Federal inspectors found the 312 Millbury Avenue facility repeatedly failed to serve hot food and couldn't obtain critical medications for residents, including pain relief for a diabetic amputee and immunosuppressive drugs for a cancer patient receiving chemotherapy.
The problems stretched back to November 2024, when the facility's pharmacy delivery issues began. By April 2025, when inspectors arrived, residents were still complaining about the same cold breakfast meals they'd raised at council meetings in February and March.
Cold Meals, Long Waits
On one unit, inspectors watched meal trucks arrive at 7:55 AM, but the last resident didn't receive their tray until 8:54 AM — nearly an hour later. Residents needing assistance with eating had to wait until the very end of the meal service, even when their trays had arrived on the first truck.
The meal trucks sat with doors open during the entire service. When inspectors tested the temperature of scrambled eggs with peppers and onions, they registered 113.1 degrees Fahrenheit and tasted lukewarm. The Food Service Director said she expected hot food to be 140 degrees or hotter.
During a resident council meeting held during the inspection, eight residents complained that food delivered to their unit was not always hot and that meal service took too long.
The Food Service Director told inspectors she was unaware that residents requiring meal assistance had to wait until the end of service for their trays. She said if she had known, she could have reorganized how meals were placed on trucks so food wouldn't sit for extended periods.
Months Without Medications
The medication problems proved more serious. Resident 94, a diabetic who had undergone amputation of two left toes, was ordered Biofreeze gel for bilateral lower leg pain and lidocaine gel for genital pain related to his urinary catheter.
Between April 1 and April 23, he missed 91 out of 92 scheduled doses of the Biofreeze and 32 of 34 scheduled doses of lidocaine because the medications were unavailable. The resident told inspectors he always experienced pain when staff provided catheter care and frequently had lower extremity pain.
Resident 38, admitted in February with myasthenia gravis and malignant melanoma, faced even more critical shortages. He required three medications: an antiviral for pneumonia prevention, an immunosuppressant related to his chemotherapy, and medication for the extreme dry mouth caused by his cancer treatment.
His medication records showed the antiviral was unavailable for 13 consecutive days in February, six days in March, and 17 days in April. The immunosuppressant was unavailable for 10 days in February, 16 days in March, and every day in April through the inspection date. The dry mouth medication was never available after being ordered in March.
The resident told inspectors that every time he asked about his missing medications, staff informed him they were on back order. He said the medications were very important because one was his immunosuppressive medication related to receiving chemotherapy.
A third resident, admitted in April with hypertension, never received his blood pressure medication. The Director of Nursing said there was no evidence the medication had ever been delivered to the facility, despite orders being placed on April 9 and April 16.
No System for Tracking
The Director of Nursing instituted a process in November 2024 where nurses would fill out forms during medication passes indicating unavailable medications and give them to unit managers. She would then email the information to the pharmacy and physicians. She said there was no improvement despite this process.
The facility administrator said he had contacted the pharmacy multiple times by email and phone since November 2024 about delivery concerns. Nurses sent communication faxes to the pharmacy every shift reporting missing medications. The administrator said there had been no improvement despite repeated communications.
The facility had no system in place to confirm that medications ordered from the pharmacy were actually received.
One nurse said that when she called the pharmacy asking about needed medications, staff would often tell her the medication was on the way. When the delivery driver arrived, the requested medication would not be included.
A nurse practitioner who started working at the facility in January 2025 said pharmacy delivery concerns had been a problem since she began. She said it had been tough receiving medications from the pharmacy.
Infection Control Lapses
Inspectors also found staff failing to follow infection control protocols designed to prevent the spread of disease. A nursing assistant entered the room of a resident on contact precautions for VRE bacteria and assisted with feeding without wearing required gloves and gown. The assistant said she didn't notice the warning sign posted outside the door.
Another resident with orders for contact and droplet precautions due to pending COVID, flu and RSV test results was visited by multiple staff members who failed to wear required masks, gowns and gloves. The resident was observed sneezing, coughing and spitting phlegm into tissues.
Personal protective equipment for that resident was stored inside the room on the bathroom door rather than at the entrance, meaning staff had to enter the room before noticing they needed protective gear.
A nurse caring for a resident with a PICC line failed to wear a required gown while flushing the central line with medications, despite enhanced barrier precaution orders specifically for device care. The nurse told inspectors she should have worn a gown but didn't.
Vaccination Failures
The facility also failed to properly document vaccination decisions. One resident's health care proxy consented to a pneumococcal vaccine in February 2024, but the facility never administered it. The Clinical Services Coordinator said the resident should have received the vaccine within days of consent.
The same resident's COVID-19 vaccination consent form was left incomplete, with blank boxes for whether the health care proxy received education about vaccine benefits and risks, and whether they consented to or declined vaccination.
Food Preferences Ignored
Beyond temperature problems, the facility repeatedly served one resident foods he specifically said he couldn't eat. Resident 38, who had swallowing difficulties and was on a mechanically altered diet, consistently received dry toast despite it being marked as disliked on his meal ticket. He was also regularly denied the fortified cereal ordered by his physician.
The resident told inspectors that staff would ask about his food preferences but never followed through. He said this happened most days, and even when he requested alternatives, he would be given food items he couldn't chew or swallow.
During three separate breakfast observations, inspectors watched the resident receive toast he couldn't eat while being denied his ordered fortified cereal. The resident said he would be satisfied with just the fortified cereal and wouldn't eat anything else on those days.
The registered dietician acknowledged the resident should not be receiving bread items and had not received the fortified cereal as indicated on physician orders and meal tickets.
The facility's quality assurance program was supposed to identify and resolve problems affecting resident care and services. But administrators acknowledged they had not developed any performance improvement plan to address the five-month medication shortage crisis that affected residents throughout the facility.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Care One At Millbury from 2025-04-25 including all violations, facility responses, and corrective action plans.