Catholic Memorial Home
Inspection Findings
F-Tag F0656
F 0656 Level of Harm - Actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
the visitor to go get staff to help. 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.
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Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
10/14/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Catholic Memorial Home
2446 Highland Avenue Fall River, MA 02720
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0689
F 0689 Level of Harm - Actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
dining room supervising him/her but had to care for another resident. CNA #4 said she then asked CNA #1 to supervise Resident #1 when she left the dining room to care for another resident. 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.
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Catholic Memorial Home in FALL RIVER, MA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in FALL RIVER, MA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Catholic Memorial Home or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.