Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Catholic Memorial Home during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of falls, who required continual supervision during ambulation, was able to leave their unit unsupervised, exit through the main entrance, and fall, resulting in a pelvic fracture. Staff interviews confirmed that although the need for supervision was documented and known, lapses in supervision occurred when staff attended to other residents, leading to the incident.
A resident with severe cognitive impairment and a high risk for falls and elopement was left unsupervised due to lapses in staff coverage. During this period, the resident exited the unit undetected, reached the main entrance, and fell, resulting in a pelvic fracture. Staff interviews confirmed the resident required continual supervision, which was not maintained at the time of the incident.
Staff were observed standing and walking around while feeding multiple residents, rather than sitting and providing individualized meal assistance as required by facility policy. This practice failed to honor residents' rights to dignity and respect during meals, as confirmed by staff interviews and observations across several units.
Surveyors observed multiple failures in infection prevention, including staff not performing hand hygiene when moving between rooms of residents on precautions, not using required PPE during high-contact care for a resident with surgical wounds, and not offering or performing hand hygiene for residents before meals. Additionally, medication carts were found dirty, and a nurse was seen touching medication with a bare finger, all contrary to facility policy.
Staff conducted a cognitive assessment for a resident with moderate impairment in a public corridor, allowing others to overhear sensitive information. Additionally, a feeding assistance list displaying the names and room numbers of multiple residents was posted on a dining room door, making protected health information visible to residents, staff, and visitors. Both actions violated HIPAA and the facility's privacy policies.
A resident with dementia and a history of falls had a care plan requiring the call light to be within reach at all times, along with reminders to use it for assistance. Surveyor observations on multiple occasions found the call light cord out of the resident's reach while in bed and in a reclining chair. Staff interviews confirmed the resident could ambulate and knew how to use the call light, and that keeping it within reach was a care plan intervention, but this was not consistently done.
Surveyors found that two residents' medications were not properly labeled or securely stored: an unlabeled pill was discovered in a medication cart by an LPN who could not identify it, and two tubes of topical antibiotics were repeatedly left unsecured in a resident's room. Facility staff confirmed these practices were not in accordance with policy.
A resident with bilateral hand contractures was not provided with recommended adaptive eating equipment, such as built-up utensil handles and handled cups, during meals. Despite OT recommendations and care plan interventions, the resident was observed struggling to use standard disposable utensils and cups, and staff did not effectively communicate or implement the necessary adaptations.
Surveyors observed that opened containers of thickened liquids in multiple kitchenettes were not dated as required, making it impossible for staff to determine when to discard them according to manufacturer and FDA Food Code guidelines. Staff interviews confirmed the absence of a system to ensure proper date marking of opened food and drink items.
A resident's medical record did not accurately reflect the activation status of their health care proxy (HCP). Although facility records such as the MDS, physician's orders, and care plan indicated the HCP was activated, both the hospital discharge summary and multiple provider notes stated otherwise. A unit manager later confirmed the HCP activation order may have been entered in error, resulting in incomplete and inaccurate documentation.
Failure to Consistently Implement Supervision Interventions for High-Risk Resident
Penalty
Summary
A resident with severe cognitive impairment, dementia, epilepsy, and anxiety was identified as being at risk for falls and elopement, requiring continual supervision during ambulation according to their care plan and resident profile. On the evening in question, the resident was able to leave their assigned unit undetected by staff, walk to the main entrance, open the door, and subsequently fall, resulting in a pelvic fracture. The facility's policy required a comprehensive, person-centered care plan to be developed and implemented for each resident, addressing all identified needs. Multiple staff interviews revealed that although the resident's need for continual supervision was documented and known, supervision was not consistently maintained. Certified Nurse Aides (CNAs) on duty were aware of the resident's fall risk and supervision requirements, but supervision was interrupted when staff attended to other residents. There was a lack of clear handoff or assurance that the resident remained in the line of sight, leading to the resident leaving the unit without staff knowledge. The Director of Nursing and other staff confirmed that the resident should have been under continual supervision and that staff should always know the resident's whereabouts. The failure to maintain required supervision directly resulted in the resident's unsupervised ambulation, exit from the unit, and subsequent fall and injury. The deficiency was attributed to staff not consistently implementing and following the care plan interventions as outlined for the resident.
