Fall River Healthcare

department did not conduct environmental rounds and relied on the unit staff to put information and

clogged.

The Maintenance Director said staff must have been pouring things down the sink and they

armoires, and if he did not know about them, he could not fix them.

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Fall River Healthcare 1748 Highland Avenue Fall River, MA 02720

During an interview on 1/31/25 at 1:30 P.M., the Physical Therapy Assistant (PTA) said on 1/30/25

gym. He said he then went to the room of Resident #105 to get this Resident to go down to the gym for rehab. He said he had never heard that there had been any issues between the two residents prior.

He said Resident #141 had music playing and as they all approached the elevator Resident #105 started yelling and became verbally aggressive.

The PTA said he was not sure exactly what was said and he had done his best to de-escalate the situation by having Resident #141 go back to his/her room while Resident #105 continued to yell. He said Resident #105 was aggressive, angry, and agitated. He said after Resident #105 went to his/her room he had Resident #141 come down to complete therapy in the Rehab gym. He said Resident #141 was very upset and told him how Resident #105 had been making racial comments and that smoking breaks had become an argumentative setting.

During an interview on 1/31/25 at 9:30 A.M., the Director of Rehabilitation (Rehab) said she was not sure of the specifics from the previous day, which involved a Physical Therapy Assistant (PTA) and she would have to get back to the surveyor on what the plan was for Resident #105 and Resident #141 who were both receiving rehab services.

She said that the residents should not be in rehab at the same time but that only the PTA needed to know this because he was the only staff who worked with both residents.

During an interview on 1/31/25 at 9:35 A.M., the Certified Occupational Therapy Assistant (COTA) said he was working with Resident #141 and had already seen the Resident this morning. He said he was not at the facility the previous day (1/30/25) but had heard there was a verbal altercation between Resident #105 and the PTA. He said as far as he knew there had not been any altercations between Resident #105 and Resident #141 since Resident #141 was first admitted .

The COTA said he had not heard anything since then and had never been told to keep the residents separated.

During an interview on 1/31/25 at 9:45 A.M., Social Work Consultant #2 said she met with Resident #141 following the verbal abuse on 1/30/25 and Resident #141 told her the racial comments from Resident #105 had been occurring daily.

During an interview with the Administrator and the DON on 2/5/25 at 12:00 P.M., the DON said she was not aware that Resident #105 had said racial slurs to Resident #141 on 1/7/25 until the surveyors brought it to her attention.

The Administrator said he was also not aware and that the racial slurs were verbal abuse and should have been investigated and reported.

The DON said the only intervention that occurred on 1/7/25 was to move Resident #105 diagonally across the hall.

The Administrator and the DON said they did not recall discussing the racial slurs at morning meeting the following day.

The Administrator said he had become aware this week that Resident #105 had been walking by the room of Resident #141, who would be visible from the door, and using it as a tool to continue to make comments towards Resident #141, including racial slurs.

The Administrator said this could weigh a lot on someone psychosocially.

Refer to F-F607, F-F609, F-F610, F-F656, F-F740, and F-F745

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Fall River Healthcare 1748 Highland Avenue Fall River, MA 02720

During an interview on 1/31/25 at 9:25 A.M., Resident #141 said he/she did not understand why Resident #105 did not like him/her and when he/she asked Resident #105 a couple of days prior Resident #105 had responded with go f*** yourself. Resident #141 went on to talk about the racial slurs Resident #105 had used the previous day and Resident #141 said he/she had gotten so upset that he/she had started to lose their temper and raised their voice and was trying hard to control themselves and not retaliate.

During an interview on 1/31/25 at 1:30 P.M., the Physical Therapy Assistant (PTA) said on 1/30/25 he went to the room of Resident #141 and asked the Resident to get ready to come down to the rehab gym. He said he then went to the room of Resident #105 to get this Resident to go down to the gym for rehab. He said he had never heard that there had been any issues between the two residents prior.

He said Resident #141 had music playing and as they all approached the elevator Resident #105 started yelling and became verbally aggressive.

The PTA said he was not sure exactly what was said and he had done his best to de-escalate the situation by having Resident #141 go back to his/her room while Resident #105 continued to yell. He said Resident #105 was aggressive, angry and agitated. He said after Resident #105 went to his/her room he had Resident #141 come down to complete therapy in the Rehab gym. He said Resident #141 was very upset and told him how Resident #105 had been making racial comments and that smoking breaks had become an argumentative setting.

