Kimwell Nursing and Rehab: Hip Fracture After Fall - MA
The resident, identified in inspection records only as Resident 1, had become shaky. Two certified nursing assistants, CNA 1 and CNA 2, lowered the resident to the floor and then transferred the resident up off the floor onto the toilet. They did not call for a nurse before doing it.
Nurse 1 was not notified until after the transfer was already complete. By then, something had gone wrong. The resident was sent to the hospital for evaluation. The diagnosis: a comminuted left femoral intertrochanteric fracture, a hip fracture in which the bone breaks into multiple fragments at one of its most structurally significant points.
Federal inspectors from the Centers for Medicare and Medicaid Services cited the facility for causing actual harm to a resident. The inspection was conducted on October 7, 2025, following a complaint.
The Director of Nursing said she learned about the incident on August 30, 2025, when Nurse 1 told her the resident was being sent out for evaluation due to a change in condition. The director said she then interviewed staff and pieced together what had happened: the resident had gone shaky, had been lowered to the floor, and had then been transferred up and onto the toilet by the two aides, all before anyone called a nurse.
Her position on what that sequence of events meant was unambiguous. Any time a resident is lowered to the floor, or there is a change in plane, she told inspectors, it is considered a fall. Her expectation, she said, was that both CNA 1 and CNA 2 should have called for the nurse before getting the resident up off the floor and before the transfer to the toilet.
They did not.
The gap between what the aides did and what the director said should have happened is the center of the violation. A resident became unstable. The aides responded by managing the situation themselves, lowering the person to the floor and then moving them again, twice, without clinical oversight. A nurse who could have assessed the resident before any transfer occurred was not in the room and was not called.
When a person becomes shaky and is lowered to the ground, the reason for the instability is unknown until someone with clinical training evaluates them. Moving that person again, without that evaluation, means moving them without knowing whether movement is safe.
The resident left the facility with a fractured hip.
The inspection report does not describe what the two aides said about their decision, or whether they understood at the time that lowering a resident to the floor constituted a fall requiring nurse notification. It does not say how long the resident was on the floor before being transferred. It does not say whether the resident said anything, or asked for anything, during the time between going shaky and ending up in the hospital.
What the report does say is that the Director of Nursing knew her staff had not followed the protocol she described as her expectation, that the deviation was identified through her own interviews with staff after the fact, and that by the time she was notified, the resident was already on the way to the hospital.
The fracture, a comminuted intertrochanteric hip fracture, is among the more serious injuries a nursing home resident can sustain. Recovery is difficult. For older adults, hip fractures carry significant risks of complications, prolonged immobility, and loss of function.
The inspection report does not say what happened to Resident 1 after the hospital visit.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Kimwell Nursing and Rehabilitation from 2025-10-07 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 10, 2026 · Our methodology
KIMWELL NURSING AND REHABILITATION in FALL RIVER, MA was cited for violations during a health inspection on October 7, 2025.
The resident, identified in inspection records only as Resident 1, had become shaky.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.