Failure to Provide Required Supervision Resulting in Resident Fall and Injury
Penalty
Summary
A resident with diagnoses including dementia, epilepsy, and anxiety, and with severe cognitive impairment, was identified as being at high risk for falls and elopement. The resident required continual supervision during ambulation due to poor safety awareness and a history of exit-seeking behaviors. The care plan and facility policy both specified the need for ongoing staff supervision and interventions to maintain the resident's safety. On the evening of the incident, the resident was initially supervised by a CNA in the dining room, but the CNA had to leave to care for another resident and asked a colleague to supervise the resident. The second CNA, who was familiar with the resident's needs, also had to leave to answer another call light and assumed the resident would be supervised by another staff member. During this lapse in supervision, the resident left the unit undetected, walked to the facility's main entrance, opened the door, and fell outside. The event was witnessed by the receptionist, who attempted to intervene but was unable to prevent the fall. Following the fall, the resident was found on the front steps with complaints of hip and leg pain and was subsequently transferred to the hospital, where a pelvic fracture was diagnosed. Interviews with staff and the DON confirmed that the resident required continual supervision and that staff were not aware the resident had left the unit. The facility's failure to provide the necessary level of supervision directly resulted in the resident's unsupervised exit and subsequent injury.
Failure to Provide Dignified Meal Assistance
Penalty
Summary
The facility failed to ensure that residents were provided meal assistance in a respectful and dignified manner, as required by policy and resident rights. Observations revealed that multiple CNAs were standing while feeding residents who were seated, with one instance where a CNA stood directly in front of a resident, resulting in the resident's head being at the CNA's chest level. Additionally, CNAs were observed walking around the dining room, feeding several residents while standing, and not sitting down to provide individualized attention during meals. The facility's policy specifically states that a tray may not be placed in front of a dependent feeder until someone is ready to sit down and immediately feed them, which was not followed in these instances. Interviews with staff confirmed these practices, with one CNA stating she never sits down in the dining room and prefers to feed residents a mouthful of food before moving on to another resident, then returning to the first. The DON acknowledged that her expectation is for staff to be seated while feeding residents. These actions and inactions resulted in a failure to provide meal assistance in a manner that promotes respect, dignity, and enhancement of residents' quality of life and individuality for six residents across three units.
Infection Control Lapses in Hand Hygiene, PPE Use, and Sanitation
Penalty
Summary
The facility failed to adhere to established infection prevention and control practices, as evidenced by multiple observed lapses in hand hygiene, personal protective equipment (PPE) use, and sanitation procedures. Staff were observed entering and exiting rooms of residents on transmission-based precautions, including isolation and contact plus precautions, without performing required hand hygiene. In one instance, a certified nursing assistant (CNA) handled clean hospital gowns and moved between resident rooms without sanitizing hands, despite signage indicating the need for hand hygiene and PPE. The infection control preventionist confirmed that hand hygiene should be performed when entering and exiting rooms of residents on precautions. In another case, a resident on Enhanced Barrier Precautions due to surgical wounds was provided direct care by a CNA who wore gloves but failed to don a gown during high-contact activities such as incontinence care and repositioning. During wound care for the same resident, a nurse was observed changing gloves multiple times without performing hand hygiene between glove changes. Both the CNA and nurse acknowledged awareness of the required precautions but did not follow them during care. Additional deficiencies were observed during meal service, where staff did not offer or perform hand hygiene for residents before meals, nor did they sanitize their own hands between assisting different residents. Medication carts were found to be dirty, with soiled and sticky drawers, and a nurse was observed touching a resident's medication with her bare finger during preparation. Facility policies reviewed by surveyors outlined the expectations for hand hygiene, PPE use, and sanitation, but these were not consistently followed by staff.
Failure to Protect Resident Privacy and Confidentiality of Health Information
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' personal and medical information in two specific instances. First, a resident with moderate cognitive impairment was assessed for cognitive status using the Brief Interview of Mental Status (BIMS) in a public corridor, where other residents and staff were present and could overhear the assessment. The MDS nurse conducting the assessment acknowledged that it should have been performed in a private space, such as the resident's room, to protect the resident's privacy and dignity. The Director of Nursing also confirmed that the assessment should not have been conducted in the hallway. Second, a sign titled 'Feeding List for 7-3 and 3-11' containing the first and last names and room numbers of 19 residents was posted on the Unit 6 dining room door. This sign was visible to residents, staff, and visitors during meal times. Staff members reported that the list was used as a reference for feeding assistance and had been posted for over a month. The Unit Manager created and updated the list, and the Administrator confirmed that posting this information publicly was a violation of HIPAA, as it made protected health information visible to unauthorized individuals.
