Fall River Healthcare

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who required transfer to the Hospital Emergency Department for an evaluation, the Facility failed ensure they sent a copy of their Notice of Intent to Discharge him/her to a representative of the Office of the Long-Term Care Ombudsman, as required.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), who required an atypical antipsychotic medication for major depressive disorder and anxiety disorder, the Facility failed to ensure he/she was free from a significant medication error, when upon re-admission to the facility following a hospitalization, his/her medication orders were not accurately reconciled by nursing resulting in him/her being administered four extra doses of his/her antipsychotic in error.

Inspectors wroteBased on records reviewed and interviews, for two of three sampled residents (Residents #2 and #3) who were severely cognitively impaired, the Facility failed to ensure they were treated in a dignified and respectful manner, when in January 2026 they both experienced an incident involving physical contact initiated by Resident #1 (who was also severely cognitively impaired), which was unwanted and without their consent.

Inspectors wroteBased on a resident group meeting, staff interviews, and document review, the facility failed to ensure grievances and concerns from the Resident Council regarding long call light wait times were acted upon to resolve the issue.

Inspectors wroteBased on document review and interviews, the facility failed to ensure residents had access to their personal funds. Specifically, the facility failed to make funds available for Resident #10 within three banking days for requests in the amount of $50 or more and failed to make funds available for same day requests for cash amounts less than $50.

Inspectors wroteBased on observations, interview, and record review, the facility failed to evaluate and assess one Resident (#97), out of a total sample of 34 residents after an unplanned 11.29% significant weight loss in six months had been identified. Specifically, the facility failed to assess and evaluate the resident for more than two months after the significant weight loss had been identified.

Inspectors wroteBased on observations, interviews, and records reviewed, the facility failed to ensure it was free from a medication error rate of greater than 5% when one of three nurses observed during the medication pass made three errors out of 31 opportunities, resulting in a medication error rate of 9.68%. Those errors impacted two Residents (#77 and #62).

Inspectors wroteBased on observations, interviews, and menu review, the facility failed to ensure that menus posted were followed.

Inspectors wroteBased on observation, interview, and test tray results, the facility failed to ensure staff served palatable, attractive, and flavorful food for 2 out of 2 test trays conducted.

Inspectors wroteBased on record review and interview, the facility failed to ensure a complete and accurate medical record was maintained for five Residents (#97, #106, #17, #46, and #6), out of a total sample of 34 residents. Specifically, the facility failed:1. For Resident #97, to:a) ensure medications and treatments were accurately documented during a leave of absence (LOA), and tob) ensure the percentage of lunch consumed was accurately documented after the meal was provided and consumed on 17 of 31 days reviewed; 2. For Resident #106, to ensure the percentage of lunch consumed was accurately documented after the meal was provided and consumed on 16 of 31 days reviewed; 3. For Residents #17 and #46, to ensure volumes of tube feeding and water flushes being administered to the Residents were accurately documented in the Medication Administration Record (MAR); and4. [...]

Inspectors wroteBased on interview and document review, the facility failed to have an effective Quality Assurance Performance Improvement (QAPI) program that had a systematic analysis and action plan to rectify identified issues. Specifically, after repeated concerns brought forward by the Resident Council regarding long call light response times the facility failed to implement their policy and procedures to include the Resident Council concerns as a QAPI project.

Inspectors wroteBased on interview and record review, the facility failed to notify the Physician (MD)/ Nurse Practitioner (NP) or Resident Representative of an 11.29% significant weight loss in six months for one Resident (#97), out of a total sample of 34 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services consistent with professional standards for one Resident (#4), out of a total sample of 34 residents. Specifically, the facility failed to implement physician's orders for Foley catheter (medical device used to drain urine from the bladder) care.

Inspectors wroteBased on observations and interviews, the facility failed to adhere to infection prevention and control standards of practice to prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to:1a. Ensure that sanitary practices were used by nursing while preparing and administering medications,b. Clean and disinfect shared equipment before and/or after use; and 2. [NAME] (put on) gloves prior to obtaining Resident #3's blood sugar.

