Provider Name: CARLETON-WILLARD VILLAGE RETIREMENT & NURSING CTR
Address: 100 OLD BILLERICA ROAD, BEDFORD, MA 01730
Phone: (781) 275-8700
County: Middlesex (090)
Ownership Type: Non profit - Corporation
Certified Beds: 179
Average Residents Per Day: 91.4 ()
Provider Type: Medicare and Medicaid, Resides in Hospital: No
Legal Business Name: CARLETON WILLARD HOMES INC
First Approved Date: December 13, 1983
Affiliated Entity: ()
Retirement Community: Y, Special Focus Status:
Ownership Change in Last 12 Months: N
Resident Family Council: Resident
Sprinkler System Status: Yes
Overall Rating: 5 ()
Health Inspection Rating: 5 ()
QM Rating: 5 ()
Long Stay QM Rating: 4 ()
Short Stay QM Rating: 5 ()
Staffing Rating: 5 ()
Staffing Report Note:
PT Staffing Note:
Nurse Aide Staff Hours Per Day, per resident: 3.29049, LPN Staff Hours Per Day: 0.8568, RN Staff Hours Per Day: 1.1789, Licensed Staff Hours Per Day: 2.0357
Total Nurse Staff Hours Per Day, per resident: 5.32628
Weekend Nurse Staff Hours: 5.05224, Weekend RN Staff Hours: 1.0013
PT Staff Hours Per Day, per resident: 0.0820
Nurse Staff Turnover: 28.2, Nurse Turnover Note:
RN Turnover: 19.2, RN Turnover Note:
Admin Left Number: 0, Admin Turnover Note:
Case Mix Nurse Aide Hours Per Day, per resident: 2.1391, Case Mix LPN Hours Per Day: 0.6334, Case Mix RN Hours Per Day: 0.2886
Adjusted Nurse Aide Hours Per Day, per resident: 3.13376, Adjusted LPN Hours Per Day: 0.9982, Adjusted RN Hours Per Day: 1.5390
Total Adjusted Nurse Hours Per Day, per resident: 5.48427
Adjusted Weekend Nurse Hours Per Day, per resident: 5.20210
Health Survey Dates and Scores: Cycle 1: 2022-12-02 (Score: 12), Cycle 2: 2021-04-27 (Score: 20), Cycle 3: 2019-05-09 (Score: 8)
Total Weighted Health Score: 14.000
Reported Incidents: 0, Substantiated Complaints: 2
Infection Control Citations: 1
Fines and Penalties: Number of Fines: 3, Total Fines in Dollars: 30991.25, Payment Denials Number: 0, Total Penalties Number: 3
Location and GPS: 100 OLD BILLERICA ROAD,BEDFORD,MA,01730 (42.5004, -71.257)
Process Date: 2024-03-01
Each record details specific health deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:
Type: Health, Deficiency: Ensure services provided by the nursing facility meet professional standards of quality.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-10-11
Type: Health, Deficiency: Ensure that residents are free from significant medication errors.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-10-11
Type: Health, Deficiency: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-10-11
Type: Health, Deficiency: Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-06-03
Type: Health, Deficiency: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-06-03
Type: Health, Deficiency: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-06-03
Type: Health, Deficiency: Provide and implement an infection prevention and control program.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-06-03
Type: Health, Deficiency: Provide and implement an infection prevention and control program.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-02-11
Each record details specific fire safety deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications: