12 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fall River, MA
2-star overall rating with 2-star inspections with $52,702 in total fines with 12 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
538 Robeson Street, Fall River, MA
(508) 679-6172
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
62
Certified beds
Average residents
59
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Azure Healthcare
Operator or chain grouping
Approved since
1988-12-27
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
6 facilities
Chain averages 1 overall / 1 health / 2 staffing / 2 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
RN hours / resident day
0.48
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.93
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
1.84
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
3.25
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.41
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
2.88
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.37
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.49
CMS adjusted RN staffing hours
Adjusted total hours
3.33
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
57%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Program rank
9,228
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
24.37
Composite VBP score used to determine payment impact.
Payment multiplier
0.9834
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
4.46
Performance 19.36% · Measure score 4.46 · Achievement 4.46 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
2.61
Performance 7.05% · Measure score 2.61 · Achievement 2.61 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
1.96
Baseline 100.00% · Performance 81.54% · Measure score 1.96 · Achievement 0 · Improvement 1.96
Adjusted total nurse staffing
0.71
Baseline 4.17 hours · Performance 3.28 hours · Measure score 0.71 · Achievement 0.71 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.76% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 126 · Observed rate 9.52% · Lower 95% interval 7.49% |
| Discharge to community | 47.77% |
50.57%
2.8 pts worse
|
No Different than the National Rate · Eligible stays 125 · Observed rate 44% · Lower 95% interval 39.76% |
| Medicare spending per beneficiary | 1.07 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 85% |
95.27%
10.3 pts worse
|
Numerator 68 · Denominator 80 |
| Falls with major injury | 1.25% |
0.77%
0.5 pts worse
|
Numerator 1 · Denominator 80 |
| Discharge self-care score | 39.66% |
53.69%
14 pts worse
|
Numerator 23 · Denominator 58 |
| Discharge mobility score | 24.14% |
50.94%
26.8 pts worse
|
Numerator 14 · Denominator 58 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 80 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.05% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 83 · Observed rate 6.02% · Lower 95% interval 4.02% |
| Staff COVID-19 vaccination coverage | 30.1% |
8.2%
21.9 pts better
|
Numerator 31 · Denominator 103 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 39.66% |
56.45%
16.8 pts worse
|
Numerator 23 · Denominator 58 |
| Transfer of health information to provider | 84% |
95.95%
12 pts worse
|
Numerator 21 · Denominator 25 |
| Transfer of health information to patient | 94.74% |
96.28%
1.5 pts worse
|
Numerator 36 · Denominator 38 |
| Resident COVID-19 vaccinations up to date | 4% |
25.2%
21.2 pts worse
|
Numerator 2 · Denominator 50 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.9
0.5 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 0.9 · Expected 1.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.9 |
1.5
0.4 pts worse
|
1.8
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.4 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.9% |
92.2%
2.7 pts better
|
93.4%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 89.4% · Q2 93.0% · Q3 97.9% · Q4 100.0% · 4Q avg 94.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 88.5% |
94.8%
6.3 pts worse
|
95.5%
7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 88.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.1% |
3.5%
1.6 pts worse
|
3.3%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 4.7% · Q3 6.4% · Q4 7.3% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 47.6% |
12.0%
35.6 pts worse
|
11.4%
36.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 65.0% · Q2 58.5% · Q3 32.6% · Q4 35.9% · 4Q avg 47.6% |
| Percentage of long-stay residents who lose too much weight | 7.1% |
5.2%
1.9 pts worse
|
5.4%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 7.1% · Q3 6.9% · Q4 8.7% · 4Q avg 7.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.1% |
19.2%
2.1 pts better
|
19.6%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 16.7% · Q3 16.7% · Q4 16.7% · 4Q avg 17.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.9% |
22.5%
15.6 pts better
|
16.7%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q3 8.7% · Q4 5.0% · 4Q avg 6.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 15.8% |
17.7%
1.9 pts better
|
16.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 18.4% · 4Q avg 15.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.9% |
17.6%
0.3 pts worse
|
14.9%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 27.6% · Q3 7.1% · Q4 27.3% · 4Q avg 17.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
1.0%
0.5 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.4% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
2.0%
2 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.2% |
21.7%
1.5 pts worse
|
19.8%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.0% · Q2 16.0% · Q3 25.9% · Q4 20.2% · 4Q avg 23.2% |
| Percentage of long-stay residents with pressure ulcers | 1.6% |
4.6%
3 pts better
|
5.1%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.1% · Q3 3.0% · Q4 1.3% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 87.0% |
77.1%
9.9 pts better
|
81.7%
5.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 56.7% · Q2 92.8% · Q3 95.5% · Q4 95.0% · 4Q avg 87.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.4% |
11.8%
0.6 pts worse
|
12.0%
0.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.4% · Observed 13.1% · Expected 11.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.0% |
77.7%
14.3 pts better
|
79.7%
12.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.4% |