Inspectors wroteBased on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential of foodborne illness to residents who are at high risk. Specifically, the facility failed to:1. Properly label and date food products and maintain safe/clean equipment in three of four nourishment kitchenettes; and2. Handle ready-to-eat food (food which does not require cooking or further preparation prior to consumption) utilizing proper hand hygiene to prevent cross contamination (transfer of pathogens from one surface to another).

Inspectors wroteBased on record review and interview, the facility failed to ensure the Health Care Proxy (HCP: health care agent designated by the resident when competent who has the authority to consent for health care decisions when a resident has been declared, by a physician, not to be competent to make his/her own health care decisions) was notified of the benefits, risks, and alternatives for the medication prior to providing psychotropic medication for one Resident (#3), out of 31 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure the state agency responsible for Preadmission Screening and Resident Review (PASRR) was notified following psychiatric hospital admissions for one Resident (#155), in a total sample of 31 residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the standard of nursing practice was followed for one Resident (#55), out of a total sample of 31 residents. Specifically, the facility failed to ensure physician's orders for bolus tube feedings (TF) were administered by nursing as written and the Resident was assessed for competency to self-administer his/her own bolus tube feeding (TF) and had a physician's order to do so.

Inspectors wroteBased on observation, interview and record review, the facility failed to arrange for an audiology appointment for one Resident (#155), out of 31 sampled residents, to address the Resident's hearing loss.

Inspectors wroteBased on interviews and records reviewed, the facility failed to ensure one Resident (#6), out of a total sample of 31 residents, received care and treatment to promote healing of a pressure ulcer. Specifically, the facility failed for Resident #6, to implement treatments from the wound consultant physician for a chronic Stage 4 pressure ulcer (full-thickness skin and tissue loss) on the ischium (lower buttocks).

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who was alert and oriented, frequently incontinent and dependent on staff to meet his/her care needs, the Facility failed to ensure he/she was free from verbal abuse by staff members when, during the night shift (11:00 P.M. to 7:00 A.M.) on 03/09/25, Certified Nurse Aide (CNA) #1 and CNA #2 yelled at, made insulting and ridiculing comments to Resident #1, who said he/she was upset, humiliated and cried after the incident.

Inspectors wroteBased on records reviewed and interviews, for three of three sampled residents (Resident #1, #2, and #3), who were dependent on staff to meet their care needs, the Facility failed to ensure they were free from verbal and mental abuse by a staff member when, during the night shift (11:00 P.M. to 7:00 A.M.) on 01/29/25 into 01/30/25, Certified Nurse Aide (CNA) #1 was witnessed by two staff members as she yelled at, swore at, and berated Residents #1, #2, and #3, who became embarrassed, upset, and cried. Resident #1 also reported to staff that he/she was afraid of CNA #1.

