Fall River Jewish Home

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and maintenance of a Peripherally Inserted Central Catheter (PICC-a flexible tube inserted through a vein in one's arm and passed through to larger veins near the heart, used to deliver medications intravenously (IV)), consistent with professional standards of practice for two Residents (#12 and #166), out of a total of 2 residents receiving intravenous therapy. Specifically, the facility failed to change the PICC dressing per professional standards.

Inspectors wroteBased on interview and document review, the facility failed to maintain a Quality Assurance and Performance Improvement (QAPI) program with documentation of the development, implementation, and evaluation of corrective actions or performance improvement activities and failed to maintain a QAPI program which addressed the full range of care and services including clinical care.

Inspectors wroteBased on interview and document review, the facility failed to maintain a Quality Assurance and Performance Improvement (QAPI) program with documentation of the development, implementation, and evaluation of corrective actions or performance improvement activities. Specifically, the facility failed to develop and implement appropriate plans of action for resident concerns regarding food temperatures.

Inspectors wroteBased on document review and interview, the facility failed to maintain an infection prevention and control program to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to implement control measures for Legionella (bacteria that can cause Legionnaires' disease, a serious type of pneumonia) and other opportunistic waterborne pathogens that could grow and spread in the facility's water system.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure one Resident (#56), out of a total sample of 16 residents, was assessed by the Interdisciplinary Care Team for self-administration of all their medications and had a physician's order to self-administer medications.

Inspectors wroteBased on record review and interview, the facility failed to implement written policies and procedures for the investigation of allegations of abuse, protection of residents during investigations and reporting of allegations and investigative findings for one Resident (#50), out of a total sample of 16 residents. Specifically, the facility failed to initiate their abuse policy after an allegation of potential abuse was reported on a grievance form dated 2/25/25.

Inspectors wroteBased on record review and interviews, the facility failed to report a potential allegation of abuse for one Resident (#50), out of a total sample of 16 residents.

Inspectors wroteBased on record review and interviews, the facility failed to investigate a potential allegation of abuse for one Resident (#50), out of a total sample of 16 residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure all drugs and biologicals used in the facility were stored in a safe and secure manner as required. Specifically, the facility failed to ensure one of two medication carts was clean and free of loose pills and debris.

Inspectors wroteBased on observation and interviews, the facility failed to ensure residents received food prepared by methods that conserve nutritive value, flavor, and appearance, and was palatable, attractive, and at a safe and appetizing temperature for two of two test trays.

Inspectors wroteBased on observation and interview, the facility failed to follow their 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: 1. Ensure the main kitchen grout and coving was maintained in a sanitary and safe condition; and 2. Ensure the refrigerators in two of two unit kitchenettes were maintained in a sanitary and safe condition.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) and Notice of Medicare Non-coverage (NOMNC) were issued with the required information for a Resident (#217) out of three applicable residents reviewed. Specifically, the facility failed to issue the SNF ABN notice and NOMNC, so the Resident/Resident Representative could decide if they wished to continue receiving skilled services that may not be paid for by Medicare, and were aware of the financial responsibility they may have to assume.

Inspectors wroteBased on record review and interview, the facility failed to designate a person who met the minimum qualifications to serve as the Food Service Director (FSD). Specifically, the facility did not employ a full-time dietitian, or have a qualified dietary employee who met the minimum qualifications to serve as the FSD.

Inspectors wroteBased on observation and interview, the facility failed to follow their policy and 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: 1. Ensure the main kitchen was pest free and maintained in a sanitary condition; 2. Ensure residents were not served undercooked, unpasteurized shell eggs; 3. Ensure food items were properly labeled and dated in the main kitchen refrigerators; 4. Ensure staff practiced proper hand hygiene to prevent cross contamination (transfer of pathogens from one surface to another) and ensure the use of gloves was limited to a single use task; and 5. Ensure staff obtained cooked food temperature prior to serving to residents.

