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:
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.