Inspectors wroteBased on records reviewed and interviews, for three of three sampled residents (Residents #1, #2, and #3), who were dependent on staff to meet their care needs, the Facility failed to ensure staff implemented and followed their Abuse Policy to prevent the potential for further abuse, when on 01/30/25 during the night shift, although Nurse #1 witnessed and was therefore aware [sometime around 12:30 A.M.], that Certified Nurse Aide (CNA) #1 had verbally abused Residents #3, she did not immediately report the abuse to facility management, as required. CNA #1 was not put on administrative leave after the first incident that night and worked the entire night shift on the same unit providing care and having access to other residents. As a result, CNA #1 verbally and mentally abused Resident #1 and #2, later that same night. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to protect Resident #141's right to be free from verbal abuse by Resident #105. The total sample was 33 residents. Specifically, after the facility staff witnessed Resident #105 use racial slurs to verbally abuse Resident #141, the facility failed to develop and implement effective interventions to prevent further resident-to-resident verbal abuse, resulting in the verbal abuse continuing for three weeks and Resident #141 crying and verbalizing wanting to decrease their socialization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their abuse policy and procedures to prevent further verbal abuse for one Resident (#141), in a total sample of 33 residents. Specifically, after the facility staff witnessed Resident #105 use racial slurs to verbally abuse Resident #141, the facility failed to implement their policy to initiate effective interventions to prevent further resident-to-resident verbal abuse, resulting in the verbal abuse continuing for three weeks and Resident #141 crying and verbalizing wanting to decrease their socialization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their policy and procedures to investigate and prevent further verbal abuse for one Resident (#141), in a total sample of 33 residents. Specifically, after the facility staff witnessed Resident #105 use racial slurs to verbally abuse Resident #141, the facility failed to implement their policy to conduct a thorough investigation and initiate effective interventions to prevent further resident-to-resident verbal abuse, resulting in the verbal abuse continuing for three weeks and Resident #141 crying and verbalizing wanting to decrease socialization.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to provide effective and appropriate treatment and services to attain the highest practicable mental and psychological well-being for one Resident (#105) with anxiety, demonstrated behaviors, and active substance use, out of a total sample of 33 residents. Specifically, the facility failed to develop, implement, and update the plan of care to meet the Resident's behavioral needs, including interventions for verbal abuse to Resident #141, interventions for intermittent explosive disorder, and interventions for active substance use resulting in emergency room visits.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to provide social services to attain the highest practicable mental and psychological well-being for two Residents (#105 and #141), out of a total sample of 33 residents. Specifically, the facility failed 1. For Resident #105, to assess, develop, implement, and update the plan of care to meet the Resident's behavioral needs, including interventions for verbal abuse to Resident #141, interventions for intermittent explosive disorder and interventions for active substance use resulting in emergency room visits; and 2. For Resident #141, to follow up after being verbally abused by Resident #105 to ensure effective interventions were implemented to prevent additional incidents of verbal abuse resulting in Resident #141 crying and verbalizing wanting to decrease socialization.

Inspectors wroteBased on observations and interviews, for one resident unit out of a total sample of four resident units, the facility failed to ensure the physical environment met the residents' needs. Specifically, the facility failed to: 1. Accommodate residents who could not open the closed doors to the River 1 unit; and 2. Ensure the handicapped switches to and from the smoking area were functioning and in good repair.

Inspectors wroteBased on observations and interviews, the facility failed to ensure the residents' environment was safe, clean, comfortable, and homelike.

Inspectors wroteBased on record review and interview, the facility failed to develop and implement a person-centered plan of care for two Residents (#105, #141), out of a total of 33 sampled residents. Specifically, the facility failed: 1. For Resident #105, to implement a care plan and interventions related to exhibited behaviors of yelling, swearing, throwing furniture, exposing themselves, alcohol intoxication and using racial slurs; and 2. For Resident #141, to have a person-centered care plan by implementing a behavior care plan that was not individualized and failed to initiate a care plan related to the trauma of military combat.

Inspectors wroteBased on interview and record review, the facility failed to provide care and services consistent with professional standards of practice for one out of four units, and for five Residents (#136, #105, #210, #457, and #110) out of a total sample of 33 residents. Specifically, the facility failed to: 1. Administer morning medications per physician's orders on one of four units; 2. For Resident #136, administer medications timely including diabetic and seizure medications; 3. For Resident #105, administer an opioid as ordered and document in the medical record when it was administered; 4. For Resident #210, administer an IV (intravenous) antibiotic timely; 5. For Resident #457, provide urostomy and colostomy care per physician's orders; and 6. For Resident #110, obtain a physician's order for an air mattress.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure it provided an environment free of potential safety hazards. Specifically, the facility failed: 1. For Resident #138, to ensure that the Resident's safety device was in place at all times when unsupervised per physician's orders; 2. For Resident #123, to safely secure his/her cigarette lighter; and 3. To ensure resident areas were free from portable space heaters.

Inspectors wroteBased on record review and interview, the facility failed to ensure a person-centered plan of care with individualized interventions for trauma-informed care was developed for four Residents (#145, #141, #105, and #77), out of a total of 33 sampled residents. Specifically, the facility failed to assess and implement care plan interventions for: 1. Resident #145 with a history of a traumatic and violent event, 2. Resident #141 with a history of military combat and war injuries, 3. Resident #105 with a new above the knee amputation, and 4. Resident #77 with a diagnosis of post-traumatic stress disorder (PTSD).

Inspectors wroteBased on record reviews and interviews, for seven Residents (#139, #55, #43,#9, #138, #17, and #88), out of 33 sampled residents, the facility failed to ensure the Resident was seen by the Physician at least every 30 days for the first 90 days after admission and at least every 60 days thereafter, with alternate visits by a Nurse Practitioner (NP) as indicated.

Inspectors wroteBased on interview and document review, the facility failed to ensure the binding Arbitration Agreement presented to residents as part of the admission packet was explained to the resident and/or his/her representative in a form and manner that he/she understands for three Residents (#146, #209, and #151), out of three sampled residents, that had signed arbitration agreements in the facility.

Inspectors wroteBased on interview and document review, the facility failed to maintain a Quality Assurance and Performance Improvement (QAPI) Committee which included the required members at their meetings. Specifically, the facility Medical Director failed to attend the last two quarterly QAPI meetings and the Director of Nurses (DON) the last QAPI meeting.

Inspectors wroteBased on observation, interview, and document review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to: 1. For Resident #118, ensure his/her respiratory equipment was stored in clean and sanitary condition when not in use; 2. For Resident #139, who has chronic wounds and indwelling devices, putting him/her at increased risk for infection, to ensure staff implemented Enhanced Barrier Precautions (EBP-an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) that employs targeted gown and glove use during high contact resident care activities; and 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to report verbal abuse for one Resident (#141), in a total sample of 33 residents. Specifically, after the facility staff witnessed Resident #105 use racial slurs to verbally abuse Resident #141, the facility failed to report the verbal abuse to the State Survey Agency.

Inspectors wroteBased on record review and interview, the facility failed, for one Resident (#43), out of 33 sampled residents, to complete Preadmission Screening and Resident Review (PASARR- screen to determine if a resident had an intellectual or developmental disability and/or serious mental illness (ID/DD/SMI) and needed further evaluation) prior to his/her admission.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure one Resident (#144) was informed of and actively participated in his/her baseline plan of care within the first 48 hours following admission, out of a total sample of 33 residents.

Inspectors wroteBased on record review and interviews, the facility failed to provide the necessary care and services to attain or maintain the highest practical physical, mental, and psychosocial well-being for one Resident (#457), out of a total sample of 33 residents. Specifically, the facility failed to fully develop and implement interdisciplinary care plans related to his/her primary language of Spanish and failed to ensure staff provided person-centered care and services to determine and support the Resident's communication needs.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure foot care, including toenail care, was provided to one Resident (#122), in a total sample of 33 residents. Specifically, for Resident #122, the facility failed to ensure toenails were cut to prevent thickened elongated nails and ensure treatment to dry flaky skin on the feet.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that all drug records were in order and that an account of all controlled drugs was maintained. Specifically, the facility failed to ensure for two Residents (#117, and #118), information was entered on the narcotic accountability record immediately after a schedule-IV controlled substance (low potential for abuse and a low risk of dependence) and schedule-V controlled substance (lowest potential for abuse) were removed from the medication cart.

Inspectors wroteBased on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to ensure the main kitchen floor and ceiling were maintained in a sanitary and safe condition.

