Inspection Reports for
Carleton-Willard Village
100 Old Billerica Road, Bedford, MA 01730, Bedford, MA, 01730
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
2.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
62% better than Massachusetts average
Massachusetts average: 7.3 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 3
Date: Jun 10, 2025
Visit Reason
Investigation of a complaint regarding a fall incident involving Resident #1 during a mechanical sling lift transfer without required staff assistance.
Complaint Details
The investigation was triggered by a complaint regarding Resident #1's fall from a mechanical sling lift on 06/03/25. The complaint was substantiated with findings that the CNA transferred the resident alone, did not report the fall, and the resident sustained serious injuries.
Findings
Resident #1 fell from a mechanical sling lift when transferred by a single CNA instead of the required two staff members, resulting in multiple serious injuries. The CNA failed to report the fall immediately, delaying necessary care. The facility was found non-compliant with policies requiring two staff for mechanical lifts and immediate incident reporting.
Deficiencies (3)
F 0600: Facility failed to protect Resident #1 from neglect when a CNA transferred the resident alone using a mechanical sling lift, causing a fall and serious injuries. The CNA did not report the fall immediately, delaying care.
F 0656: Facility failed to ensure staff consistently followed Resident #1's care plan requiring two staff for mechanical sling lift transfers, resulting in a fall and serious injuries.
F 0689: Facility failed to provide adequate supervision and prevent accident hazards when Resident #1 was transferred alone by a CNA using a mechanical sling lift, causing a fall and multiple fractures and internal injuries.
Report Facts
Residents on unit: 33
Injuries: 1
Fall height: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Named in fall incident for transferring Resident #1 alone and failing to report the fall |
| Nurse #1 | Nurse | Provided care to Resident #1 post-fall and gave report to CNA #1 |
| CNA #2 | Lead Certified Nurse Aide | Observed conditions around time of fall and provided statements |
| Unit Manager #1 | Unit Manager | Responded to incident, assessed Resident #1, and interviewed staff |
| Director of Nurses | Director of Nurses (DON) | Oversaw facility policy enforcement and staff education related to incident |
| Nurse Practitioner #1 | Nurse Practitioner | Ordered transfer of Resident #1 to hospital after fall |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Feb 7, 2025
Visit Reason
The inspection was conducted to investigate complaints regarding failure to implement a comprehensive person-centered care plan for Resident #72, including failure to provide covered cups for hot beverages and failure to cut up food as directed by the care plan, as well as to assess medication labeling and storage practices.
Complaint Details
The investigation was complaint-driven, focusing on Resident #72's care plan implementation failures and medication labeling issues. The complaint was substantiated based on observations and interviews.
Findings
The facility failed to implement the care plan for Resident #72 by not providing covered cups for hot beverages and not cutting up food as required. Additionally, medications in three medication carts were found to be opened and undated, violating labeling and storage policies.
Deficiencies (2)
F 0656: The facility failed to implement a comprehensive care plan for Resident #72 by not providing covered cups for hot beverages as directed and not cutting up food as required by the care plan.
F 0761: The facility failed to ensure medications were labeled and dated once opened according to manufacturer's guidelines in three medication carts.
Report Facts
Sample size: 20
Medication carts observed: 3
Medication bottle volume: 887
Medication expiration days: 90
Medication expiration sprays: 120
Medication expiration days: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietitian | Interviewed regarding Resident #72's care plan and beverage handling | |
| Certified Nurse Assistant (CNA) #2 | Interviewed about Resident #72's care plan and meal tray instructions | |
| Certified Nurse Assistant (CNA) #3 | Interviewed about Resident #72's care plan and meal tray instructions | |
| Nurse Unit Manager #2 | Interviewed about Resident #72's care plan implementation | |
| Director of Nursing (DON) | Interviewed about care plan compliance and medication labeling | |
| Nurse #1 | Interviewed about medication labeling requirements | |
| Nurse #2 | Interviewed about medication labeling requirements | |
| Nurse #3 | Interviewed about medication labeling requirements |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: May 29, 2024
Visit Reason
The inspection was conducted following complaints regarding the facility's failure to implement fall prevention interventions and provide appropriate care after resident falls.
Complaint Details
The investigation was complaint-driven, focusing on allegations that the facility failed to implement fall prevention measures and provide proper care following resident falls. The complaints were substantiated based on findings of inadequate use of alarms, insufficient supervision, and failure to assess neurological status after falls.
