Care One at Millbury

In the surveyor’s words

From the most serious findings on record at Care One at Millbury, in the surveyor’s own words.

• Immediate jeopardy, isolatedF656Feb 1, 2022

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had stage IV [CONDITION(S)] and dysphagia (difficulty with swallowing food or liquids), per Physician's Orders was NPO (nothing by mouth), and required enteral feedings via a tube feeding (delivery of nutrition directly to the stomach) to maintain his/her nutritional status, the Facility failed to ensure staff implemented and followed interventions identified in Resident #1's Comprehensive Plan of Care to maintain NPO status per Physician Orders. […]

• Immediate jeopardy, isolatedF689Feb 1, 2022

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had stage IV [CONDITION(S)] with dysphagia (difficulty with swallowing food or liquids), per Physician's Orders was NPO (nothing by mouth), and required enteral feedings (a way of delivering nutrition directly to the stomach) to maintain his/her nutritional status, the Facility failed to ensure services provided by staff were appropriate, that his/her safety was adequately maintained in an effort to to prevent an incident resulting in serious harm and death. On [DATE], Certified Nurse Aide (CNA) #1, who was unfamiliar with Resident #1, and had not provided care to him/her prior to this date, responded to his/her call light, and when Resident #1 asked her for a cookie, she gave him/her one. […]

• Actual harm, isolatedF689Nov 19, 2025

  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. […]

• Actual harm, isolatedF580Apr 25, 2025

  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. […]

• Actual harm, isolatedF697Apr 25, 2025

  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. […]