Care One At Millbury
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
should be ample documentation in a residents' medical record if education, including risks, was provided to
a resident who refused the use of assistive devices and that the provider should be notified of refusals. The SDC said that if education is given verbally to a resident, the staff [nursing and rehabilitation] are responsible to write a progress note indicating education was completed.During a telephone interview on 11/19/25 at 4:05 P.M., the Director of Rehabilitation said when Resident #1 was discharged from skilled therapy on 09/20/25 the discharge plan included using two person staff assist with use of the stand aid for transfers, to maintain the safety of both Resident #1 and the staff. The Director of Rehabilitation said she had not been notified of Resident #1's refusals to use the stand aid prior to his/her fall on 10/04/25, and if
she had been notified, the therapists would have re-evaluated him/her because refusing to use the required assistive devices for transfers becomes a safety issue.Review of Resident #1's medical record indicated that prior to the incident on 10/04/25, there was no documentation to support that nurses or rehab staff were made aware of Resident #1's refusals to use the stand aid or that education was provided to him/her regarding the risks of not using the stand aid.During an interview on 11/19/25 at 4:17 P.M, the Director of Nurses (DON) said when Resident #1 refused to use the stand aid the CNAs should have kept him/her in bed to maintain patient safety and let the supervisor know. The DON said no one had told her that Resident #1 had refused the stand aid prior to his/her fall on 10/04/25. The DON said if Resident #1 had been educated about the risks of not using the stand aid it would have been documented in the nursing progress notes. The DON said she thought the CNAs had brought the stand aid into Resident #1's room to transfer him/her out of bed on 10/04/25, she said she did not realize that was not the case.
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CARE ONE AT MILLBURY in MILLBURY, MA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in MILLBURY, MA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from CARE ONE AT MILLBURY or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.