Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Carleton-willard Village Retirement & Nursing Ctr during CMS and state inspections, most recent first.
A CNA transferred a resident requiring two-person assistance with a mechanical sling lift alone, resulting in a fall. The CNA did not report the incident or the resident's injuries to nursing staff, instead returning the resident to bed and leaving them unassessed for over two hours. The resident, who had multiple comorbidities, was later found to have sustained serious injuries including fractures and head trauma.
A CNA transferred a resident with significant mobility and neurological conditions using a mechanical sling lift without the required second staff member, contrary to the care plan and facility policy. During the transfer, the resident fell from the lift and sustained multiple serious injuries, including rib and scapula fractures, subdural bleeds, and a pneumothorax.
A resident with multiple complex diagnoses who required two-person assistance for mechanical lift transfers was transferred by a CNA without a second staff member, contrary to facility policy. During the transfer, the sling detached, causing the resident to fall and sustain multiple serious injuries, including fractures and head trauma. The CNA did not seek help or immediately report the incident, despite adequate staffing being present.
The facility failed to ensure medications were labeled and dated once opened, as per manufacturer's guidelines, across three medication carts. Observations revealed several medications, including Pro-Stat Liquid Protein and fluticasone nasal spray, were opened and undated, making it impossible to determine expiration dates. Interviews with nursing staff and the DON confirmed the requirement for medications to be dated when opened and removed if undated.
A resident with significant visual impairments did not receive the necessary care as outlined in their care plan, which included the use of covered cups for hot beverages and assistance with cutting up food. Observations showed the resident was given uncovered mugs and uncut food, leading to difficulties in eating. Staff interviews revealed a lack of awareness of the care plan requirements, resulting in repeated failures to provide the necessary assistance.
A resident at high risk for falls, with conditions like orthostatic hypotension and legal blindness, experienced two falls resulting in injuries due to the facility's failure to implement and monitor required bed and chair alarms. Despite the care plan's directives, alarms were not consistently used, leading to a head laceration and a nasal fracture.
A resident at high risk for falls, with a history of orthostatic hypotension and other conditions, experienced two falls resulting in injuries due to the facility's failure to implement necessary monitoring devices and provide adequate supervision. Despite being assessed as high risk, the resident did not have bed and chair alarms in place, leading to falls that caused a head laceration and a nasal bone fracture.
A resident with a history of subdural hematoma was found on the floor after an unwitnessed fall. Two CNAs moved the resident to the bed without a nurse's assessment, violating facility policy. The incident was not properly communicated to the nurse, leading to a delay in initiating required neurological assessments.
Failure to Follow Mechanical Lift Transfer Protocol and Timely Reporting of Resident Fall
Penalty
Summary
A certified nurse aide (CNA) transferred a resident who required two-person assistance with a mechanical sling lift by herself, contrary to the facility's policy and the resident's care plan. During the transfer, the resident fell from the lift onto the floor. The CNA did not immediately report the fall to nursing staff, nor did she wait for a nurse to assess the resident before moving them. Instead, she physically lifted the resident from the floor and placed them back in bed without notifying anyone of the incident. After the resident was returned to bed, the CNA still did not inform nursing staff about the fall or the presence of blood on the resident's head. The resident remained in bed for over two and a half hours, during which time he was found to be bleeding from a head wound and was complaining of severe pain. The incident was only discovered when a family member noticed blood during a video call and alerted staff, prompting further assessment and eventual transfer to the hospital. The resident, who had diagnoses including Parkinson's disease, Alzheimer's disease, osteoarthritis, osteoporosis, and peripheral neuropathy, was subsequently found to have sustained multiple serious injuries, including several fractured ribs, a fractured scapula, spinal fractures, bilateral subdural bleeds, a head laceration, and other internal injuries. The CNA admitted to being aware of the facility's policies regarding mechanical lift transfers and the requirement to report falls but failed to follow them, resulting in a significant delay in care and assessment.