Inspectors wroteBased on document review and interview, the facility failed to develop and implement their facility assessment (a document assessing the capability of the facility and its resources to provide both emergency and day to day care of the population the facility currently serves). Specifically, the facility failed to: 1. Implement and utilize the identified resources in the facility assessment to provide care to the resident population; and 2. Ensure active involvement of all required members when conducting the facility assessment.

Inspectors wroteBased on record review and interview, the facility failed to ensure a Notice of Intent to Transfer Resident with Less than 30 Days' Notice was issued to two Residents (#22 and #46), out of a sample of 33 residents and three discharge records reviewed. Specifically, the facility failed to send a copy of the Notice of Intent to Transfer Resident with Less than 30 Days' Notice to the Ombudsman's office when the Residents were transferred to the hospital.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment was complete and accurate to reflect the status of five Residents (#22, #30, #107, #47, #154), out of a sample of 33 residents. Specifically, the facility failed: 1. For Resident #22, to complete MDS Section J0200, Pain Assessment Interview; 2. For Residents #30, #107, #47, and #154, to complete MDS Section C0200, Brief Interview for Mental Status (BIMS), and D0150, Resident Mood Interview.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who had an unwitnessed fall on 11/21/24, and was noted on 11/22/24 and 11/23/24 to have a change in status that included left hand/wrist edema, bruising, and pain, the Facility failed to ensure his/her Provider was notified timely of the change, when the Nurse Practitioner (NP) was not made aware of the changes until 11/25/24, at which time the NP ordered an X-ray for Resident #1 and he/she was diagnosed with a left wrist fracture.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1) who was cognitively intact, the Facility failed to ensure staff treated Resident #1 in a dignified and respectful manner, when it was reported that during an overnight shift (04/15/24 into 4/16/24), Nurse #1 confronted Resident #1 and used profanity when questioning Resident #1 about a statement he/she (Resident #1) had made about him (Nurse #1) to another staff member.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), the facility failed to ensure Resident #1's Durable Power of Attorney (POA)/responsible party (which was Family Member #1) was provided with statements for Resident #1's personal needs account (PNA) quarterly, as required.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), who had a diagnosis of Diabetes with long-term use of insulin, with Physician's orders that included parameters for the administration of Glucagon (hormone that increases blood sugar) via intramuscular injection (IM) in the event of hypoglycemia (low blood sugar), the Facility failed to ensure Resident #1 was provided with nursing care and treatment that met professional standards for quality, when on 10/10/23, after Resident #1 was found lethargic by nursing and unable to take anything by mouth, despite obtaining his/her blood sugar reading that confirmed he/she was hypoglycemic, nursing did not administer Glucagon IM to Resident #1 per physician's orders, as an intervention to treat him/her.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), whose Plan of Care indicated that he/she required the physical assistance of two staff members with bed mobility and was assessed by nursing as being at high risk for falls, the Facility failed to ensure nursing staff consistently implemented and followed interventions identified in his/her Plan of Care while meeting his/her care needs. On 01/28/24, Certified Nurse Aide (CNA) #1 provided care to Resident #1 who was in bed, without the assistance of another staff member, Resident #1 rolled and fell out of bed on the opposite side of the bed where CNA #1 was standing, and sustained a laceration to his/her right lower eyelid. Resident #1 was transferred to the Hospital Emergency Department (ED) for evaluation and required five sutures to close the wound to his/her right lower eyelid.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who was assessed by nursing to be at high risk for falls, and required the physical assistance of two staff members with bed mobility, the Facility failed he/she was provided with the required level of staff assistance in an effort to prevent an accident resulting in an injury. On 01/28/24, Certified Nurse Aide (CNA) #1 provided care to Resident #1, who was in bed, without the assistance of another staff member, Resident #1 rolled and fell out of bed, on the opposite side of the bed where CNA #1 was standing, and sustained a laceration to his/her right lower eyelid. Resident #1 was transferred to the Hospital Emergency Department (ED) for evaluation and required five sutures to close the wound to his/her right lower eyelid.