Inspectors wroteBased on observation, interview, and documentation review, the facility failed to implement an effective pest control program, as evidenced by small black flies and sanitation concerns in the main kitchen, and small black flies in the main dining room throughout the survey.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to provide services that met professional standards of quality for one Resident (#303), out of a total sample of 15 residents. Specifically, the facility failed for Resident #303, to implement orders for the care and management of a Peripherally Inserted Central Catheter (PICC-a thin flexible tube inserted into a vein in the upper arm and guided into a large vein above the right side of the heart called the superior vena cava (SVC) used for intravenous (IV) medications), specifically for monitoring and flushing of a PICC line and changing the equipment for the PICC line.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure quality of care was provided, according to the plan of care, facility protocols, and professional standards of practice for two Residents (#28 and #38), out of 15 sampled residents. Specifically, the facility failed: 1. For Resident #28, to ensure wound care treatments were reflective of recommendations from the physician wound consultant and in line with the primary physician treatment plan; and 2. For Resident #38, to ensure wound care treatments and preventative recommendations from the physician wound consultant were implemented and provided in accordance with the treatment orders.

Inspectors wroteBased on observation, manufacturer's suggestion for use, and interview, the facility failed to ensure that staff properly labeled all medications stored in 1 of 2 medication carts with the date opened or the Resident's name.

Inspectors wroteBased on observation, interview, and test tray results, the facility failed to provide food to residents that was palatable and served at appetizing temperatures for both food and drinks.

Inspectors wroteBased on observation, interviews, and record review, the facility failed for one Resident (#303), out of a sample of 15 residents, to ensure Enhanced Barrier Precautions (EBP) were implemented and Personal Protective Equipment (PPE) was utilized when providing high contact resident care as required.

Inspectors wroteBased on record review and interview, the facility failed to implement an Antibiotic Stewardship Program to measure and improve how antibiotics are prescribed by clinicians and include antibiotic use protocols and monitoring antibiotic use in line with the facility antibiotic stewardship program. Specifically, the facility failed to ensure accurate monitoring of infections and antibiotic use was completed for 12 infection occurrences of 12 Residents (#2, #253, #43, #303, #45, #38, #24, #255, #12, #1, #36, and #45) from the March, April, and May 2024 line list.

Inspectors wroteBased on record review and interview, the facility failed to ensure resident representatives were provided the opportunity to participate in the care planning process, to be included in decisions and changes in the care plan, and failed to ensure that care planning meetings were held to review and make changes in the care plan as needed for one Resident (#8), out of a total sample of 15 residents.

Inspectors wroteBased on interviews and record review, the facility failed to ensure mail was delivered, unopened to residents. Specifically, the facility failed to maintain the privacy of Resident #2 by opening his/her mail, completing a form on their behalf and mailing the form back to an agency without ever having presented the mail to the Resident.

Inspectors wroteBased on interviews and record review, the facility failed to formulate a written grievance and follow up with one Resident (#2) following a voiced grievance. Specifically, Resident #2 voiced concerns regarding staff opening his/her mail, completing a form on their behalf and mailing the form back to an agency without ever having presented the mail to the Resident, and the Resident had not received follow up from the facility on the concern.

Inspectors wroteBased on interviews and record review, the facility failed to ensure potential misappropriation was reported to the Department of Public Health (DPH) no later than 24 hours in accordance with federal guidelines. Specifically, the facility failed to report when the previous facility allegedly kept $2,213.55 of Resident #19's personal money.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure that a baseline care plan was developed within 48 hours of admission, for two Residents (#20 and #153), out of a total sample of 15 residents, that included the instructions needed to provide effective, person-centered care of the resident, that met professional standards of practice. Specifically, the facility failed: 1. For Resident #20, to implement and initiate a baseline care plan to address mental health diagnoses; and 2. For Resident #153, to provide a copy of the baseline care plan summary to the Resident/Resident Representative.

Inspectors wroteBased on interviews and record review, the facility failed to ensure comprehensive care plans were developed for two Residents (#40 and #2) to include nutritional goals and interventions, out of a total sample of 15 residents.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure residents who use psychotropic medications, as needed, were limited to 14 days, or extended beyond 14 days with a documented clinical rationale and duration, for one Resident (#89), out of a total sample of 15 residents.

Inspectors wroteBased on interview and record review, the facility failed to take into consideration the dietary preferences of each resident. Specifically, the facility failed to accommodate preferences of Resident #2 for a high protein diet. The total sample was 15 residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure diets as ordered by the physician were served in proper form for one Resident (#40), out of a total of 15 sampled residents. Specifically, the facility failed to ensure the physician's order to have nectar thick liquids (liquids that have been altered to a thicker consistency for people who have difficulty swallowing) was followed for Resident #40.