During an interview on 1/31/25 at 9:35 A.M., the Certified Occupational Therapy Assistant (COTA) said he was working with Resident #141 and had already seen the Resident this morning. He said he was not at the facility the previous day, 1/30/25 but had heard there was a verbal altercation between Resident #105 and the PTA. He said as far as he knew there had not been any altercations between Resident #105 and Resident #141 since Resident #141 was first admitted .

The COTA said he had not heard anything since then and had never been told to keep the residents separated.

During an interview with the Administrator and the DON on 2/5/25 at 12:00 P.M., the DON said she was not aware that Resident #105 had said racial slurs to Resident #141 on 1/7/25 until the surveyors brought it to her attention.

The Administrator said he was also not aware and that the racial slurs were verbal abuse and should have been investigated and reported.

The DON said the only intervention that occurred on 1/7/25 was to move Resident #105 diagonally across the hall.

The Administrator and the DON said they did not recall discussing the racial slurs at morning meeting the following day.

The Administrator said he had become aware this week that Resident #105 had been walking by the room of Resident #141, who would be visible from the door, and using it as a tool to continue to make comments towards Resident #141, including racial slurs.

The Administrator said this could weigh a lot on someone psychosocially.

Refer to F-F609 and F-F610

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Fall River Healthcare 1748 Highland Avenue Fall River, MA 02720

Review of the Health Care Facility Reporting System (HCFRS) from 1/1/25 through 1/31/25 failed to indicate any incidents of verbal abuse of Resident #141 by Resident #105 were reported by the facility.

During an interview on 1/30/25 at 2:42 P.M., the Director of Nurses (DON) said Resident #105 previously had a verbal altercation with Resident #141 when Resident #141 was admitted to the facility and a room change was initiated.

She was unaware Resident #105 had used racial slurs during that altercation and the incident had not been reported to DPH.

During an interview on 2/5/25 at 12:00 P.M., the Administrator said he was not aware racial slurs were said to Resident #141 on 1/7/25, that the racial slurs were verbal abuse and should have been reported.

Refer to F-F610

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Fall River Healthcare 1748 Highland Avenue Fall River, MA 02720

During an interview on 2/4/25 at 1:45 P.M., the DON confirmed there was no investigation to review

During an interview on 1/31/25 at 9:25 A.M., Resident #141 said he/she did not understand why Resident #105 did not like him/her and when he/she asked Resident #105 a couple of days prior Resident #105 had responded with go f*** yourself. Resident #141 went on to talk about the racial slurs Resident #105 had used the previous day and Resident #141 said he/she had gotten so upset that he/she had started to lose their temper and raised their voice and was trying hard to control themselves and not retaliate.

During an interview on 1/31/25 at 1:30 P.M., the Physical Therapy Assistant (PTA) said on 1/30/25 he went to the room of Resident #141 and asked the Resident to get ready to come down to the rehab gym. He said he then went to the room of Resident #105 to get this Resident to go down to the gym for rehab. He said he had never heard that there had been any issues between the two residents prior.

He said Resident #141 had music playing and as they all approached the elevator Resident #105 started yelling and became verbally aggressive.

The PTA said he was not sure exactly what was said and he had done his best to de-escalate the situation by having Resident #141 go back to his/her room while Resident #105 continued to yell. He said Resident #105 was aggressive, angry and agitated. He said after Resident #105 went to his/her room he had Resident #141 come down to complete therapy in the Rehab gym. He said Resident #141 was very upset and told him how Resident #105 had been making racial comments and that smoking breaks had become an argumentative setting.

During an interview on 1/31/25 at 9:35 A.M., the Certified Occupational Therapy Assistant (COTA) said he was working with Resident #141 and had already seen the Resident this morning. He said he was not at the facility the previous day, 1/30/25 but had heard there was a verbal altercation between Resident #105 and the PTA. He said as far as he knew there had not been any altercations between Resident #105 and Resident #141 since Resident #141 was first admitted .

The COTA said he had not heard anything since then and had never been told to keep the residents separated.

During an interview with the Administrator and the DON on 2/5/25 at 12:00 P.M., the DON said she was not aware that Resident #105 had said racial slurs to Resident #141 on 1/7/25 until the surveyors brought it to her attention.

The Administrator said he was also not aware and that the racial slurs were verbal abuse and should have been investigated.

The DON said the only intervention that occurred on 1/7/25 was to move Resident #105 diagonally across the hall.

The Administrator and the DON said they did not recall discussing the racial slurs at morning meeting the following day.

The Administrator said he had become aware this week that Resident #105 had been walking by the room of Resident #141, who would be visible from the door, and using it as a tool to continue to make comments towards Resident #141, including racial slurs.

The Administrator said this could weigh a lot on someone psychosocially.

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Fall River Healthcare 1748 Highland Avenue Fall River, MA 02720

During an interview on 2/4/25 at 9:07 A.M., Social Worker #1 said nurses complete the transfer/discharge notices and send them with the resident to the hospital.

She said Resident #46 is not his/her own responsible party, and the transfer notices should have been provided to Resident #46's Health Care Proxy (HCP).

Social Worker #1 said she should have mailed these notices to the Resident #46's HCP but did not.

She said she had not been sending transfer notices when residents go to the hospital.

She said she was not sure exactly what the process should be for completing transfer/discharge notices and ensuring the resident, resident representative, and ombudsman receive copies.

During an interview on 2/4/25 at 9:25 A.M., the Director of Nurses (DON) said she was not aware the transfer/discharge notices were not being sent to the ombudsman.

The DON said she expected a resident or their responsible party and the Ombudsman to receive transfer/discharge notices.

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Fall River Healthcare 1748 Highland Avenue Fall River, MA 02720

During an interview on 2/4/25 at 3:30 P.M., Social Work Consultant #1 said the BIMS and Mood assessments should have been completed for the residents and does not know why they were not. He said if the social service assessment weren't complete, then often the other assessments were not as well. He said the residents should have completed assessments either through resident interview or staff interview.

During an interview on 2/5/25 9:08 A.M., the DON said there is no specific facility policy related to MDS completion but the facility follows the Resident Assessment Instrument (RAI) manual.

She said she expects that the assessments are being completed accurately and reflective of the residents' current cognition and mood.

Review of the medical record indicated a PASARR had not been completed until one day after his/her admission to the facility.

During an interview on 1/30/25 at 12:27 P.M., Social Worker #1 reviewed Resident #43's medical record and said Resident #43's PASARR was not completed prior to admission.

Social Worker #1 said the PASARR should have been completed before the Resident was admitted .

During an interview on 1/30/25 at 2:23 P.M., Corporate Nurse #2 said the facility did not have a PASARR policy.

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Fall River Healthcare 1748 Highland Avenue Fall River, MA 02720

Review of the facility's policy titled Baseline Care Plan, dated as revised 11/2017, indicated but was not limited to: -To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within 48 hours of the resident's admission -The resident and their representative will be provided a summary of the baseline care plan that includes but is not limited to: a.

The initial goals of the resident; b. A summary of the resident's medications and dietary instructions; c.

Any services and treatments to be administered by the facility and personnel acting on behalf of the facility. Resident #144 was admitted to the facility in September 2024 with diagnoses of Parkinson's disease, Type II diabetes, and delusional disorders.

Review of the Minimum Data Set (MDS) assessment, dated 11/7/24, indicated the Resident scored 2 out of 15 on the Brief Interview for Mental Status (BIMS) assessment indicating severe cognitive impairment.

Review of Physician's orders, dated 11/19/24, indicated Resident #144's Health Care Proxy was activated.

During an interview on 2/3/25 at 1:58 P.M., Social Worker #1 said the process is supposed to include the initiation and completion of the baseline care plan under the evaluation tab in the electronic health record (EHR).

She said there was a lapse in consistent social service coverage and Resident #144's baseline care plan did not get completed.

During an interview on 2/5/25 at 3:20 P.M., Social Work Consultant #1 said the contract for the consulting company was initiated on 1/6/25 and he cannot speak to previous missed baseline care plan meetings. He said he was aware that meetings were not being conducted regularly and the meeting is where the resident and resident representative would receive a copy of the initiated baseline care plan. He said because the meetings were not occurring it is possible that the baseline care plans were not being completed previously. He said Resident #144 did not have a baseline care plan and the representative did not receive a copy.

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Fall River Healthcare 1748 Highland Avenue Fall River, MA 02720

During an interview on 1/31/25 at 1:30 P.M., the Physical Therapy Assistant who works with

often order a second tray of food.

During an interview on 2/4/25 at 8:48 A.M., the Activity Director said Resident #141 had not had any behaviors.

During an interview on 2/4/25 at 9:34 A.M., CNA #7 said she worked on the unit of Resident #141 and the Resident had not exhibited any behaviors.

During an interview on 2/4/25 at 10:00 A.M., CNA #8 said she was the assigned CNA for Resident #141 and the Resident had not had any behaviors of yelling or verbal outbursts.

During an interview on 2/4/25 at 3:05 P.M., Social Work Consultant #1 said the reaction of being frustrated with getting the wrong meal was reasonable and a behavioral care plan for verbal abuse was not warranted for Resident #141.

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Fall River Healthcare 1748 Highland Avenue Fall River, MA 02720

During an interview on 2/5/25 at 12:00 P.M., the Director of Nurses (DON) said the nurses should be documenting on the MAR as medications were administered and medications should be administered between one hour before and one hour after the scheduled time.

• Resident #110 was admitted to the facility in May 2023 with diagnoses that included venous

thrombosis and embolism and type 2 diabetes.

Review of Resident #110's MDS assessment, dated 11/27/24, indicated Resident #110 scored 12 out of 15 on the BIMS indicating he/she had moderate cognitive impairment.

The MDS also indicated but was not limited to the following: -Resident #110 had not been on a scheduled pain medication regimen and did not receive pain medication on an as-needed basis and did not receive non-medication intervention for pain; -Resident #110's skin was intact; -Skin and ulcer treatments included applications of ointments/medications other than to feet; pressure reducing device for bed was not selected.

The surveyor observed Resident #110 lying on his/her air mattress on 1/29/25, 1/30/25, 2/3/25, 2/4/25, and 2/5/25.

Review of Resident #110's Physician's Orders did not indicate an order for an air mattress.

During an interview on 2/5/25 at 11:42 A.M., Nurse #12 said Resident #110 used an air mattress but did not know why the Resident had one or what the settings were to be.

Nurse #12 said the air mattress indication and settings were in the physician's order.

Nurse #12 reviewed the Resident's physician's orders and said there was no physician's order for an air mattress.

Nurse #12 reviewed the Resident's care plan and said there was no care plan for the Resident's air mattress.

Nurse #12 said Resident #110's air mattress should have a physician's order and be documented in the Resident's care plan.

During an interview on 2/5/25 at 1:05 P.M., the DON said Resident #110 should have a physician's order for his/her air mattress and the air mattress should be included in the Resident's care plan.

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Fall River Healthcare 1748 Highland Avenue Fall River, MA 02720

During an interview on 2/5/25 at 1:05 P.M., the Director of Nursing (DON) said the facility utilizes Spanish speaking employees for general questions to residents, but not for detailed interviews.

The DON said she was unaware if staff had translating competencies on file.

The DON said the facility has a contracted on-demand phone interpreting service which should be used with non-English speaking residents, and she expected staff to be aware of and know how to use the translating service.

During an interview on 2/5/25 at 3:21 P.M., Corporate Nurse #2 said there was no documentation of staff training/competency on translating on file and no written consent to disclose Patient Health Information to family members per the facility's policy.

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Fall River Healthcare 1748 Highland Avenue Fall River, MA 02720

Review of the Minimum Data Set (MDS) assessment, dated 12/18/24, indicated Resident #122 scored 11 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident had a moderate cognitive impairment.

The MDS also indicated Resident #122 was their own responsible person.

During an interview with observation on 1/29/25 at 10:47 A.M., Resident #122 said they had not seen a podiatrist and would like their toenails and feet looked at.

The surveyor observed Resident #122's feet to have long, overgrown toenails which curled off of the toes and dry flaky skin on the toes and bottoms of the feet.

Review of the Physician's Orders included an order to consult with a podiatrist as needed.

During an interview on 1/30/25 at 9:00 A.M., Unit Manager #2 said the facility utilized a contracted provider for podiatry services including toenail care.

She said the consent forms were uploaded into the electronic medical record.

Review of the electronic and paper medical record failed to indicate Resident #122 had been offered to see a podiatrist since their admission on e year prior.

Review of the Weekly Skin Evaluation failed to indicate Resident #122 had elongated toenails or scaly skin on the feet.

During an interview on 1/30/25 at 12:47 P.M., Unit Manager #2 said feet should be checked as part of the weekly skin assessment and the Resident's toenails or flaky skin should have been noted.

She said Resident #122 definitely needed to be seen by a podiatrist and the podiatrist was coming to the facility on the following day.

Review of the Podiatry Group visit from 1/31/25 indicated Resident #122 was being seen for elongated toenails and onychomycosis (a fungal infection of the nails).

Review of the visit indicated all toenails were elongated, discolored, yellow, 6 millimeters thick (the height of 3 stacked nickels).

The visit indicated the Resident had dry flaky skin on the bilateral feet/digits.

During an interview on 1/31/25 at 2:01 P.M., Resident #122 said they were very happy their toenails were cut.

During an interview on 1/31/25 at 2:22 P.M., the Director of Nurses said the nurses or the Certified Nursing Assistants should have noticed the Resident's toenails and skin on the feet and reported it to the Unit Manager so that the Resident could have been seen by the Podiatrist.

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Fall River Healthcare 1748 Highland Avenue Fall River, MA 02720

The surveyor observed the portable radiator in the Resident's closet.

She said the wall unit

During an interview on 2/3/25 at 9:30 A.M., the Maintenance Director said the wall unit heater for Resident #53 and #76 was not working and that a replacement had been ordered, but it was back ordered. He said the Residents should not have had a portable heater as they could be hot to the touch.

During an interview on 2/5/25 at 3:10 P.M., the Maintenance Director said there should not be any portable heaters as they are fire hazards and he would look for any policies regarding electrical devices or fire safety.

During an interview on 2/5/25 at 4:00 P.M., the Maintenance Director said he was unable to locate any policies on electrical devices or fire safety. He said the process for an electrical device brought in to the facility was to have it checked by maintenance first to ensure the device was UL- listed (Underwriters Laboratory- ensure that electrical products are capable of transmitting or insulating currents without exposing people to hazards) and grounded (provides a path for excess electricity to escape in case of a fault, preventing potential electric shock). He said he had not checked either of these portable heaters.

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Fall River Healthcare 1748 Highland Avenue Fall River, MA 02720

Review of the Minimum Data Set (MDS) assessments, dated 9/12/24 and 12/11/24, indicated

Review of the medical record indicated his/her Social Service Evaluation was completed on 12/11/24, three months after his/her admission.

Review of the Social Service Evaluation, dated 12/11/24, section E, failed to identify his/her history of trauma.

Further review of the Social Service Evaluation, Plan of Care/Comments section, indicated his/her diagnoses included PTSD.

Review of Resident #77's medical record failed to indicate a care plan for Trauma Informed Care/PTSD had been formulated and failed to identify any potential triggers or interventions to prevent re-traumatization.

During an interview on 1/30/25 at 1:34 P.M., Unit Manager #4 said the Social Service department completed trauma informed care and PTSD assessments.

The surveyor and Unit Manager #4 reviewed Resident #77's medical record and Unit Manager #4 said he/she had a history of PTSD but there was no care plan.

Unit Manager #4 said she was not aware of potential triggers or interventions to prevent re-traumatization.

During an interview on 2/4/25 at 12:10 P.M., Social Worker #1 said Resident #77's Social Service Evaluation was not completed with his/her admission in September; it was not completed until three months later.

Social Worker #1 said Resident #77 did have a history of PTSD and a care plan should have been developed.

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Fall River Healthcare 1748 Highland Avenue Fall River, MA 02720

physician visits may alternate with Nurse Practitioner visits, so the Resident may be seen every 120

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Fall River Healthcare 1748 Highland Avenue Fall River, MA 02720

During an interview on 2/5/25 at 12:00 P.M., the DON said she was at the facility on 1/7/25 when Resident #105 was yelling at Resident #141.

She said she was not aware that Resident #105 had used racial slurs.

She said the Resident was moved diagonally across the hall and when the Resident was not de-escalating and would not take Ativan the Resident was sent to the hospital.

She said no additional interventions were implemented to keep Resident #105 and Resident #141 separated and there were more interventions they could have done.

During an interview on 2/5/25 at 12:00 P.M., the Administrator said facility staff did not know Resident #105 had continued to walk by the room of Resident #141 (in the same hallway) and continued to use racial slurs. He said the Social Workers should have evaluated/assessed the behaviors of Resident #105 and implemented care plans following a face-to-face assessment with resident specific interventions. He said he was unaware the Social Workers were not initiating behavioral care plans and they should be involved from a psychosocial standpoint. He said the SUD Counselor had started services at the facility approximately a month and a half prior and 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.

Refer to F-F745

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Fall River Healthcare 1748 Highland Avenue Fall River, MA 02720

Review of the medical record for Resident #141 failed to indicate any information regarding the Resident being called racial slurs and failed to indicate any follow-up was conducted with Resident #141 to determine the effectiveness of the room change across the hall.

During an interview on 1/31/25 at 9:40 A.M., Social Worker #1 said she was at the facility on 1/7/25 when Resident #105 was yelling at Resident #141.

She said she had not directly heard the racial slurs, but staff had told her.

She said she met with Resident #141 at that time and the Resident was crying.

She said she invited Resident #141 to sit in her office the next day as the Resident was walking by and the Resident talked about how sad he/she was about the racial slur.