Failure to Follow Care Plan for Mechanical Lift Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when a certified nurse aide (CNA) attempted to transfer a resident using a mechanical sling lift without the required assistance of a second staff member, as mandated by both the resident's care plan and facility policy. The resident, who had diagnoses including Parkinson's disease, Alzheimer's disease, osteoarthritis, osteoporosis, and peripheral neuropathy, was care planned to require two staff for all mechanical lift transfers. Despite being aware of this requirement and having received relevant training, the CNA proceeded alone with the transfer. During the transfer, the upper left hook on the sling became disconnected while the resident was suspended approximately four feet above the floor, resulting in the resident falling directly to the ground. The incident was not witnessed by other staff, and the CNA did not request assistance prior to or during the transfer, despite being reminded by a nurse earlier that two staff were needed for such transfers. Other staff on the unit were available at the time, and the staffing schedule confirmed adequate personnel were present. As a result of the fall, the resident sustained multiple serious injuries, including bilateral subdural bleeds, several rib fractures (some with significant displacement and flail segments), a comminuted and displaced scapula fracture, spinal fractures, a pneumothorax, a hemothorax, and a head laceration. The resident was transferred to the hospital for evaluation and treatment before returning to the facility. The failure to follow the care plan and facility policy directly led to the resident's injuries.
Failure to Provide Required Staff Assistance During Mechanical Lift Transfer Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when a certified nurse aide (CNA) attempted to transfer a resident using a mechanical sling lift without the required assistance of a second staff member, as mandated by facility policy. The resident, who had diagnoses including Parkinson's disease, Alzheimer's disease, osteoarthritis, osteoporosis, and peripheral neuropathy, was care planned to require two staff for all mechanical lift transfers. Despite being aware of this requirement and having received training, the CNA proceeded alone, citing short staffing as the reason for not seeking help. During the transfer, the upper left clip of the sling detached from the lift, causing the resident to fall approximately four feet to the floor. The resident sustained multiple serious injuries, including bilateral subdural bleeds, several rib fractures (some with significant displacement and flail segments), a comminuted and displaced scapula fracture, spinal fractures, a pneumothorax, a hemothorax, and a head laceration. The resident was subsequently transferred to the hospital for evaluation and treatment. Interviews and record reviews confirmed that the CNA was aware of both the resident's needs and facility policy but did not request assistance. Other staff members, including a nurse and another CNA, were present on the unit and available to assist. The staffing schedule indicated adequate staffing levels at the time of the incident. The incident was not immediately reported to nursing staff, and the resident was not assessed by a nurse until later, after signs of injury were observed.
Failure to Label and Date Medications
Penalty
Summary
The facility failed to ensure that medications were labeled and dated once opened, as per the manufacturer's guidelines, across three medication carts. During observations, several medications were found opened and undated, making it impossible to determine their expiration dates. Specifically, a bottle of Pro-Stat Liquid Protein, fluticasone nasal spray, atropine ophthalmic eye drops, and brinzolamide suspension were all found opened and undated. The manufacturer's instructions for these medications require them to be discarded after a certain period post-opening, which could not be verified due to the lack of dating. Interviews with nursing staff confirmed that medications should be dated when opened and that undated medications should be removed from the medication cart. The Director of Nursing also acknowledged that medications must be dated and labeled appropriately when opened, according to the manufacturer's instructions, and that expired medications must be removed. This deficiency indicates a failure in adhering to the facility's policy on the storage of medications, which mandates that medications and biologicals be stored safely, securely, and properly following the manufacturer's recommendations.
Failure to Implement Comprehensive Care Plan for Visually Impaired Resident
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident with significant visual impairments, including glaucoma and macular degeneration, leading to moderate cognitive impairment. The care plan specified the need for covered cups for hot beverages and assistance with cutting up food due to the resident's inability to see well enough to manage these tasks independently. However, observations revealed that the resident was consistently provided with uncovered mugs of tea, which were not in accordance with the care plan, and the meal slips did not indicate the need for covered cups. Additionally, the resident's care plan required that food be cut up to accommodate their visual impairment, but this was not consistently done. The resident was observed struggling to eat uncut food items, such as runny fried eggs and sandwiches, which were not prepared according to the specified cut-up diet. Interviews with staff, including CNAs and the Dietitian, confirmed that they were unaware of the specific requirements outlined in the resident's care plan, leading to repeated failures in providing the necessary assistance. The lack of adherence to the care plan was further highlighted during interviews with the Nurse Unit Manager and the Director of Nursing, who acknowledged that the interventions specified in the care plan, such as providing covered cups and cutting up food, should have been implemented. The oversight in following the care plan resulted in the resident experiencing difficulties with eating and increased the risk of spillage and potential harm from hot beverages.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to implement and follow the interventions identified in the care plan for a resident assessed as high risk for falls. The resident, who had multiple diagnoses including orthostatic hypotension and was legally blind, was supposed to have bed and chair alarms as part of their fall risk care plan. However, there was no documentation indicating that these alarms were in place or monitored by staff, leading to two falls within 24 hours, both resulting in injuries. The first fall occurred when the resident was found on the floor in their room with a head laceration, requiring hospital treatment. Interviews with staff revealed that no alarms were in place at the time of the fall, despite the care plan's requirements. The resident was returned to the facility with bed and chair alarms implemented by a nurse, but the alarms were not consistently used or monitored by staff. The second fall happened when a CNA left the resident unattended in the bathroom without an alarm. The resident fell, sustaining a nasal fracture and a hematoma. Staff interviews confirmed that the alarms were not in place during this incident, and the Director of Nurses acknowledged that alarms should have been implemented and residents should not be left alone without them.
Failure to Implement Fall Prevention Measures for High-Risk Resident
Penalty
Summary
The facility failed to ensure the safety of a resident who was at high risk for falls, resulting in two separate incidents where the resident sustained injuries. The resident, who had a history of orthostatic hypotension, chronic atrial fibrillation, stroke, macular degeneration, and was legally blind, was assessed as being at high risk for falls. Despite this assessment, the facility did not implement the necessary monitoring devices, such as bed and chair alarms, as indicated in the resident's care plan. This lack of implementation was confirmed by multiple staff members who reported that the alarms were not in place at the time of the incidents. On the first occasion, the resident fell in their room and sustained a laceration to the head, requiring hospital treatment. The incident occurred because the resident was left unattended without the necessary alarms in place. Following this fall, bed and chair alarms were implemented; however, the resident experienced a second fall the following day. During this incident, a CNA left the resident unattended in the bathroom without reactivating the alarm, leading to another fall where the resident sustained a nasal bone fracture and a large forehead hematoma. Interviews with the nursing staff and CNAs revealed a lack of adherence to the facility's fall prevention protocols and care plan requirements. The Director of Nursing acknowledged that alarms should have been implemented as per the care plan and that residents with such alarms should not be left alone without them. The failure to provide adequate supervision and safety devices directly contributed to the resident's falls and subsequent injuries.
Failure to Follow Protocol After Unwitnessed Fall
Penalty
Summary
The facility failed to provide quality care consistent with professional standards for a resident with a history of subdural hematoma. On the specified date, two CNAs found the resident on the floor after an unwitnessed fall. Contrary to the facility's policy, they moved the resident to the bed before a licensed nurse could assess them for potential injuries. This action led to a failure in measuring and documenting the resident's neurological signs as required by the facility's policy for unwitnessed falls. The incident was compounded by a lack of communication and documentation. CNA #5 reported a skin tear to Nurse #3 but did not mention the fall. Nurse #3 did not inquire further about the cause of the skin tear or collect statements from other staff. It was only two days later that the resident informed Unit Manager #1 about the fall. This delay resulted in the nursing staff not initiating the necessary neurological assessments following the unwitnessed fall, as confirmed by the Director of Nurses.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Bedford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Meadow Green Nursing And Rehabilitation Center | 4.2 mi | ★★★★★ | 17 | 0 |
| The Commons Skilled Nursing & Rehabilitation | 4.9 mi | ★★★★★ | 9 | 0 |
| Woburn Rehabilitation And Nursing Center | 5.2 mi | ★★★★★ | 0 | 0 |
| Care One At Lexington | 5.4 mi | ★★★★★ | 11 | 0 |
| Care One At Wilmington | 6 mi | ★★★★★ | 0 | 0 |
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