Findings
The facility failed to implement and follow care plans for residents at high risk for falls, resulting in multiple falls with injuries. Additionally, the facility did not properly assess or monitor neurological signs after an unwitnessed fall, and failed to provide adequate supervision and safety devices to prevent accidents.
Deficiencies (3)
F 0656: The facility failed to implement and follow the care plan for Resident #1, who required bed and chair alarms, resulting in two falls with injuries including a head laceration and nasal fracture.
F 0684: The facility failed to provide appropriate treatment and care for Resident #2 after an unwitnessed fall, as neurological signs were not assessed or documented per policy.
F 0689: The facility failed to ensure a safe environment and adequate supervision for Resident #1, who fell in the bathroom after being left unattended without an alarm, resulting in a nasal bone fracture and forehead hematoma.
Report Facts
Staples required: 6
Laceration size: 4
Skin tear size: 4
Skin tear size: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #1 | Reported Resident #1's fall and implemented bed and chair alarms after first fall. | |
| Certified Nurse Aide #1 | Witnessed Resident #1 fall on 05/08/24 and assisted Resident #2 after fall on 05/19/24. | |
| Certified Nurse Aide #2 | Assisted Resident #1 to bathroom on 05/09/24 and left him/her unattended, leading to a fall. | |
| Certified Nurse Aide #4 | Assigned to care for Resident #1 on 05/08/24; reported no alarms in place during fall. | |
| Certified Nurse Aide #5 | Assisted Resident #2 after fall and reported skin tear to Nurse #3. | |
| Nurse #3 | Assessed Resident #2 after fall but did not initiate neurological monitoring. | |
| Nurse #4 | Worked night shift 05/08-05/09/24; monitored Resident #1's alarms and documented fall. | |
| Director of Nurses | Director of Nurses (DON) | Stated staff should implement alarms and monitor residents per care plans. |
| Unit Manager #1 | Reported delay in nursing knowledge of Resident #2's fall and lack of neurological monitoring. |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Feb 15, 2024
Visit Reason
Annual inspection survey of Carleton-Willard Village Retirement & Nursing Center to assess compliance with health regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Sep 13, 2023
Visit Reason
The inspection was conducted following complaints regarding medication administration errors and incomplete medication record documentation at Carleton-Willard Village Retirement & Nursing Center.
Complaint Details
The complaint investigation substantiated that Resident #1 was given another resident's medications by mistake, causing adverse effects and hospital transfer. It also found that Resident #3's medication orders were not properly transcribed or administered, and medication administration records were incomplete.
Findings
The facility failed to ensure proper medication administration when a nurse administered another resident's medications to Resident #1, causing potential harm. Additionally, the facility failed to transcribe and administer a diuretic medication as ordered for Resident #3 and did not maintain complete and accurate medication administration records.
Deficiencies (3)
F 0658: The facility failed to ensure care met professional standards when Nurse #7 administered Resident #2's medications to Resident #1 without proper resident identification, resulting in Resident #1 becoming somnolent and requiring hospital transfer.
F 0760: The facility failed to ensure residents were free from significant medication errors when Resident #1 received another resident's medications and Resident #3's physician orders for a diuretic were not transcribed or administered as ordered.
F 0842: The facility failed to maintain complete and accurate medical records for Resident #3, with missing documentation of medication administration for Lasix doses in August 2023.
Report Facts
Medication doses administered incorrectly: 4
Pro b-type natriuretic peptide lab result: 6911
Lasix dosage: 40
Dates of medication errors: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #7 | Staffing Agency Nurse | Administered wrong medications to Resident #1 and failed to properly identify resident. |
| Nurse #1 | Unit nurse who oriented Nurse #7 and reported the medication error. | |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding medication errors and facility policies. |
| Unit Manager #2 | Reported transcription errors and missing medication documentation for Resident #3. | |
| Nurse #6 | Wrote Nurse Progress Note regarding missed Lasix dose for Resident #3. | |
| Nurse #5 | Administered Lasix to Resident #3 but forgot to sign off on MAR. | |
| Physician | Ordered Lasix medication for Resident #3 and provided clinical information. |
Inspection Report
Deficiencies: 0
Date: Dec 2, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction for a nursing home inspection conducted by the Centers for Medicare & Medicaid Services.
Findings
No health deficiencies were found during the inspection.
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