Cycle 1
Health 2025-02-07 · Fire 2025-02-07
5 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Bedford, MA
Carleton-Willard Village Retirement & Nursing Ctr
4-star overall rating with 2-star inspections with abuse icon flag with $25,497 in total fines with 5 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
100 Old Billerica Road, Bedford, MA
(781) 275-8700
Overall
4 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
179
Certified beds
Average residents
94
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1983-12-13
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.05
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.78
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
3.31
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
5.13
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.82
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
4.95
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.92
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.15
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
1.15
CMS adjusted RN staffing hours
Adjusted total hours
5.65
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
17%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
28%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Value-based purchasing
Program rank
932
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
61.98
Composite VBP score used to determine payment impact.
Payment multiplier
1.0170
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.07
Performance 19.55% · Measure score 4.07 · Achievement 4.07 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
4.31
Performance 6.55% · Measure score 4.31 · Achievement 4.31 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
8.56
Baseline 20.72% · Performance 28.69% · Measure score 8.56 · Achievement 8.56 · Improvement 0
Adjusted total nurse staffing
7.85
Baseline 5.29 hours · Performance 5.31 hours · Measure score 7.85 · Achievement 7.85 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.83% |
10.72%
1.9 pts better
|
No Different than the National Rate · Eligible stays 107 · Observed rate 3.74% · Lower 95% interval 5.53% |
| Discharge to community | 40.83% |
50.57%
9.7 pts worse
|
No Different than the National Rate · Eligible stays 104 · Observed rate 35.58% · Lower 95% interval 32.94% |
| Medicare spending per beneficiary | 1 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 77 · Denominator 77 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 77 |
| Discharge self-care score | 50.77% |
53.69%
2.9 pts worse
|
Numerator 33 · Denominator 65 |
| Discharge mobility score | 53.85% |
50.94%
2.9 pts better
|
Numerator 35 · Denominator 65 |
| Pressure ulcers or injuries, new or worsened | 1.3% |
2.29%
1 pts better
|
Numerator 1 · Denominator 77 · Adjusted rate 1.41% |
| Healthcare-associated infections requiring hospitalization | 6.55% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 90 · Observed rate 4.44% · Lower 95% interval 3.9% |
| Staff COVID-19 vaccination coverage | 16.18% |
8.2%
8 pts better
|
Numerator 55 · Denominator 340 |
| Staff flu vaccination coverage | 23.89% |
42%
18.1 pts worse
|
Numerator 118 · Denominator 494 |
| Discharge function score | 55.38% |
56.45%
1.1 pts worse
|
Numerator 36 · Denominator 65 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 24 · Denominator 24 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 25 · Denominator 25 |
| Resident COVID-19 vaccinations up to date | 78.57% |
25.2%
53.4 pts better
|
Numerator 22 · Denominator 28 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.9
0.9 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.7 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
1.5
0.4 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 0.9 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.2% |
92.2%
7 pts better
|
93.4%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.9% · Q2 98.9% · Q3 100.0% · Q4 98.9% · 4Q avg 99.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.9% |
94.8%
4.1 pts better
|
95.5%
3.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.8% |
3.5%
0.7 pts better
|
3.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 1.1% · Q3 3.4% · Q4 4.5% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.3% |
12.0%
11.7 pts better
|
11.4%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% |
| Percentage of long-stay residents who lose too much weight | 3.6% |
5.2%
1.6 pts better
|
5.4%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 5.4% · Q3 5.2% · Q4 2.5% · 4Q avg 3.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.9% |
19.2%
2.3 pts better
|
19.6%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.7% · Q2 17.3% · Q3 15.2% · Q4 17.3% · 4Q avg 16.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.2% |
22.5%
12.3 pts better
|
16.7%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 10.0% · Q3 10.3% · Q4 11.6% · 4Q avg 10.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 12.7% |
17.7%
5 pts better
|
16.3%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.1% · Q2 15.9% · Q3 10.7% · Q4 8.0% · 4Q avg 12.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.2% |
17.6%
2.4 pts better
|
14.9%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.4% · Q2 18.5% · Q3 13.6% · Q4 13.1% · 4Q avg 15.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.0%
1 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.4% |
2.0%
0.6 pts better
|
1.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 1.2% · Q3 1.2% · Q4 1.1% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.6% |
21.7%
4.1 pts better
|
19.8%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.7% · Q2 17.4% · Q3 18.1% · Q4 23.4% · 4Q avg 17.6% |
| Percentage of long-stay residents with pressure ulcers | 3.9% |
4.6%
0.7 pts better
|
5.1%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 3.6% · Q3 1.9% · Q4 4.3% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.3% |
77.1%
12.2 pts better
|
81.7%
7.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.0% · Q2 86.4% · Q3 87.5% · Q4 90.5% · 4Q avg 89.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.4% |
11.8%
7.4 pts better
|
12.0%
7.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.4% · Observed 3.8% · Expected 9.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.6% |
77.7%
10.9 pts better
|
79.7%
8.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.3% |
25.8%
10.5 pts better
|
23.9%
8.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 15.3% · Observed 13.2% · Expected 20.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-15 · Fire 2024-02-15
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2022-12-02 · Fire 2022-12-02
3 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-07
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2025-03-28
F · Potential for more than minimal harm
2025-02-07
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-03-28
F · Potential for more than minimal harm
2025-02-07
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-03-28
F · Potential for more than minimal harm
2025-02-07
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-03-28
F · Potential for more than minimal harm
2025-02-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-28
F · Potential for more than minimal harm
2025-02-07
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-03-28
E · Potential for more than minimal harm
2025-02-07
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-03-28
E · Potential for more than minimal harm
2025-02-07
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2025-03-28
E · Potential for more than minimal harm
2025-02-07
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-28
E · Potential for more than minimal harm
2024-02-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-01
D · Potential for more than minimal harm
2024-02-15
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-04-01
D · Potential for more than minimal harm
2024-02-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-04-01
Inspection history
Recent health citations
J · Immediate jeopardy
2025-06-10
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-06-09
J · Immediate jeopardy
2025-06-10
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-06-09
J · Immediate jeopardy
2025-06-10
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-06-09
E · Potential for more than minimal harm
2025-02-07
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-03-12
D · Potential for more than minimal harm
2025-02-07
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-03-12
G · Actual harm
2024-05-29
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-07-05
G · Actual harm
2024-05-29
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-05
D · Potential for more than minimal harm
2024-05-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-05
D · Potential for more than minimal harm
2023-09-13
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-10-11
D · Potential for more than minimal harm
2023-09-13
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-10-11
D · Potential for more than minimal harm
2023-09-13
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-10-11
Penalties and ownership
What sits behind the stars
$16,985
2025-06-10
Fine
Fine · fine $16,985
Fine
$8,512
2024-05-29
Fine
Fine · fine $8,512
Fine
Ownership
Carleton-Willard Homes Inc
5% Or Greater Direct Ownership Interest · Organization
Mancini, Lauren
Operational/Managerial Control · Individual
Matthews, Michael
Corporate Officer · Individual
Nearby options
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#2
The Commons Skilled Nursing & Rehabilitation
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5-star overall rating with 4-star inspections with 8 recent health deficiencies
#3
Woburn Rehabilitation And Nursing Center
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1-star overall rating with 2-star inspections with $8,512 in total fines with 15 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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