cognitive impairment and diagnoses including bacteremia and ESBL, staff did not wear the required gown and gloves while assisting with feeding, despite clear signage indicating contact precautions. The staff member was unaware of the resident's precaution status and did not observe the posted instructions before entering the room. Another resident, who had a tracheostomy and was dependent on staff for care, was placed on both contact and droplet precautions due to pending respiratory infection tests. Multiple staff members, including a CNA and a housekeeper, entered the resident's room without donning any PPE, even though signs were posted and the resident was actively coughing and sneezing. PPE supplies were not positioned at the room entrance, which contributed to staff missing the requirement to use them before entry. For a third resident with a PICC line and orders for Enhanced Barrier Precautions (EBP), a nurse failed to wear a gown while performing high-contact care activities such as flushing the PICC line, despite signage and policy requiring both gown and gloves for such procedures. The nurse believed EBP was only necessary for wound care, not device care, and only wore gloves. The staff development coordinator confirmed that EBP should have been followed for all high-contact care involving the PICC line.
Failure to Administer Pneumococcal Vaccine After Consent
Penalty
Summary
The facility failed to administer a Pneumococcal Conjugate Vaccine (PCV) to a resident after obtaining proper consent from the resident's activated Health Care Proxy (HCP). The resident, who had a history of Delusional Disorder and a cerebrovascular accident, was determined to lack capacity, and the HCP's consent for the PCV was documented. Despite this, there was no evidence in the medical record that the vaccine was administered following the consent. Facility policy required that pneumococcal vaccines be administered in accordance with current CDC recommendations, which, for adults over 50 who previously received PPSV23, includes administration of a PCV after one year. The resident had received PPSV23 in the past, and the HCP consented to the PCV, but the vaccine was not given. The Clinical Services Coordinator confirmed that the vaccine should have been administered within a few days of consent, but this did not occur.
Failure to Document COVID-19 Vaccine Education and Consent for Resident with Activated HCP
Penalty
Summary
The facility failed to provide and document pertinent information regarding COVID-19 vaccination for one resident out of five sampled for immunizations. Specifically, for this resident, there was no indication in the medical record that the resident or the resident's Health Care Proxy (HCP) was provided education about the benefits and potential risks associated with the COVID-19 vaccine. Additionally, the documentation did not show whether the HCP consented to or declined the COVID-19 vaccine for the resident. The resident in question was admitted with diagnoses including Delusional Disorder and a history of cerebrovascular accident, and had an activated HCP to make medical decisions. Review of the Informed Consent for COVID-19 Vaccine form revealed that key acknowledgment boxes regarding receipt of information, opportunity to ask questions, and consent or declination of the vaccine were left blank. During an interview, the Clinical Services Coordinator confirmed that the consent form was incomplete and did not document whether the HCP was informed or had made a decision regarding the vaccine.
Significant Medication Error Due to Transcription Mistake
Penalty
Summary
The Facility failed to ensure that a resident was free from significant medication errors, resulting in the administration of two different anticoagulant medications for five days. This error occurred due to a transcription mistake by a nurse who did not discontinue the resident's previous anticoagulant medication, Xarelto, after entering a new order for Pradaxa. As a result, the resident received both medications simultaneously, leading to a critical low hemoglobin level and the presence of blood in the stool, necessitating hospital admission for further treatment. The resident, who had a history of atrial fibrillation, hypertension, gastrointestinal hemorrhage, melena, anemia, and atherosclerotic heart disease, was admitted to the Facility in September 2023. On 1/17/24, the resident's Physician ordered a switch from Xarelto to Pradaxa, but the nurse failed to discontinue the Xarelto order. Despite the new order for Pradaxa, the resident continued to receive Xarelto, and no documentation indicated that any nurse questioned the administration of both anticoagulants. The error was discovered on 1/24/24 when the resident exhibited symptoms of rectal bleeding and a critically low hemoglobin level. The resident was transferred to the hospital for evaluation and treatment, where it was confirmed that the resident had been receiving both anticoagulants. Interviews with the involved nurses and the Director of Nurses revealed that the Facility's policy for transcribing physician orders was not followed, leading to the significant medication error.
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Illustrative
What surveyors actually found near you
We read the 392 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Millbury
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Blaire House Of Worcester | 2.1 mi | ★★★★★ | 11 | 0 |
| Vantage At Worcester Llc | 2.2 mi | ★★★★★ | 14 | 0 |
| Worcester Rehabilitation & Health Care Center | 2.3 mi | ★★★★★ | 1 | 0 |
| St Francis Rehabilitation & Nursing Center | 2.6 mi | ★★★★★ | 5 | 0 |
| St Mary Health Care Center | 3.6 mi | ★★★★★ | 10 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.