25.8%
6.4 pts better
|
23.9%
4.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.4% · Observed 19.6% · Expected 24.1% · Used in QM five-star |
Survey summary
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Top issue: Nutrition and Dietary (5 deficiencies)
5 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Top issue: Quality of Life and Care (8 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-06-16
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-16
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-06-16
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-07-08
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2024-07-16
Fire Safety
Develop a communication plan.
Corrected 2024-07-16
Fire Safety
Establish emergency prep training and testing.
Corrected 2024-07-16
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-07-16
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-07-16
Inspection history
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2025-06-10
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2025-06-10
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-06-10
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-10
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-06-10
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-06-10
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-06-10
Health
Respond appropriately to all alleged violations.
Corrected 2025-06-10
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-06-10
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-07-01
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-06-10
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-06-10
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2024-06-27
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-07-05
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-07-05
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-07-05
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-05
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-07-05
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-07-05
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-05
Health
Implement a program that monitors antibiotic use.
Corrected 2024-07-05
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2024-07-05
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2024-07-05
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-07-05
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-07-05
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-07-05
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-07-05
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-07-05
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2024-07-05
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2024-07-05
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-07-05
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2024-04-12
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-04-05
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-04-05
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-01-19
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-01-19
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2023-12-15
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-03-10
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-03-20
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-03-20
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-03-21
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-03-24
Health
Implement a program that monitors antibiotic use.
Corrected 2023-03-24
Health
Report COVID19 data to residents and families.
Corrected 2023-02-24
Health
Perform COVID19 testing on residents and staff.
Corrected 2023-05-15
Health
Ensure staff are vaccinated for COVID-19
Corrected 2023-03-24
Health
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
Corrected 2023-03-24
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2023-03-24
Health
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected 2023-03-24
Health
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Corrected 2023-02-24
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-03-28
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-03-24
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-03-24
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-03-24
Health
Provide and implement an infection prevention and control program.
Corrected 2023-02-24
Health
Keep all essential equipment working safely.
Corrected 2023-05-15
Health
Give the resident's representative the ability to exercise the resident's rights.
Corrected 2023-03-24
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2023-05-15
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-03-24
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-03-24
Health
Respond appropriately to all alleged violations.
Corrected 2023-03-24
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-03-24
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-05-15
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-03-24
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2023-03-24
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-03-24
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected 2023-03-24
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2023-03-24
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2023-03-24
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-05-15
Health
Ensure a qualified health professional conducts resident assessments.
Corrected 2023-03-24
Penalties and ownership
Fine · fine $52,702
Fine
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Nearby options
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2-star overall rating with 2-star inspections with $8,278 in total fines with 9 recent health deficiencies with 17 fire-safety deficiencies in the latest cycle
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1-star overall rating with 1-star inspections with $22,526 in total fines with 22 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
Fall River, MA
1-star overall rating with 1-star inspections with abuse icon flag with $557,805 in total fines with 12 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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