Care One At Millbury

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

65.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 388 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 60.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 195 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.61 therapist hours per resident per day in 2026Q1 — more than 88% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 33% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 154 beds and averages 144.0 residents a day — about 94% occupied, or roughly 10 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.64 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.53 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.10 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.34 hrs/resident/day on weekends vs 3.76 on weekdays — 11% thinner on weekends. RN hours go from 0.58 to 0.40 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 46% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

37 citations, most serious first. The 15 most serious are shown; the remaining 22 are one tap away and print in full.

• Actual harm · G2025-11-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review and interviews, the facility failed to provide adequate supervision and assistive devices to ensure one of three sampled residents (Resident #1) remained free from accident hazards during transfers, resulting in Actual Harm. Specifically, for Resident #1, who was assessed as being at high risk for falls and requiring a two-person stand aid for safe transfer, two Certified Nurse Aides (CNAs) attempted a manual transfer after the resident reportedly refused the stand aid, gait belt, and Hoyer lift. The CNAs failed to wait for supervision (Nurse or Rehabilitation staff) to intervene regarding the refusal, which resulted in an unsafe transfer contrary to the resident's care plan, demonstrating a failure to implement safety protocols when an assistive device required by the care plan was refused. Consequently, Resident #1 fell, required transfer to the Hospital Emergency Department for evaluation and was diagnosed with a cervical neck fracture (C7).Findings include:Review of the Facility's policy, titled Using a Mechanical Lifting Machine, dated 07/2017, indicated…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2025-04-25 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews for two Residents (#94 and #38) out of a total sample of 29 residents, the facility failed to notify the Physician/Nurse Practitioner (NP) of the need to significantly alter treatment (need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment). Specifically, 1. For Resident #94, the facility failed to notify the Physician/NP of the Resident's uncontrolled pain during indwelling urinary catheter care and 34 missed doses of Lidocaine (pain medication) Gel, out of 46 ordered doses, to be applied topically for the Resident's genital pain resulting in ineffective pain management. 2. For Resident #38, the facility failed to notify the Physician/NP when the Resident's Atovaquone Oral Suspension medication (antiviral medication), Mycophenolate Mofetil Oral Suspension medication (immunosuppressant medication) and Xylimelts Mouth/Throat Disk medication (artificial saliva medication) were not received from the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2025-04-25 · tag F0697 — failed to manage pain — isolated
  Provide safe, appropriate pain management for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, interviews, and record reviews, the facility failed to ensure that effective pain management that was consistent with professional standards of practice and the Resident's comprehensive person-centered care plan was provided for one Resident (#94) out of a total sample of 29 residents. Specifically, for Resident #94, the facility failed to: -adequately assess the Resident's pain during personal care of an indwelling urinary catheter when facility staff were aware the Resident had a genital wound and experienced pain during urinary catheter care, resulting in the Resident experiencing pain during indwelling urinary catheter related procedures. -provide interventions for pain management during personal care of an indwelling urinary catheter which resulted in the Resident anticipating and experiencing pain relative to indwelling urinary catheter care. -offer alternate pain interventions when prescribed pain medication specifically ordered for genital pain related to the Resident's genital wound was unavailable which resulted in the Resident experiencing pain.…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2024-04-03 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on records reviewed and interviews for one of three sampled residents (Resident #1), whose diagnoses included atrial fibrillation (irregular heartbeat) with a Physician's order for an anticoagulant (blood thinner) medication to manage the condition, the Facility failed to ensure he/she was free from significant medication errors, when due to a transcription error by nursing, Resident #1 was administered two different anticoagulant medications for five days and on 1/24/24 he/she was found to have blood in his/her stool, blood laboratory work indicated he/she had a critical low hemoglobin (helps red blood cells carry oxygen to muscles and tissues) level, he/she was transferred to the Hospital Emergency Department (ED) for evaluation and required admission for further treatment. Findings Include: Review of the Facility Policy titled, Physician Orders: Obtaining and Transcribing, dated as revised 09/29/2015, indicated the following: -directive known as Physician Orders will be obtained to manage the medical condition and plan of care for each resident -physician orders can be…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Past Non-Compliance
• Actual harm · G2022-08-16 · tag F0698 — failed to provide proper dialysis care — isolated
  Provide safe, appropriate dialysis care/services for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure transportation was arranged for hemodialysis (HD) treatments for one Resident (#174) resulting in two missed dialysis treatments and a subsequent hospitalization, in a total sample of 25 residents. Findings include: Resident #174 was admitted to the facility in July 2022, and readmitted to the facility in August 2022, with a diagnosis of End Stage Renal Disease (ESRD). Review of the admission progress note dated 7/29/22, indicated the Resident was starting HD treatments on a Tuesday/Thursday/Saturday schedule. Review of laboratory results, collected on 7/29/22, indicated the following: -Elevated Blood Urea Nitrogen (BUN) - 62 (indicates how well kidneys are functioning with a normal range being 10-24) -Elevated Creatinine 5.4 (waste product filtered by the kidneys with a normal range of 0.7 to 1.5) -Potassium (an electrolyte filtered out of the body by the kidney) was normal at 4.6 with a normal range of 3.3 to 5.1. Review of a Nursing progress…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-05-14 · tag F0761 — failed to label and store drugs safely — isolated
  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.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was newly admitted to the facility, and whose Physician orders included administration of Teriparatide (parathyroid hormone used to treat osteoporosis) injectable pen, which required refrigeration, the facility failed to ensure nursing stored the medication in accordance with manufacturer recommendations when the medication was not refrigerated as required.Findings include:Review of the Facility's policy titled Adverse Consequences and Medication Errors, dated as revised June 2025, indicated medications are administered in a safe and timely manner, and as prescribed;- A medication error is the preparation or administration of medication which is not in accordance with manufacturer specifications.- Failure to follow manufacturers' instructions and or accepted professional standards.Review of the [NAME] Lilly and Company product information manual dated as revised 8/04/21 indicated; Refrigerate the Teriparatide pen…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-03-17 · tag F0578 — failed to honor advance directives / code status — isolated
  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.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed and interviews for one of three sampled residents (Resident #1), who had an invoked Health care Proxy (HCP) and whose Advanced Directives while in the hospital prior to his/her transfer to the facility, had been DNR (Do not Resuscitate)/DNI (Do not Intubate), the Facility failed to ensure that Resident #1 and/or his/her Health Care Agent choices related to the formulation of advanced directives were appropriately addressed by staff upon admission.Findings include:Review of the Facility policy titled Advance Directives, dated 09/2022, indicated the following:-Prior to or upon admission of a resident, the Social Services Director or designees inquires of the resident, his/her family member and/or his/her legal representative about the existence of any written advance directives.-The residents' wishes are communicated to the residents' direct care staff and physician by placing the advance directive documents in a prominent, accessible location in the medical record and discussing the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Past Non-Compliance
• Potential for harm · E2025-04-25 · tag F0755 — failed to provide safe pharmacy services — pattern
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, observations, and interviews, the facility failed to provide pharmacy services for routine medications for three Residents (#341, #94, and #38) out of a total sample of 29 residents. Specifically, 1. For Resident #341, the facility failed to procure and administer Amlodipine Besylate-Valsartan (high blood pressure medication) as ordered by the Physician when the Resident had a known history of Hypertension (high blood pressure). 2. For Resident #94, the facility failed to provide pharmaceutical services for obtaining Lidocaine Gel and Biofreeze (topical pain medications) when Lidocaine Gel and Biofreeze were ordered by the Physician to be administered to the Resident for pain management. 3. For Resident #38, the facility failed to provide pharmaceutical services for obtaining Atovaqone Oral Suspension (antiviral medication), Mycophenolate Mofetil Oral Suspension (immunosuppressant medication), and XyliMelts Mouth/Thorat Disk (artificial saliva medication) when the medications were…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-04-25 · tag F0865 — failed to run a quality-improvement (QAPI) program — pattern
  Have a plan that describes the process for conducting QAPI and QAA activities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interviews and records reviewed, the facility failed to maintain an effective, comprehensive, data-driven QAPI (Quality Assurance and Performance Improvement - a comprehensive approach in healthcare that combines quality assurance and performance to systematically monitor and evaluate the quality and appropriateness of systems and process with a goal to enhance patient care and improve outcomes through a data-drive, proactive approach) program relative to pharmaceutical services for three Residents (#341, #94, and #38) out of a total sample of 29 total residents, which resulted in ordered medications not being administered to the Residents. Specifically, the facility failed to develop and implement a performance improvement plan relative to pharmaceutical services when: -The facility was unable to obtain ordered medications for Resident's #341, #94, and #38, which resulted in ordered medications not being administered to the Residents and increased each Resident's risks for medical complications. -The facility had been unable to obtain ordered medications for all residents…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-04-25 · tag F0561 — failed to honor residents' choices — isolated
  Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that one Resident (#40) out of a total sample of 29 residents, had the ability to make choices about their daily preferences. Specifically, for Resident #40, the facility failed to ensure the Resident's preference to be out of bed and dressed before breakfast was honored. Findings include: Review of the Residents' [NAME] of Rights provided to the survey team by the facility, undated, indicated: -You have the right to make choices in your daily routine and the facility must ensure a reasonable accommodation of your individual needs. Resident #40 was admitted to the facility in June 2024, with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), muscle weakness, and right leg pain. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #40: -was moderately cognitively impaired as evidenced by a Brief Interview of Mental Status (BIMS) score of 12 out of a total 15 -has clear speech…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-04-25 · tag F0641 — isolated
  Ensure each resident receives an accurate assessment.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interview the facility failed to accurately complete a Comprehensive Minimum Data Set (MSS) Assessment reflective of the status of two Residents (#128 and #340) out of a total sample of 29 residents. Specifically, 1. For Resident #128, the facility failed to conduct a Brief Interview for Mental Status (BIMS) Assessment in the Residents' primary language placing the Resident at risk for an inaccurate assessment, as well as inappropriate delivery of care and services. 2. For Resident #340, the facility failed to accurately code one comprehensive Minimum Data Set (MDS) Assessment to indicate the Resident had a surgical wound, when the Resident was admitted to the facility with a surgical wound, resulting in an inaccurate assessment of the Resident. Findings include: 1. Review of the CMS Resident Assessment Instrument RAI) Manual 3.0, located at Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual | CMS included but was not limited to: < The RAI process is the basis for…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-04-25 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, and interviews, the facility failed to provide adequate assistance for Activities of Daily Living (ADL - basic care task that an individual does on a day-to-day basis such as eating, bathing, dressing, grooming and mobility) for one Resident (#126) out of a total sample of 29 residents. Specifically, for Resident #126, the facility failed to ensure that the Resident who desired to have his/her facial hair removed and required assistance, was offered facial grooming care, resulting in unwanted facial hair. Findings include: Review of the facility policy titled Activities of Daily Living (ADL) Supporting, effective 2001 indicated: -Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: -hygiene, mobility, elimination, dining, grooming, meals. -If a resident with cognitive impairment or dementia resists care, staff…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-04-25 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to provide treatment and care in accordance with professional standards of practice relative to post-operative care of a non-pressure skin condition for one Resident (#340) out of a total sample of 29 residents. Specifically, the facility failed to assess Resident #340's surgical wound and implement post-operative instructions for surgical wound care, when the Resident was admitted to the facility with a surgical incision site on his/her neck, putting the Resident at risk for infection and delayed wound healing. Findings include: Review of the facility's Policy and Procedure titled Pressure Ulcers/Skin Breakdown - Clinical Protocol, dated 2001 and revised March 2024, indicated the following: -The staff will examine the skin of a new admission for ulcerations or alterations in skin. -The Physician will authorize pertinent orders related to wound treatments, including .dressings . Resident #340 was admitted to the facility in April 2025,…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-04-25 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
  Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interviews, and record reviews, the facility failed to provide care and services, consistent with professional standards of practice and the Resident's comprehensive person-centered plan of care relative to the care of an indwelling urinary catheter for one Resident (#94) out of a total sample 29 residents. Specifically, the facility failed to adhere to a Physician order for elevating Resident #94's genital area when the Resident experienced an indwelling catheter associated complication of genital slit and swelling, increasing the Resident's risk for further urinary catheter associated complications. Findings include: Review of the facility's Urinary Catheter Care Policy and Procedure, dated 2001 and revised August 2022, indicated the following: -The purpose of the procedure was to prevent urinary catheter-associated complications . -Review the resident's care plan to assess for any special needs of the resident. Resident #94 was admitted to the facility in September 2022 with diagnoses including Urinary Tract Infection (UTI) and retention of urine. Review of…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-04-25 · tag F0694 — isolated
  Provide for the safe, appropriate administration of IV fluids for a resident when needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, record reviews, and interviews, the facility failed to provide care and maintenance of intravenous (IV) therapy consistent with professional standards of practice for two Residents (#343 and #68), out of a total sample of 29 residents. Specifically, 1. For Resident #343, the facility failed to ensure nursing staff correctly transcribed and administered Physician orders for a Peripherally Inserted Central Catheter (PICC) relative to flushing when the Resident was admitted to the facility with a PICC line in place, placing the Resident at risk for PICC line blockage and impaired medication administration. 2. For Resident #68, the facility failed to provide care of a peripheral intravenous catheter (PIV) consistent with professional standards of practice and in accordance with Physician orders relative to flushing the IV and the duration of time the PIV was left in place. Findings include: 1. Review of the facility policy, Central Venous Catheter Flushing and Locking, revision date March 2022, included but was not limited to: -The purpose of this procedure is to…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

$95,138 in federal fines across 3 penalties.

• $12,438 — penalty dated 2025-11-19
• $72,173 — penalty dated 2025-04-25
• $10,527 — penalty dated 2024-02-02

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to CAREONE — 37 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 8 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted.

4 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

This home reported $3.1M paid to related parties — landlords or management companies under common ownership — equal to about 14% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in MA