FALL RIVER, MA - Federal inspectors found Fall River Healthcare failed to properly investigate and prevent ongoing racial abuse between residents, allowing the harassment to continue for three weeks and causing significant emotional distress to the victim.
Investigation Reveals Systematic Failures
A February 2025 federal inspection uncovered that Fall River Healthcare at 1748 Highland Avenue failed to follow their own abuse investigation policies after a resident repeatedly used racial slurs against another resident. The facility's inadequate response allowed the verbal abuse to persist, resulting in the victim isolating himself and expressing reluctance to participate in facility activities.
The incident began on January 7, 2025, when Resident #105 screamed racial slurs at his new roommate, Resident #141, who had just been admitted for rehabilitation services. Multiple staff members witnessed the attack, with one certified nursing assistant reporting that Resident #105 called the victim the "N-word" and said he was making the room "smell like a zoo."
Staff immediately moved Resident #105 to a different room, placing him diagonally across the hall from his victim. However, inspectors found this minimal intervention failed to prevent continued harassment, as Resident #105 regularly walked past Resident #141's room and continued making racial comments over the following weeks.
Ongoing Harassment and Emotional Impact
On January 30, 2025, inspectors observed Resident #141 crying in his room after another incident. The victim told inspectors that while walking to rehabilitation therapy earlier that day, Resident #105 had yelled at him about his music, saying "Why are you listening to that? I don't want to hear N* music."
Resident #141 explained there had been "other negative encounters" with Resident #105 involving racial slurs and comments about his smell. The emotional toll was evident as the victim told inspectors he would stay in his room to "avoid situations like today" and would not go to communal areas of the facility.
The victim's withdrawal from facility activities represents a significant impact on his quality of life and rehabilitation progress. Resident #141 had been admitted for physical and occupational therapy services but was now limiting his participation due to fear of encountering his abuser.
Facility Policy Violations
Fall River Healthcare's own abuse investigation policy, revised in February 2024, required comprehensive actions that were never implemented. The policy mandated thorough investigations, separation of residents to prevent access to each other, emotional support for victims, and interviews with appropriate individuals including witnesses.
None of these required steps occurred. The Director of Nurses confirmed to inspectors that no investigation was conducted to review the verbal abuse incident. Staff responsible for the facility's response were unaware that racial slurs had been used, despite multiple witnesses reporting the specific language to supervisors.
The facility's policy also required reporting results of investigations within five business days and implementing corrective actions if violations were verified. Since no investigation took place, these protective measures were never activated.
Staff Awareness and Training Gaps
Inspectors found troubling gaps in staff awareness about the severity of the situation. The Director of Nurses initially told inspectors she was unaware that racial slurs had been used during the January 7 incident, only learning about it when federal surveyors brought it to her attention three weeks later.
Multiple staff members confirmed they had witnessed or been told about the racial abuse but assumed the room change was sufficient intervention. A certified nursing assistant said she "did not know any other ways to manage the behaviors" when Resident #105 became aggressive.
The Activity Director, who oversaw programs where both residents participated including smoking breaks, was unaware of any altercations between the two residents until January 30. This lack of communication meant staff could not take precautions to prevent encounters in common areas.
Perpetrator's Escalating Behaviors
Medical records revealed Resident #105 had a pattern of aggressive behavior and substance abuse issues that were not adequately addressed. On December 31, 2024, he returned from a family visit intoxicated, yelling, swearing, throwing furniture, and exposing himself to staff before being sent to the hospital.
Emergency room records from January 7 indicated Resident #105 was treated for agitation and provided educational materials about Intermittent Explosive Disorder, a condition involving recurrent aggressive outbursts. The materials recommended cognitive behavioral therapy, group therapy, relaxation methods, and medications to control outbursts.
Despite these concerning incidents and medical recommendations, the facility failed to develop behavioral care plans or implement therapeutic interventions. Staff continued using minimal responses like "giving space" when the resident became aggressive, rather than evidence-based approaches to address underlying behavioral issues.
Regulatory Requirements and Standards
Federal regulations require nursing homes to protect residents from abuse and ensure their psychological well-being. Verbal abuse is specifically defined as language that willfully includes disparaging and derogatory terms, regardless of a resident's ability to comprehend.
The facility's failure to investigate meets the regulatory definition of actual harm, as the ongoing abuse caused Resident #141 to withdraw from activities and express emotional distress. The three-week duration demonstrates the inadequacy of the facility's initial response.
Medical evidence supports the psychological impact of racial harassment on victims. Social isolation, as exhibited by Resident #141's withdrawal to his room, can significantly impair rehabilitation outcomes and overall health. The victim's statements about avoiding communal areas indicate the abuse successfully achieved its intimidating effect.
Administrative Response
When confronted with the findings, facility leadership acknowledged serious failures in their response. The Administrator confirmed that racial slurs constitute verbal abuse requiring investigation and admitted being unaware that Resident #105 had continued walking past the victim's room to make additional comments.
The Administrator recognized the psychological impact, stating the ongoing harassment "could weigh a lot on someone psychosocially." However, this awareness came only after federal inspectors identified the pattern of abuse that had continued for weeks under the facility's supervision.
Social work staff acknowledged that trauma-informed care plans should have been implemented for the victim, particularly given his military combat history. The combination of racial harassment and inadequate institutional response created additional layers of psychological stress for a resident already dealing with combat-related trauma.
Systemic Implications
This incident reflects broader challenges in nursing home abuse prevention and response. The facility's policy appeared comprehensive on paper but failed in implementation due to inadequate staff training, poor communication systems, and unclear responsibility assignments for abuse investigations.
The case demonstrates how seemingly minor interventions like room changes can create false security while allowing abuse to continue. Without proper investigation and comprehensive safety planning, minimal responses may actually enable perpetrators to find new ways to target their victims.
The facility's failure to address Resident #105's substance abuse and behavioral issues also contributed to the unsafe environment. Federal inspectors found the facility had contracted with substance abuse counselors and psychiatric services but failed to refer Resident #105 despite multiple concerning incidents.
Fall River Healthcare's inadequate response to racial abuse violated fundamental resident rights and federal regulations designed to protect vulnerable nursing home residents. The three-week duration of continued harassment after staff intervention demonstrates the need for comprehensive abuse prevention protocols that go beyond simple room changes to address underlying behavioral issues and ensure victim safety.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Fall River Healthcare from 2025-02-05 including all violations, facility responses, and corrective action plans.
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