Fall River Jewish Home

In the surveyor’s words

From the most serious findings on record at Fall River Jewish Home, in the surveyor’s own words.

• Actual harm, patternF686Feb 23, 2023

  Based on observations, interviews, and record review, the facility failed to ensure three Residents (#43, #34, and #22), out of a total sample of 17 residents, received care and treatment to prevent and to promote healing of pressure injuries. Specifically, the facility failed: 1. For Resident #43, to implement treatments as ordered to a pressure injury of the left ischium (forms the lower and back region of the hip bone) that became an infected stage 4 pressure injury, and worsening bilateral heel pressure injuries; 2. For Resident #34, to ensure monitoring and pressure related interventions were consistently implemented to prevent the development of a pressure injury to the Resident's bilateral heels; and 3. […]

• Actual harm, isolatedF600Mar 20, 2024

  Based on records reviewed and interviews, for two of three sampled residents (Resident #2 and Resident #1), the Facility failed to ensure they were free from physical and/or verbal abuse by staff members when; 1) On 2/19/24, Resident #2, who was alert and oriented, reported to a staff member that during an 11:00 P.M. to 7:00 A.M. shift (later determined to be on 2/18/24) he/she had a fall, that Nurse #2 picked him/her up, put him/her back into bed, that Nurse #2 then put his hand over his/her mouth and verbally threatened him/her saying he (Nurse #2) would hurt his/her (Resident #2's) family if he/she told anyone. Resident #2 told staff he/she was scared of Nurse #2, and he/she became visibly upset and cried even weeks later, when interviewed regarding the incident. […]

• Actual harm, isolatedF689Mar 8, 2023

  Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), who was assessed by nursing to be at an increased risk for elopement, had a history of wandering the unit, and told staff he/she wanted to go home, the Facility failed to ensure staff responded appropriately to a sounding exit door alarm, in an effort to maintain Resident #1's safety and prevent an incident/accident (elopement), resulting in an injury. On 2/23/23, sometime during the evening shift (3:00 P.M. to 11:00 P.M.), Resident #1 who was last seen in the day room on his/her unit, exited the Facility, unbeknownst to staff. The Facility received a call from someone in the community saying they heard someone outside the Facility yelling for help. […]

• Actual harm, isolatedF580Feb 23, 2023

  Based on interview, policy review, and record review, the facility failed to notify the Resident's physician about changes in condition, to re-evaluate the potential need to alter the treatment plan for one Resident (#43), from a total sample of 17 residents. Specifically, the facility failed to notify the primary physician of: a. a change in a new pressure injury in order to alter the treatment plan to prevent deterioration, and b. a significant weight loss of over 9% in 7 weeks in order to alter the plan of care to prevent an additional weight loss of 4.96%. Findings include: Resident #43 was admitted to the facility in October 2022 with diagnoses of dementia and hypertension. a. […]

• Actual harm, isolatedF688Feb 23, 2023

  Based on observation, record review, and interview, the facility failed to ensure interventions were implemented for the treatment of bilateral hand contractures for one Resident (#22) out of a sample of 17 residents. Specifically, the facility failed to ensure bilateral palmar guards were in place as ordered by the physician to maintain and prevent further contracture and increased pain with range of motion. Findings include: Resident #22 was admitted to the facility in July 2019 with diagnoses including Alzheimer's dementia and contracture of the right and left shoulder. […]