Catholic Memorial Home
Catholic Memorial Home in FALL RIVER, MA — inspection on October 14, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During a telephone interview on 10/24/25 at 10:39 A.M., Certified Nurse Aide (CNA) #4 said Resident #1 had been on her assignment during the 3:00 P.M. to 11:00 P.M. (evening) shift on 09/19/25 and said Resident #1 needed continual supervision for safety because he/she was a fall risk. CNA #4 said that Resident #1's information about level of assistance he/she required could be found on his/her care plan or on his/her resident profile card. CNA #4 said Resident #1 had been standing up frequently that evening and that she (CNA #4) had been in the dining room supervising him/her. CNA #4 said that when she had to care for another resident, she asked CNA #1 to supervise Resident #1 while she (CNA #4) stepped away. CNA #4 said that when she returned to supervise Resident #1, she heard Resident #1 had fallen.
During a telephone interview on 10/14/25 at 12:38 P.M., (which included review of her Written Witness Statement, dated 09/19/25), CNA #1 said that she had not typically worked on Resident #1's unit but said she was familiar with Resident #1 and knew he/she required continual supervision due to his/her fall risk. CNA #1 said that on 09/19/25, Resident #1 kept trying to go to the exits at the ends of his/her unit hallway and she had stopped him/her (Resident #1) twice already before she had to go provide care for another resident. CNA #1 said as she was walking into another resident's room, she saw Resident #1 walking towards another CNA, so she figured Resident #1 would be supervised. CNA #1 said that by the time she was done providing care for another resident, Resident #1 had already left his/her unit.
During an interview on 10/14/25 at 3:16 P.M., Nurse #1 said Resident #1 required continual supervision and should therefore always be in staff's line of site.
Nurse #1 said Resident #1 had been agitated during the evening shift on 09/19/25 because he/she thought he/she had to go home to make dinner.
Nurse #1 said she asked CNA #1 to keep a close eye on Resident #1 because she had to give medications to another resident at the end of the hallway.
Nurse #1 said Resident #1 should not have been able make his/her way off his/her unit and all the way to the front entrance where he/she fell, but he/she had.
During an interview on 10/15/25 at 2:35 P.M., the Director of Nurses (DON) said that according to his/her care plan and Resident Profile, Resident #1 required continual supervision for ambulation, which meant that staff should know where Resident #1 was and what he/she was doing at all times.
The DON said that all CNAs know that they need to look at the Resident Profile for a resident's level of assist.
The DON said that no one [staff working on Resident #1's unit] was aware that Resident #1 had left the unit.
The DON said that, had Resident #1 been supervised as required, he/she would not have been able to walk off his/her unit alone to the front entrance door and fall, which resulted in a pelvic fracture.
During an interview on 10/14/25 at 3:31 P.M., the Administrator said that if Resident #1's care plan indicated that he/she required continual supervision for ambulation, then he/she should have had continual supervision by staff.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/14/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Catholic Memorial Home
2446 Highland Avenue Fall River, MA 02720
SUMMARY STATEMENT OF DEFICIENCIES
During a telephone interview on 10/14/25 at 12:38 P.M., CNA #1 said that she had not typically worked on Resident #1's unit but said she was familiar with Resident #1 and knew he/she required continual supervision due to his/her fall risk. CNA #1 said she had been supervising Resident #1 when she had to leave him/her to answer another resident's call light. CNA #1 said as she was walking into another resident's room, she saw Resident #1 walking toward another CNA, so she figured Resident #1 would be supervised. CNA #1 said that by the time she was done providing care for another resident, Resident #1 had already left his/her unit.
During an interview on 10/14/25 at 3:16 P.M., Nurse #1 said Resident #1 requires continual supervision and should therefore always be in staff's line of site.
Nurse #1 said Resident #1 had been agitated during the evening shift on 09/19/25 because he/she thought he/she had to go home to make dinner.
Nurse #1 said she asked CNA #1 to keep a close eye on Resident #1 because she had to go give medications to another resident at the end of the hallway.
Nurse #1 said Resident #1 should not have been able to leave the unit unsupervised and walk all the way down the hall to the front entrance where he/she opened the door and fell.
Review of Nurse #5's Written Witness Statement, dated 09/19/25, indicated that on 09/19/25, she was working on a unit other than Resident #1's unit, when she heard a visitor call out that someone had fallen.
Nurse #5 said she ran to the front entrance where she saw Resident #1 laying on the top step in front of the main entrance with his/her walker next to him/her and that Receptionist #1 was standing near Resident #1.
Nurse #5 said she assessed Resident #1 for potential injuries and paged other nurses to emergently come to assist.
During an interview on 10/15/25 at 2:35 P.M., the Director of Nurses (DON) said that Resident #1 required continual supervision for ambulation, and that staff should have known where he/she was and what he/she was doing at all times.
The DON said that no one [staff working on Resident #1's unit] was aware that Resident #1 had left the unit.
The DON said that had Resident #1 been supervised, he/she would not have been able to walk off his/her unit alone, make it to the front entrance door, and fall, which resulted in a pelvic fracture.
Facility ID: