Care One at Millbury
312 Millbury Avenue, Millbury, MA 01527 · Worcester County · 154 certified beds · avg 144 residents/day · certified since Jan 23, 1997
Part of chain: CAREONE (37 facilities, chain avg rating 3.4★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Nov 19, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Dec 17, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Apr 25, 2025 · F-0580
The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away.
Why it matters: A family could learn about a serious injury or decline days later, after the chance to act has passed.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jun 2, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Apr 25, 2025 · F-0697
The facility did not provide safe and appropriate pain management for a resident who needed it.
Why it matters: Untreated pain causes needless suffering and can lead to depression, poor sleep, and declining health.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jun 2, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Apr 3, 2024 · F-0760 · triggered by a complaint
The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
Why it matters: A serious medication error can cause real harm, hospitalization, or worse.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jan 30, 2024 (Past Non-Compliance)
▲ Actual harm, one-off · Aug 16, 2022 · F-0698
The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail.
Why it matters: Mistakes in dialysis care can quickly become life-threatening for residents with kidney failure.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Sep 19, 2022 (Deficient, Provider has date of correction)
All citations in the current public record (37)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| May 14, 2026 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint |
| Mar 17, 2026 | D · Potential for harm, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. · from a complaint |
| Nov 19, 2025 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Apr 25, 2025 | ▲ G · Actual harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. |
| Apr 25, 2025 | ▲ G · Actual harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. |
| Apr 25, 2025 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Apr 25, 2025 | E · Potential for harm, repeated | The facility did not have a written plan describing how it runs its quality improvement program — the ongoing process of finding problems in care and fixing them. |
| Apr 25, 2025 | D · Potential for harm, one-off | The facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time. |
| Apr 25, 2025 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Apr 25, 2025 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Apr 25, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Apr 25, 2025 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Apr 25, 2025 | D · Potential for harm, one-off | The facility did not safely and appropriately administer IV fluids (fluids given through a vein) for residents who needed them. |
| Apr 25, 2025 | D · Potential for harm, one-off | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Apr 25, 2025 | D · Potential for harm, one-off | The facility did not make sure special medical diets — like low-sodium or diabetic diets — were properly ordered by the resident's doctor or managed by a qualified dietitian as state law allows. |
| Apr 25, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Apr 25, 2025 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| Apr 25, 2025 | D · Potential for harm, one-off | The facility did not educate residents and staff about COVID-19 vaccination, offer the vaccine to those eligible after that education, or properly document everyone's vaccination status. |
| Apr 3, 2024 | ▲ G · Actual harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Feb 2, 2024 | D · Potential for harm, one-off | The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need. |
| Feb 2, 2024 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. |
| Feb 2, 2024 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Feb 2, 2024 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Feb 2, 2024 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Feb 2, 2024 | D · Potential for harm, one-off | The facility did not help a resident get vision and hearing services — such as eye exams, glasses, hearing tests, or hearing aids. |
| Feb 2, 2024 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Feb 2, 2024 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Aug 16, 2022 | ▲ G · Actual harm, one-off | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. |
| Aug 16, 2022 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Aug 16, 2022 | E · Potential for harm, repeated | The facility did not perform required COVID-19 testing on residents and staff. |
| Aug 16, 2022 | D · Potential for harm, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| Aug 16, 2022 | D · Potential for harm, one-off | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. |
| Aug 16, 2022 | D · Potential for harm, one-off | The facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave. |
| Aug 16, 2022 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Aug 16, 2022 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Aug 16, 2022 | D · Potential for harm, one-off | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. |
| Aug 16, 2022 | D · Potential for harm, one-off | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (8 → 15).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2022 | 10 | 1 | G ▲ |
| 2024 | 9 | 1 | G ▲ |
| 2025 | 16 | 3 | G ▲ |
| 2026 | 2 | 0 | D |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
3 fines totaling $95,138.
| Date | Type | Amount / length |
|---|---|---|
| Nov 19, 2025 | Fine | $12,438 |
| Apr 25, 2025 | Fine | $72,173 |
| Feb 2, 2024 | Fine | $10,527 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Massachusetts avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.40 | 3.89 | 3.95 | bottom 25% in Massachusetts; bottom 31% in the U.S. |
| Registered Nurse hours | 0.50 | 0.65 | 0.69 | bottom 30% in Massachusetts; bottom 37% in the U.S. |
| Weekend total nurse staffing | 3.12 | 3.51 | 3.50 | bottom 32% in Massachusetts; bottom 38% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.40 | 0.46 | 0.48 | bottom 47% in Massachusetts; top 48% in the U.S. |
| Total nursing staff turnover (%) | 45.7 | 38.2 | 45.8 | bottom 25% in Massachusetts; bottom 48% in the U.S. |
| RN turnover (%) | 45.0 | 42.6 | 42.9 | bottom 43% in Massachusetts; bottom 44% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.64, RN 0.53, weekend 3.34. Staffing rating: 2/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: 5/5 · short-stay residents: 4/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Care Realty, LLC | Organization | 5% or Greater Indirect Ownership Interest | — | 04/30/2002 |
| Des-I 2016 Grat | Organization | 5% or Greater Indirect Ownership Interest | — | 12/01/2021 |
| Straus, Daniel | Individual | 5% or Greater Indirect Ownership Interest | — | 07/01/2003 |
| Straus, Moshael | Individual | 5% or Greater Indirect Ownership Interest | — | 07/01/2003 |
| Thci of Massachusetts, LLC | Organization | 5% or Greater Direct Ownership Interest | — | 07/01/2003 |
| Baruch, David | Individual | W-2 Managing Employee | NOT APPLICABLE | 12/01/2021 |
| Baruch, David | Individual | Corporate Officer | NOT APPLICABLE | 12/01/2021 |
| Healthbridge Management LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 07/01/2003 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "If my family member falls or their condition changes, exactly when and how will I be notified?"
- "How do you assess and manage residents' pain, especially for those who have trouble communicating?"
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "How do you coordinate and monitor care for residents who receive dialysis?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "How do you record and honor each resident's treatment wishes and advance directives, and how do staff know about them?"
- "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Blaire House of Worcester | 2.1 mi | Worcester, MA | ★★★☆☆ | 3/5 | |
| Vantage at Worcester LLC | 2.2 mi | Worcester, MA | ★☆☆☆☆ | 1/5 | |
| Worcester Rehabilitation & Health Care Center | 2.3 mi | Worcester, MA | ★☆☆☆☆ | 1/5 | |
| St Francis Rehabilitation & Nursing Center | 2.6 mi | Worcester, MA | ★★★★☆ | 3/5 | |
| St Mary Health Care Center | 3.6 mi | Worcester, MA | ★★☆☆☆ | 2/5 | |
| Christopher House of Worcester | 3.6 mi | Worcester, MA | ★★★☆☆ | 3/5 | |
| Lutheran Rehabilitation and Skilled Care Center | 3.9 mi | Worcester, MA | ★★★★★ | 5/5 | |
| West Side House LTC Facility | 3.9 mi | Worcester, MA | ★★★★★ | 5/5 | |
| Notre Dame Long Term Care Center | 4.5 mi | Worcester, MA | ★★★★☆ | 4/5 | |
| Parsons Hill Rehabilitation & Health Care Center | 4.7 mi | Worcester, MA | ★★☆☆☆ | 2/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 225720.