She said she had not checked with Resident #141 on the effectiveness of the intervention of moving Resident #105 diagonally across the hall.

During an interview on 1/31/25 at 9:45 A.M., Social Work Consultant #2 said she met with Resident #141 following the verbal abuse on 1/30/25 and Resident #141 told her the racial comments had been happening every day.

During an interview on 2/3/25 at 1:30 P.M., Social Worker #1 said the facility staff did not pay enough attention to Resident #141 and Resident #105 following the verbal altercation on 1/7/25.

During an interview on 2/5/25 at 12:00 P.M., the DON said 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.

During an interview on 2/5/25 at 12:00 P.M., the Administrator said facility staff did not know Resident #105 had continued to walk by the room of Resident #141 (in the same hallway) and continued to use racial slurs. He said the Social Workers should have followed up with Resident #141 to determine if there had been any further interactions with Resident #105.

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Fall River Healthcare 1748 Highland Avenue Fall River, MA 02720

Review of Resident #118's current Physician's Orders included but was not limited to the following: -Pregabalin 25 mg Give 1 capsule by mouth two times a day for chronic pain During inspection of the Medication Cart on the Riverside 1 Unit (high side) on 1/30/25 at 2:24 P.M. with Nurse #6, the surveyor observed the following: -The Narcotic Medication Card in the Medication Cart for Resident #117's Pregabalin 25 mg capsules (schedule-V controlled substance medication) contained 30 capsules. -The Narcotic Book documentation log for Resident #118's Pregabalin 25mg capsules had 31 capsules on the register.

Review of Resident #118's MAR indicated Pregabalin 25 mg was administered by Nurse #6 on 1/30/25 at 9:36 A.M.

During an interview on 1/30/25 at 2:30 P.M., Nurse #6 said she administered Resident #118's Pregabalin dose as ordered earlier in her shift.

Nurse #6 said she should have signed the medication out of the Narcotic Book at the time of administration but did not.

Nurse #6 showed the surveyor her documentation in the Resident's electronic medical record indicating that the dose had been administered during the morning medication pass.

During an interview on 2/5/25 at 9:35 A.M., the Director of Nurses said all narcotics should be signed out of the Narcotic Book when they are removed from the medication cart and administered, not later in the day.

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Fall River Healthcare 1748 Highland Avenue Fall River, MA 02720

During an interview on 1/29/25 at 8:20 A.M., the surveyor and Food Service Director (FSD) observed areas of the main kitchen's floor grout and ceiling.

The FSD said the grout was recessed and the floor could use regrouting.

The FSD said steam causes ceiling tiles to [NAME] and sag as well as black splotchy growth on the metal ceiling grids.

The FSD said any compromised ceiling tiles or metal ceiling grid should be replaced to prevent potential contamination.

During an interview on 2/5/25 at 3:04 P.M., the Director of Nursing (DON) said the floor grout and ceiling tiles and gridding in the main kitchen should be in good repair and easy to clean.

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Fall River Healthcare 1748 Highland Avenue Fall River, MA 02720

Review of the Facility Assessment, dated December 2024, indicated the following participant sections were left blank: -Direct Care Staff Member (RN, LPN, CNA, etc.) -Resident -Family Member -Resident Representative -Staff Representative During an interview on 2/5/25 at 1:45 P.M., the Assistant Administrator said the facility assessment was completed with help from the Administration team including the Administrator, Director of Nurses, Infection Control Nurse, the Governing Body, and Department Heads.

As of the end of the survey, on 2/5/25, the survey team did not receive any additional documentation to support the involvement of required members in completing the Facility Assessment.

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Fall River Healthcare 1748 Highland Avenue Fall River, MA 02720

During the Resident Group Meeting on 1/30/25 at 10:00 A.M., Residents in attendance said they do not understand what arbitration is.

They said they were asked to sign papers after they were admitted and never received a copy of what they signed.

During an interview on 1/30/25 at 12:18 P.M., the Administrator said he was not sure who was responsible for having residents sign the arbitration agreement. He said either the Receptionist or nursing would have residents sign the agreement. He said the business office reported that nursing staff have residents sign the agreement upon admission.

During an interview on 1/30/25 at 12:20 P.M., the Receptionist said she has residents sign admission paperwork in four spots, she said she puts a sticky note where the resident needs to sign.

She said she does not know what arbitration is and cannot explain it to the residents.

She said she has them sign the paperwork because she is responsible for getting these signatures but doesn't have knowledge of what the documents are.