Inspectors wroteBased on policy review, record review, and interview, the facility failed to inform 3 out of 3 Residents, or their representatives, of potential liability for payment for non-covered services including estimated cost of services.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who was alert and oriented, was able to make his/her needs known and required medication every two hours in an effort to control his/her symptoms related to a progressive brain disease that affected his/her movements and speech, the Facility failed to ensure he/she was treated in a dignified and respectful manner, when on 04/08/24, Nurse #1 spoke to Resident #1 in a degrading, insulting manner and slammed a door in his/her face.

Inspectors wroteBased on records reviewed and interviews, for two of three sampled residents (Resident #2 and Resident #1), the Facility failed to ensure they were free from physical and/or verbal abuse by staff members when; 1) On 2/19/24, Resident #2, who was alert and oriented, reported to a staff member that during an 11:00 P.M. to 7:00 A.M. shift (later determined to be on 2/18/24) he/she had a fall, that Nurse #2 picked him/her up, put him/her back into bed, that Nurse #2 then put his hand over his/her mouth and verbally threatened him/her saying he (Nurse #2) would hurt his/her (Resident #2's) family if he/she told anyone. Resident #2 told staff he/she was scared of Nurse #2, and he/she became visibly upset and cried even weeks later, when interviewed regarding the incident. [...]

Inspectors wroteBased on records reviewed and interviews, for one of two sampled Employee Files, the Facility failed to ensure staff implemented and followed their Abuse Policy when a Massachusetts Nurse Aide Registry (NAR) check was not conducted on Nurse #2 prior to his date of employment at the Facility as required, and in accordance with the Facility's Abuse Policy.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), who was assessed by nursing as being at high risk for the potential for skin breakdown, the Facility failed to ensure nursing developed and implemented an individualized comprehensive care plan with interventions, treatment goals and outcomes that addressed his/her risk for skin breakdown, and Resident #1 developed actual alteration in his/her skin integrity to both his/her heels.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), who was assessed by nursing as being at high risk for the potential for skin breakdown, and subsequently developed a pressure injury to his/her right heel, the Facility failed to ensure care and treatment to the pressure injury was consistently monitored, assessed and documented by nursing to determine if the area was improving or to prevent worsening of the area.

Inspectors wroteBased on interviews and records reviewed, for one of three sampled residents (Resident #1) who was discharged home from the facility less than 24 hours after being admitted , the Facility failed to ensure Resident #1's discharge was safe, orderly, and that the medications provided to him/her upon discharge were accurately reconciled by nursing, when upon his/her discharge on e of the medications sent home with Resident #1 belonged to another facility resident, was not a medication Resident #1 was prescribed by his/her physician, and therefore placed him/her at increased risk for the potential for adverse side effects in the event he/she consumed the medication.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure three Residents (#43, #34, and #22), out of a total sample of 17 residents, received care and treatment to prevent and to promote healing of pressure injuries. Specifically, the facility failed: 1. For Resident #43, to implement treatments as ordered to a pressure injury of the left ischium (forms the lower and back region of the hip bone) that became an infected stage 4 pressure injury, and worsening bilateral heel pressure injuries; 2. For Resident #34, to ensure monitoring and pressure related interventions were consistently implemented to prevent the development of a pressure injury to the Resident's bilateral heels; and 3. For Resident #22 to ensure interventions were implemented to maintain skin integrity of a contracted hand.

Inspectors wroteBased on interview, policy review, and record review, the facility failed to notify the Resident's physician about changes in condition, to re-evaluate the potential need to alter the treatment plan for one Resident (#43), from a total sample of 17 residents. Specifically, the facility failed to notify the primary physician of: a. a change in a new pressure injury in order to alter the treatment plan to prevent deterioration, and b. a significant weight loss of over 9% in 7 weeks in order to alter the plan of care to prevent an additional weight loss of 4.96%.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure interventions were implemented for the treatment of bilateral hand contractures for one Resident (#22) out of a sample of 17 residents. Specifically, the facility failed to ensure bilateral palmar guards were in place as ordered by the physician to maintain and prevent further contracture and increased pain with range of motion.

Inspectors wroteBased on observations, interviews, record review, and policy review, the facility failed to monitor the nutritional status for Resident #43 with an unplanned, significant weight loss, out of a total sample of 17 residents. Specifically, the facility failed to implement nutritional interventions to prevent further weight loss.

Inspectors wroteBased on document review and interview, the facility failed to maintain an active antibiotic stewardship program to monitor residents receiving antibiotic medications.

Inspectors wroteBased on document review and interview, the facility failed to inform residents, families, and resident representatives of a confirmed COVID-19 infection by 5:00 P.M. the next calendar day.