Failure to Implement Fall Risk Intervention: Call Light Not Kept Within Reach
Penalty
Summary
The facility failed to implement a person-centered care plan intervention for a resident with dementia and a history of falls. The care plan required that the call light be kept within the resident's reach at all times, with additional interventions to remind and educate the resident to use the call light for assistance. Despite these documented interventions, multiple observations by the surveyor revealed that the call light cord was not within the resident's reach while the resident was in bed or seated in a reclining chair. The red string attached to the call light box was observed hanging at the foot of the bed or on the bed, out of the resident's immediate reach during several checks throughout the day. Interviews with facility staff confirmed that the resident was able to ambulate with a rolling walker and would attempt to get up independently, and that the resident knew how to use the call light. Staff also acknowledged that the call light should be within the resident's reach as part of the care plan interventions. The medical record indicated that the resident had experienced multiple falls during their stay, and the care plan interventions were specifically designed to address this risk. However, the facility did not consistently ensure that the call light was accessible to the resident as required by the care plan.
Failure to Properly Label and Securely Store Medications
Penalty
Summary
Surveyors identified two deficiencies related to medication labeling and storage. For one resident, a nurse was observed preparing medications and an unlabeled, unidentified white pill was found in a plastic medication cup inside the medication cart. The nurse was unable to identify the medication, its dose, the intended recipient, or when it was to be administered. The nurse speculated that it might belong to the resident and could be a dose of levothyroxine, but was not certain. Both the nurse and the Director of Nurses confirmed that leaving medications unlabeled and stored in the medication cart is prohibited and should not occur under any circumstances. In a separate incident, surveyors observed that two tubes of topical antibiotic ointments (Mupirocin and Bacitracin) belonging to another resident were repeatedly left unsecured in a basin on top of the resident's dresser over several days. The Unit Manager confirmed that these medications should not be stored unsecured in the resident's room. These findings indicate a failure to follow facility policies and accepted professional principles for medication labeling and secure storage.
Failure to Provide Adaptive Eating Equipment for Resident with Hand Contractures
Penalty
Summary
The facility failed to provide adaptive eating equipment as recommended for a resident with bilateral hand contractures. Despite occupational therapy (OT) recommendations for built-up handles on utensils and handled cups to maximize the resident's independence during meals, the resident was observed using standard disposable plastic utensils and cups without adaptations. The care plan indicated the need to follow OT recommendations, but during multiple meal observations, the resident struggled to grip and use the provided utensils and cups, resulting in difficulty eating and drinking independently. Interviews with staff revealed that the foam handles previously used did not fit the plastic utensils currently in use due to ongoing kitchen repairs, and this issue was not communicated to management. The OT had educated at least one CNA about the adaptive equipment but did not ensure the recommendations were documented or communicated to the kitchen for implementation. There was also a lack of clear documentation and follow-through on the OT discharge recommendations, leading to the resident not receiving the necessary adaptive equipment during meals.
Failure to Date and Store Opened Food Items per Food Safety Standards
Penalty
Summary
The facility failed to adhere to professional standards of food safety by not properly dating and storing food items in all three kitchenettes observed. Specifically, surveyors found multiple opened containers of thickened liquids on Unit 6 that were not dated to indicate when they had been opened, despite manufacturer instructions requiring use or disposal within a specified number of days after opening. The lack of date marking made it impossible for staff to determine when the containers should be discarded, as required by both the FDA Food Code and manufacturer guidelines. Interviews with staff confirmed that there was no system in place to ensure opened food and drink items were dated. A CNA acknowledged that opened items should be dated so staff know when to discard them, but was unable to determine when the thickened liquid container had been opened. The Food Service Director also confirmed that items should be dated upon opening and discarded according to manufacturer instructions, indicating a failure in following established food safety protocols.
Inaccurate Documentation of Health Care Proxy Activation
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one resident by not correctly documenting the activation status of the resident's health care proxy (HCP). The resident, who was admitted with diagnoses including left calf hematoma evacuation, wound debridement, and atrial fibrillation, was assessed as moderately cognitively impaired with a BIMS score of eight out of 15. The facility's records, including the Minimum Data Set (MDS), physician's orders, and care plan, indicated that the resident's HCP was activated. However, review of the outside hospital's discharge summary showed that while the resident had signed advanced directives and a HCP document, there was no indication that the HCP had been invoked at the hospital. Further review of physician and nurse practitioner progress notes consistently documented that the HCP was not activated. During an interview, a unit manager acknowledged that the order indicating HCP activation may have been entered in error. This inconsistency in documentation resulted in the resident's medical record failing to accurately reflect the true status of the HCP activation, contrary to the facility's policy and accepted professional standards.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Fall River
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fall River Healthcare | 0.7 mi | ★★★★★ | 14 | 0 |
| Somerset Ridge Center | 1.8 mi | ★★★★★ | 14 | 0 |
| Sarah S Brayton Center | 1.8 mi | ★★★★★ | 19 | 0 |
| Kimwell Nursing And Rehabilitation | 1.8 mi | ★★★★★ | 13 | 0 |
| Fall River Jewish Home | 2.1 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.