She said she has not been trained on arbitration agreements.

During an interview on 1/30/25 at 12:39 P.M., Resident #146 said he/she signed a bunch of papers on the day they arrived, but he/she doesn't recall anything being explained about an arbitration process.

The Resident said he/she does not know what arbitration is.

During an interview on 1/30/25 at 12:48 P.M., Resident #209 said he/she did not know if he/she signed an arbitration agreement.

The Resident said he/she was told to sign a lot of papers and shown where to sign but it was not explained.

During an interview on 1/30/25 at 01:43 P.M., Resident #151 said he/she was handed a pile of papers with sticky notes of where to sign.

The Resident said he/she did not know what arbitration was and wouldn't have signed it if he/she understood what it was.

The Resident said the arbitration process and agreement were not explained to him/her.

During an interview on 1/30/25 at 2:35 P.M., the Administrator said he expects that the residents are educated on what they are asked to sign. He said there should be someone who can explain the arbitration agreement and their current process needs to be revised because it isn't working.

225723 02/05/2025

Fall River Healthcare 1748 Highland Avenue Fall River, MA 02720

Review of the facility's policy titled Quality Assurance Performance Improvement (QAPI), dated as revised 6/2019, indicated but was not limited to: -the facility will form a QAPI Steering Committee designed to meet quarterly.

The Steering Committee must include the Medical Director (attendance required quarterly), Administrator, DON, Pharmacist, Staff Development Coordinator (ADON), and Social Services.

Review of the facility's QAPI Attendee sign-in sheets for October 2024 indicated the line for the Medical Director signature was blank.

Review of the facility's QAPI Attendee sign-in sheets for January 2025 indicated the line for the Medical Director and Director of Nurses signature was blank.

During an interview on 2/5/25 at 1:45 P.M., with the Administrator and Assistant Administrator, the Assistant Administrator said the facility completed monthly QAPI meetings and conducts a larger Quarterly QAPI meeting.

The Administrator said the last quarterly QAPI meetings were held in January 2025 and October 2024.

The Administrator said the Medical Director attended the Quarterly QAPI meetings.

During an interview on 2/5/25 at 1:46 P.M., with the Administrator and Assistant Administrator, the surveyor reviewed the QAPI Attendee sign-in sheets and the Assistant Administrator said sometimes the Medical Director attended telephonically and when that was the case he/she would fax over a copy of the signed attendance sheet.

The Assistant Administrator said the DON may have been on vacation at the last QAPI meeting.

The Assistant Administrator said she would provide the survey team with the updated attendance sheets.

During an interview on 2/5/25 at 2:01 P.M., the Medical Director (Physician #1) said the facility usually reports any issues they have to him but he did not attend the QAPI meetings.

At the time of survey completion, on 2/5/25, the facility failed to provide any additional documentation to the survey team.

225723 02/05/2025

Fall River Healthcare 1748 Highland Avenue Fall River, MA 02720

Review of Resident #220's medical record indicated that the Resident was being treated for a blood infection with the MDRO, MRSA.

Review of the January 2025 Medication Administration Record indicated a physician's order to Maintain Contact Precautions/MRSA blood, dated 1/29/25 at 7:00 A.M.

On 1/31/25 at 12:15 P.M., 1/31/25 at 2:19 P.M., and 2/4/25 at 8:45 A.M., the surveyor observed the sign posted on the entrance to the Resident's room was for Enhanced Barrier Precautions, not Contact Precautions, as required.

On 1/31/25 at 12:15 P.M., the surveyor observed Nurse #5 preparing to administer the Resident's IV (intravenous) antibiotic (Vancomycin).

The surveyor did not observe Nurse #5 wearing a gown as required.

On 1/31/25, between 12:15 P.M. and 2:30 P.M., the surveyor observed Nurse #5 enter Resident #220's room without donning a gown, as required for a resident on Contact Precautions.

During an interview on 2/5/25 at 12:35 P.M., Unit Manager (UM) #1 said that from 1/29/25 through 2/5/25, the precaution sign on the Resident's doorway was not the correct one; the Enhanced Barrier Precaution sign should have been a Contact Precaution sign for the Resident's MRSA infection.

She said that nursing staff should have been donning gown and gloves, when providing care to any resident with a MRSA infection.

During an interview and observation on 2/4/25 at 11:24 A.M., the Infection Preventionist (IP) and the surveyor observed the signage posted outside of Resident #220's room.

The IP said that the Enhanced Barrier Precaution sign was the wrong sign.