Inspectors wroteBased on document review, observation, and interview, the facility failed to ensure staff conducted COVID-19 self-testing in a manner that was consistent with current standards of practice set forth by the Centers for Disease Control and Prevention (CDC) and manufacturer's guidelines during a COVID-19 outbreak in the facility. Specifically, the facility failed to: 1. Ensure COVID-19 Indicaid tests were being fully developed for proper results; 2. Ensure staff COVID-19 test results are monitored and logged to maintain an accurate record of staff testing; and 3. Ensure staff are completing testing prior to reporting to their assigned work area for the day.

Inspectors wroteBased on interview, policy review, and document review, the facility failed to develop and implement their COVID-19 vaccination exemption policy for medical exemptions that were inclusive of all regulatory requirements and documents for one of two exempt employees reviewed.

Inspectors wroteBased on interview, document review, and policy review, the facility failed to ensure three out of four facility staff (Staff #8, #9, and #10) reviewed were educated on the rights of the residents as well as the responsibilities of the facility to properly care for its residents.

Inspectors wroteBased on document review and interview, the facility failed to provide annual abuse training for their staff, as required. Specifically, the facility failed to provide in-servicing that included resident abuse prohibition training.

Inspectors wroteBased on interview and policy review, the facility failed to ensure, as part of its quality assurance and performance improvement (QAPI) program, that mandatory training that outlined and informed staff of the elements and goals of the facility's QAPI program was conducted.

Inspectors wroteBased on policy review and interview, the facility failed to implement and permanently maintain an effective training program for all staff, which included, training on standards, policies, and procedures for the facility's infection prevention and control program.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure that staff provided care and services according to accepted standards of clinical practice for three Residents (#34, #45, #14), out of a total sample of 17 residents. Specifically, the facility failed: 1. For Resident #34, to ensure physician's orders were in place for the care and treatment of the Resident's cardiac pacemaker; 2. For Resident #45, to address the presence of and management of the Resident's cardiac pacemaker; and 3. For Resident #14, to ensure the Psychiatric consultant's recommendations that were reviewed and approved by the Physician were implemented.

Inspectors wroteBased on interview and record review. the facility failed to ensure for five Residents (#14, #22, #33, #19, and #155) that each Resident's drug regimen was free from unnecessary psychotropic medications, in a total sample of 17 residents. Specifically, the facility failed to ensure: 1. For Resident #14, resident specific, targeted behaviors were monitored for the use of the psychotropic medications Trazodone (antianxiety) and Zoloft (antidepressant); 2. For Resident #22, resident specific, targeted behaviors were monitored for the use of the psychotropic medication Effexor (antianxiety); 3. For Resident #33, resident specific, targeted behaviors were monitored for the use of the psychotropic medication Gabapentin (anticonvulsant medication used to treat anxiety); 4. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure that drugs and biologicals were secured (limited access) and safely stored. Specifically, the facility failed to ensure that: 1. The Director of Nurses' (DON) office, with medications visible from the office doorway, was locked/secured when she was not present; and 2. The treatment cart on Unit 2 was locked.

Inspectors wroteBased on observations, interviews, and policy review, the facility failed to store food in accordance with professional standards for food service safety in the main kitchen and in the unit kitchenettes.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure their infection control and prevention program was implemented throughout the facility. Specifically, the facility failed to: 1. Implement and utilize a system of surveillance for staff, symptomatic or positive for COVID-19, to include return to work criteria; 2. Ensure staff wore personal protective equipment (PPE) according to posted signs when entering or working within a COVID-19 positive resident's room; and 3. For Resident #24, ensure staff implemented infection prevention and control practices including donning the appropriate personal protective equipment (PPE) prior to entering a COVID-19 positive room.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of three refrigerators in the main kitchen and one of two Unit refrigerator/freezers were maintained in good working condition. Specifically, the facility failed: 1. For the Unit #3 Resident kitchenette refrigerator, to ensure the refrigerator was functioning properly to maintain refrigerator product at or below 41 degrees, and failed to ensure the replacement refrigerator was working properly; 2. For the main kitchen Walk-In Refrigerator (labeled #3), to maintain the refrigerator unit by evidence of a slow leak of refrigerant coolant and rusted unreadable thermostat dial resulting in the refrigerator not maintaining the temperature at or below 41 degrees Fahrenheit (F); and 3. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure one Resident's (#46) representative, as designated by the Resident, was able to make medical decisions for the Resident. The total sample was 17 residents.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure the resident and/or their representative were fully informed in advance and given information necessary to make health care decisions, including the purpose for psychotropic medications as well as the risks and benefits, prior to their use for two Residents (#14 and #33), out of a total sample of 17 residents. Specifically, the facility failed to ensure: 1. For Resident #14, informed consent was obtained from the Health Care Proxy (HCP- a designated individual to legally make medical decisions for another when a doctor declares the person incompetent) prior to the administration of the antidepressant medication Trazodone and Depakote (an anticonvulsant used to treat agitation and anxiety) outside of the dose range consented by the HCP; and 2. [...]

