Fall River Healthcare: Racial Abuse, Drug Overdose - MA

Resident #105 called Resident #141 the "N-word" and said he didn't want to hear "N* music" on January 7, sending the victim to tears. Staff moved the aggressor's room diagonally across the hall but never followed up to see if the intervention worked.

It didn't. The racial abuse continued every day, Social Work Consultant #2 discovered when she met with Resident #141 on January 30.

"Resident #141 told her the racial comments had been happening every day," the consultant told inspectors.

The facility's social workers admitted they don't create behavioral care plans or implement interventions for verbal abuse, yelling, or aggressive behavior. Social Worker #1 said she met with the crying victim once but "had not checked with Resident #141 on the effectiveness of the intervention."

Resident #105 had been admitted in December 2024 with a new above-the-knee amputation, anxiety, and cannabis dependence. Over a month later, no social worker had completed the required evaluation that includes substance use disorder assessment.

The resident's behavioral problems escalated rapidly. On December 31, he returned from a family visit intoxicated, "verbally loud and noisy, making inappropriate statements to staff and slurring his speech." He threatened to punch someone, threw furniture around his room, came into the hallway swearing and exposing himself to nurses. Emergency services transported him to the hospital.

Seven days later came the racial abuse incident. Then on February 3, staff found Resident #105 lethargic with uneven pupils and a slight facial droop. Another resident told staff that Resident #105 had taken Xanax from a visitor.

The facility had recently contracted with a Substance Use Disorder counselor, but the counselor told inspectors he'd never been referred Resident #105 for services. The counselor had been provided a list of residents with substance abuse diagnoses from mid-December — before Resident #105's admission — but never received an updated list.

"The SUD had not been provided with any additional information to indicate which residents to prioritize based on most recent use or most at risk for relapse," Social Work Consultant #1 told inspectors.

Administrator said he was "unaware the Social Workers were not initiating behavioral care plans" and that "there had not been a system in place for the SUD Counselor referral or to prioritize the residents who were at risk or currently using substances."

The facility's own assessment identified that 145-155 residents required behavioral health needs and 50-70 residents had active substance use disorders. Yet social workers told inspectors they don't participate in behavioral care plans.

"The facility staff did not pay enough attention to Resident #141 and Resident #105 following the verbal altercation on 1/7/25," Social Worker #1 admitted.

Director of Nurses acknowledged that "no additional interventions were implemented following the verbal abuse on 1/7/25 to keep Resident #105 and Resident #141 separated and there were more interventions they could have done."

The facility also failed basic infection control protocols. Staff repeatedly failed to wear required gowns when caring for residents with chronic wounds and infectious diseases.

Resident #139, who had a tracheostomy, feeding tube, chronic wound, and urinary catheter, required Enhanced Barrier Precautions. Inspectors observed Nurse #4 performing tracheostomy care and repositioning the resident while wearing only gloves — no gown as required.

Another resident being treated for a MRSA blood infection had the wrong precaution sign posted outside his room for a week. The sign indicated Enhanced Barrier Precautions when Contact Precautions were ordered. Nurse #5 was observed entering the room without required protective equipment.

"The Enhanced Barrier Precaution sign was the wrong sign," the Infection Preventionist told inspectors. "The Resident has a MRSA infection in his/her blood and should have a Contact Precaution sign."

Medication errors compounded the problems. Nurse #6 failed to immediately document controlled substances in the narcotic log after administration, leaving discrepancies between actual pill counts and recorded amounts for two residents' pain medications.

The facility's quality oversight also broke down. The Medical Director failed to attend the last two quarterly Quality Assurance meetings, and the Director of Nurses missed the most recent meeting. The Medical Director told inspectors he "did not attend the QAPI meetings."

Kitchen conditions violated food safety standards. Inspectors found crumbling grout with debris and standing water throughout the main kitchen floor, along with ceiling tiles that didn't fit properly and had "black, clustered splotches and/or peeling" on metal grid work.

The Food Service Director acknowledged the floor "could use regrouting" and said "any compromised ceiling tiles or metal ceiling grid should be replaced to prevent potential contamination."

During admission, residents were handed arbitration agreements without explanation. Three residents told inspectors they signed documents they didn't understand.

"I was handed a pile of papers with sticky notes of where to sign," Resident #151 said. "I did not know what arbitration was and wouldn't have signed it if I understood what it was."

The receptionist responsible for obtaining signatures told inspectors she "does not know what arbitration is and cannot explain it to the residents."

The facility's assessment process also failed federal requirements. The December 2024 facility assessment left blank the signature lines for required participants including direct care staff, residents, family members, and resident representatives.

Fall River Healthcare serves a younger population with complex psychosocial needs including trauma histories, substance abuse, and psychiatric conditions. Yet the facility's social service department was not equipped to handle behavioral interventions for this vulnerable population.

The Administrator acknowledged that "trauma-informed care/behavioral issues were not on his radar" and that the current process for explaining arbitration agreements "needs to be revised because it isn't working."

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.

Additional Resources

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