The IP said the Resident has a MRSA infection in his/her blood and should have a Contact Precaution sign posted at the entrance to the room.

The IP said that the unit managers are typically the ones to ensure the proper precaution signs are posted.

The IP did not know why the proper precaution sign was not posted.

225723 02/05/2025

Fall River Healthcare 1748 Highland Avenue Fall River, MA 02720

Review of the Minimum Data Set (MDS) assessment, dated 1/13/25, indicated Resident #141 scored 14 out of 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was cognitively intact and was a smoker.

Resident #105 was admitted to the facility in December 2024 for short term rehabilitation and was receiving physical therapy services.

Review of the MDS assessment, dated 12/29/24, indicated Resident #105 scored 14 out of 15 on the BIMS indicating he/she was cognitively intact and was a smoker.

On 1/30/25 at 2:10 P.M., the surveyor observed Resident #141 from their doorway.

The Resident did not wave or smile to the surveyor and was visibly upset.

The surveyor entered the Resident's room and observed Resident #141 crying.

During an interview at this time, the Resident said he/she was listening to his/her music earlier in the day on the way to Rehab when Resident #105 said Why are you listening to that? I don't want to hear Nxxxxx music. Resident #141 said he/she did not know why Resident #105 did not like him/her. Resident #141 said there had been other negative encounters with Resident #105 saying he/she smelled and using racial slurs.

Resident #141 said he/she tries to stay in his/her room, as he/she had a TV and iPad he/she could use to pass time. Resident #141 said after today's incident, he/she will stay in his/her room and will not be going to communal places within the facility (such as the drop-in day room) as to avoid situations like today. Resident #141 said he/she was going to just sit in his/her bed in the current spot and that's where the surveyor will find him/her next week when the surveyor returned.

Review of the medical record for Resident #105 indicated on 1/7/25 Resident #105 was screaming racial slurs at roommate (Resident #141) and the Resident became aggressive with redirection. Resident #105 was sent to the hospital for a change in mental status.

Further review indicated Resident #105 had a room change on 1/7/25 so that he/she was not rooming with Resident #141. Resident #105 was moved two rooms down, diagonally across the hall from Resident #141.

Review of the emergency room After Visit Summary from 1/7/25 indicated Resident #105 presented with agitation and included an educational attachment for Intermittent Explosive Disorder which included treatment goals to stop outbursts through the use of cognitive behavioral therapy, group therapy, relaxation methods and medications.

Review of the progress notes and care plans for Resident #105 failed to address behaviors and failed to identify interventions.

Review of the medical record for Resident #141 failed to indicate any information regarding the Resident being called racial slurs and failed to indicate any follow-up was conducted with Resident #141 to determine the effectiveness of the room change across the hall.

225723

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 225723 B.

Wing 02/05/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Fall River Healthcare 1748 Highland Avenue Fall River, MA 02720

Review of the facility's Social Service Job Description indicated the Social Work employees had the following functions:

-work with the interdisciplinary team and administration to promote and protect resident rights and the psychosocial well-being of each resident.

Prevent and address abuse as mandated by law and professional licensure

-complete a social history and psychosocial assessment for each resident that identifies social, emotional, and psychosocial needs

-participate in the development of written, interdisciplinary plan of care for each resident that identifies the psychosocial needs/issues of the resident, the goals to accomplish those needs/issues, and the appropriate social worker interventions

-ensure or provide therapeutic interventions to assist residents in coping with their transition and adjustment to a long term care facility, including their social, emotional, and psychological needs

1. Resident #105 was admitted to the facility in December 2024 with a new above the knee amputation of the left leg, anxiety and cannabis dependence.

Review of the Minimum Data Set (MDS) assessment, dated 12/29/24, indicated Resident #105 scored 14 out of 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was cognitively intact.

Review of the medical record on 1/30/25 failed to indicate a social service evaluation had been completed with Resident #105, over a month after he/she was admitted .

Review of the nursing progress notes indicated on 12/31/24 Resident #105 returned to the facility at 7:00 P. M. following a personal leave with family.

When the Resident returned he/she was verbally loud and noisy, making inappropriate statements to staff and slurring his/her speech.

The note indicated the Resident became very agitated, threatening to punch someone if he/she did not get their medication.

The Resident went to their room and started throwing around furniture, came back into the hallway swearing and exposing him/herself to the nurse, while yelling with slurred speech. 911 was called and Resident #105 was sent to the hospital.

225723

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 225723 B.

Wing 02/05/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Fall River Healthcare 1748 Highland Avenue Fall River, MA 02720