Inspectors wroteBased on policy review, record review, and interview, the facility failed to ensure staff implemented the facility's abuse policy for one Resident (#109), out of a total sample of 17 residents. Specifically, the facility failed to follow their policy for investigating and reporting an allegation of verbal abuse by staff documented in the the Resident's medical record and facility's Grievance Book.

Inspectors wroteBased on policy review, record review, and interview, the facility failed to ensure staff implemented the facility's abuse policy for one Resident (#109), out of a total sample of 17 residents. Specifically, the facility failed to report an allegation of verbal abuse to the Department of Public Health (DPH) as required.

Inspectors wroteBased on policy review, record review, and interview, the facility failed to ensure staff implemented the facility's abuse policy for one Resident (#109), out of a total sample of 17 residents. Specifically, the facility failed to follow their policy for investigating an allegation of verbal abuse documented in the facility's Grievance Book.

Inspectors wroteBased on record review and interview, the facility failed to develop a baseline care plan within 48 hours of the resident's admission that promoted and managed the delivery of safe nursing care in accordance with accepted Standards of Nursing Practice for three residents (#108, #45, and #24), out of a total sample of 17 residents. Specifically, the facility failed: 1. For Resident #108, to develop a baseline care plan for pain management; 2. For Resident #45, to develop a baseline care plan for pacemaker care; and 3. For Resident #24, to develop a baseline care plan on admission for COVID-19 diagnosis.

Inspectors wroteBased on record review, interview, document review, and policy review, the facility failed to ensure that individualized, comprehensive care plans were developed and/or implemented for one Resident (#34), out of a total of 17 sampled residents. Specifically, the facility failed to develop and implement an individualized plan of care for a cardiac pacemaker.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to review and revise the care plan for one Resident (#22), out of a total sample of 17 residents. Specifically, the facility failed to ensure the care plan was updated to reflect the discontinuation of pacemaker monitoring.

Inspectors wroteBased on observation, interview, and record review, the facility failed to arrange for an audiology appointment for one Resident (#31), out of 17 sampled residents, to address the Resident's hearing loss.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure each resident's environment remained as free of accident hazards as is possible and received adequate supervision to help reduce the risk for falls for two Residents (#19, #37), out of a total sample of 17 residents. Specifically, the facility failed to: 1. For Resident #19, a. ensure the Resident's level of assist for ambulation (to walk), toileting, and transfer was accurately reflected in the medical record, b. ensure staff were aware of the Resident's high risk for falls and implemented interventions to reduce the risk for falls, and c. ensure the post fall process was implemented after each fall per facility requirement; and 2. For Resident #37, to ensure staff were aware of the Resident's risk for falls and provide adequate supervision to reduce the risk for falls.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the physician reviewed and evaluated the total program of care for Resident #43, out of a total sample of 17 residents. Specifically, the physician failed to review and evaluate the significant weight loss and stage 4 pressure areas of Resident #43.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure Resident #43 was seen by a physician at least once every 30 days for the first 90 days after admission. The total sample was 17 residents.

Inspectors wroteBased on observation, interview, policy review, and record review, the facility failed to ensure staff developed and implemented a comprehensive, person-centered care plan to address the dementia care needs of two Residents (#155 and #47) to attain or maintain their highest practicable physical, mental, and psychosocial well-being, out of a total sample of 17 residents. Specifically, Resident #155 and Resident #47 were observed to be behind a closed day room door exhibiting visual and verbal distress.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to maintain a complete medical record for one Resident (#11), out of a total sample of 15 residents. Specifically, the medical record failed to include a physician evaluation and review for Resident #11 since his/her admission to the facility.

Inspectors wroteBased on document review and interview, the facility failed for one Resident (#41) to complete a Minimum Data Set (MDS) within the resident assessment instrument (RAI) time guidelines.