The resident at Care One at Millbury had developed a large genital slit from his long-term catheter. His care plan noted he experienced pain "almost constantly" at a level of 8 out of 10. Staff knew catheter care hurt him. Yet when federal inspectors observed a nurse examine his catheter on April 23, the resident furrowed his brow, clenched his teeth, raised his hands and made fists as she lifted the tubing.
The nurse left without asking about his pain.
"The surveyor observed that Nurse #10 failed to assess Resident #94 for pain during the observation of the indwelling urinary catheter," inspectors wrote.
Certified nursing aide #8 told inspectors she would "just try to talk the Resident through urinary catheter care" because she knew it hurt him. She would tell him "she knew it was sore, and that the catheter care just needed to be done."
The resident told inspectors staff frequently asked about his leg pain but never asked about genital pain during catheter procedures. Staff would just tell him "they know the urinary catheter care hurts and is sore, and that they just need to keep him clean."
Medication Missing for Months
The facility had ordered lidocaine gel to numb the resident's genital wound twice daily starting March 24. But the medication wasn't available, and staff administered it only 16 times out of 46 scheduled doses between April 1 and April 23.
Nurse #10 told inspectors the lidocaine gel "had been unavailable for quite some time" and she didn't know when the facility last requested it from the pharmacy. No alternate pain interventions were offered.
The nurse practitioner said if staff had told her the resident always experienced pain during catheter procedures, "she would have reassessed the Resident's pain and provided orders for effective pain management." She also didn't know the lidocaine gel was unavailable.
Treatment records showed the resident reported genital pain on 19 out of 23 days reviewed in April.
Nurse #11, who had worked at the facility for five years, said the resident "always anticipated pain and would scream, even before initiating procedures for care of the urinary catheter."
Surgical Wound Left Unexamined
Another resident arrived from the hospital with a surgical neck incision after spinal fusion surgery, but staff never properly assessed or treated the wound according to discharge instructions.
Resident #340 had undergone cervical spine surgery on April 7 and was admitted to the nursing home April 9 with a dressing covering the incision. Hospital discharge instructions specified the dressing should be removed April 10, with the wound left open to air or covered with sterile gauze for comfort.
The instructions also required daily checks for signs of infection and immediate contact with the surgeon for any drainage or increased pain.
Instead, nursing staff left the original hospital dressing in place for the resident's entire 12-day stay. When inspectors observed the resident April 17, the white gauze dressing had "three small, distinct dried bloody areas."
The admitting nurse should have obtained physician orders for wound monitoring and treatment based on the hospital discharge instructions, the Director of Nursing told inspectors. No such orders were ever written.
Multiple nurses told inspectors they received verbal reports not to remove the dressing unless there was significant drainage. None reviewed the hospital discharge instructions or the resident's medical record for wound care requirements.
Nurse #4, who completed the resident's admission skin assessment April 10, said she didn't observe the surgical site because the resident wore a soft collar she wasn't allowed to remove. She failed to check the box for "surgical wound" on the assessment form.
The Staff Development Coordinator, who also served as wound nurse, said she never assessed the incision because nursing staff told her "the incision was not an issue, had no drainage, and was being left open to air."
Grooming Requests Ignored
A third resident who needed help with personal care repeatedly asked staff to shave his facial hair but was ignored for days.
Resident #126 was cognitively intact and required assistance with daily hygiene and grooming. His care plan specified he should be "clean, dressed and well groomed daily to promote dignity and psychosocial well-being."
When inspectors observed the resident April 17, he had 1.5 inches of facial hair on his chin and upper lip. The resident said he didn't like facial hair and that staff would help remove it when he remembered to ask.
The next day, the facial hair remained. The resident told inspectors he would ask staff to remove it. When surveyor #2 observed him later that morning, the resident asked if the surveyor could shave him.
By April 18 at 11:21 AM, the resident was still asking inspectors if someone could help him shave. He said "he had been asking to have the facial hair shaved but the CNA had not done so."
Certified nursing aide #3 told inspectors she was familiar with the resident and knew he had facial hair, but she hadn't provided the requested grooming care.
The Director of Nursing said CNAs should ask all residents with facial hair if they want it removed. "The DON said removal of the facial hair should have been addressed with Resident #126's daily ADL care but that it was not addressed."
Catheter Orders Botched
The facility also failed to properly manage intravenous therapy for two other residents, putting them at risk for complications.
Resident #343 arrived with a double-lumen PICC line for antibiotic treatment, but nursing staff never obtained proper orders for flushing the central line. The facility's protocols required flushing unused lumens every eight hours with normal saline followed by heparin, and flushing the medication lumen before and after each antibiotic dose.
When inspectors observed Nurse #4 flush the PICC line April 22, she told them it was the first time the line had been flushed since the resident's admission April 9. The medication administration record showed no evidence of any prior flushes.
"Nurse #4 said that if the Resident's PICC line did not get flushed with Saline and Heparin as ordered, the PICC line could become blocked," inspectors noted.
Another resident kept a peripheral IV line for eight days instead of the standard 72 hours, with a dressing dated April 9 that was "partially lifted away from the Resident's skin" when inspectors observed it April 18.
The facility's protocols required IV site rotation every 96 hours, but no orders were obtained for flushing, dressing changes, or site monitoring. The nurse who was supposed to remove the IV April 17 signed the medication record indicating it was discontinued but never actually removed it.
Care One at Millbury operates 180 beds in this Worcester County town. The inspection found violations affecting pain management, wound care, grooming assistance, and IV therapy protocols across multiple residents during the April 25 federal survey.
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.