‘Worst of the worst’: Fall River nursing home repeatedly cited

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The toilet was full of feces, urine and blood. Sheila Lambert judged that it had been broken for days.

Lambert dreaded visiting her father at Fall River Healthcare. She came by the nursing home three or four times a week, and would often arrive in the early afternoon to find him undressed, unwashed, and soiled, she says.

“You call, call, call. Nobody comes,” she remembers her father, Edward Pereira, telling her.

This wasn’t the first time Lambert found her father’s bathroom dirty, but this was the worst she had ever seen it, she said. She wondered why no one had helped her father use a different bathroom — or at least cleaned the growing mess.

She flagged down the nursing home’s maintenance man, who simply pointed to a sign on the bathroom door saying “do not use” — a message her father wouldn’t have understood at that stage in his mental decline. 

Pereira ended up at Fall River Healthcare in early 2024 when his dementia, diabetes, and prostate cancer made it impossible for Lambert to care for him by herself. Now, it was August 2024 and she was desperately searching for another nursing home with an open bed.

“That place should not be open, whatsoever,” said Lambert, a nurse aide who has worked for decades in hospitals and nursing homes.

Fall River Healthcare felt “dismal,” she said. She found the food was cold, the building was filthy, and staff didn’t seem to give residents the attention or care they needed.

“It’s like they put them there and they forget about them,” she said. 

Fall River Healthcare is among the most troubled nursing homes in the U.S., according to experts and advocates who reviewed its health inspection records for The Light. They say the 176-bed facility doesn’t appear to have enough workers to properly care for residents. State prosecutors have accused its for-profit parent company, Next Step Healthcare, of putting residents at risk at Fall River Healthcare and other facilities by deliberately understaffing.

More than a year after Next Step Healthcare settled those allegations with the Massachusetts attorney general and agreed to make improvements, a New Bedford Light analysis has found that most of the chain’s 15 facilities in Massachusetts still fall below minimum state staffing benchmarks. 

State health officials have repeatedly cited Fall River Healthcare for harming its residents. Bedsores got worse as staff failed to follow doctor’s orders for treating them, and residents didn’t always get their medications on time, according to inspection reports from the past two years. Nurse aides swore at and insulted residents experiencing incontinence, constipation, and trouble breathing, inspections from February and March 2025 show.

“It’s such an in-your-face flouting of the most basic standards of nursing home care, and really the standards of humanity,” said Richard Mollot, executive director of the New York-based advocacy group Long Term Care Community Coalition.

Next Step Healthcare has acknowledged The Light’s numerous emails and phone calls requesting comment, but the company did not make any executives available for an interview and did not answer a detailed list of questions.

Late last year, Fall River Healthcare made it onto Medicare’s Special Focus Facilities list, an enforcement program designed to put extra pressure on nursing homes with a history of serious, repeated problems. Only 88 of the country’s over 14,721 nursing homes can be selected for the list at any one time.

“They’re the worst of the worst facilities in the country,” Mollot said. “You can’t get a worse designation than ‘Special Focus Facility.’” 

Fall River Healthcare now faces extra scrutiny from state and federal health officials. If it doesn’t show consistent and meaningful improvement, it could lose access to Medicare funds — a rare and severe penalty, experts and advocates say.

The Massachusetts Department of Public Health inspects the state’s nursing homes and selects facilities for Medicare’s Special Focus Facilities list. Katheleen Conti, spokesperson for the agency, said Fall River Healthcare was selected “because of its repeated poor performance” during inspections over the past two years.

Conti referred to nine health violations from 2023 to 2024 that caused harm to residents, including citations for bedsores, a medication error, and violating resident rights. She said the facility was “back in compliance” within months of each inspection.

During its most recent inspection in July, Fall River Healthcare received six citations, none of which caused “actual harm,” according to a copy of the inspection report provided to The Light by Next Step Healthcare. The inspection included citations for failing to provide care according to doctor’s orders, unsanitary food preparation, and not getting proper consent before prescribing medications.

The company was required to submit a plan of correction to state health officials in response to the inspection. It did not provide that plan to The Light when it provided the inspection report.

As of August, the facility was in “substantial compliance” with state and federal requirements, Conti said.

Nursing homes on the Special Focus Facility list tend to “yo-yo” in and out of compliance on health inspections, without resolving the underlying problems that caused the health violations, according to Medicare’s description of the program. Fall River Healthcare remained on the list as of September, when the list was most recently updated.

To graduate from the Special Focus Facilities program, a facility must pass two consecutive inspections with only 12 or fewer minor violations. Inspection records show Fall River Healthcare met those requirements in its July inspection, meaning it only needs to pass one more inspection to graduate. Special Focus Facilities are due for inspections every six months.

The Department of Public Health did not make an official available for an interview. The agency “does not comment beyond its survey/inspections results documents,” Conti wrote in an email to The Light.

Paul Lanzikos, co-founder of Dignity Alliance Massachusetts, a coalition of senior and disability advocacy organizations, said Fall River Healthcare’s history of repeated violations is an all-around failure by managers, supervisors, and workers.

“It’s repulsive,” he said. “It would be bad enough if it was a singular incident, but there’s a pattern here.”

Nurse aides mistreated residents

Inspections at Fall River Healthcare have documented a string of incidents where staff were cruel to residents or failed to stop residents from being cruel to each other.

The staffers have resigned or been fired. Experts who reviewed the reports said they show the staff didn’t appear to be well-supervised. 

Around 2 a.m. one night in March 2025, two aides came into a resident’s room after the resident was incontinent in bed, an inspection report said.

The aides told the resident to get their “ass out of bed and get to the shower,” without first helping to clean the feces off them, according to the report. The resident told an inspector they continued to be incontinent with diarrhea as they walked to the shower, and in the shower.

“He/she’s doing it again, shitting like a cow,” the aides said, according to the resident.

The resident apologized in tears as the aides shamed them, telling the resident they “ought to be sorry” and to “stop acting like an animal,” according to the inspection report.

Both aides were fired, the inspection report said.

In January 2025, another nurse aide “yelled at, swore at, and berated” three residents during one night shift. There was no supervisor on duty, so she worked her entire shift and wasn’t stopped, staff told an inspector.

When a resident with dementia asked for juice around 12:30 a.m., the aide called the resident “disgusting” and said, “No, because you will shit yourself,” other staffers told an inspector.

Later, a resident with dementia who was on hospice started repeatedly asking for their window to be opened or closed because they were having trouble breathing, the inspection report said. The aide yelled with frustration until the resident cried — then, the aide yelled, “and now this one is f—ing crying too!” and “why is everyone crying?” staffers told an inspector.

Around 3:30 or 4 a.m., a resident asked for help with their constipation, the inspection report said. The resident and other staffers told an inspector that the aide accused the resident of faking it, saying “I am not your f—ing friend.”

Inspectors interviewed staff about the incidents, reports show.

The facility’s director of nursing told an inspector that the aide should have been removed from the facility, per company policy. The aide “denied the allegations of verbal abuse, refused to write a witness statement, and then resigned from the Facility,” the director of nursing told the inspector.

Another nurse was fired after a resident reported that the nurse came into their room and said “I hope you die, asshole.” The nurse told the inspector he never said, “I hope you die,” but he did say to the resident, “Why are you being an asshole to me?”

Experts and advocates were dismayed by the reports.

“This is really a situation which is so degrading and so sadistic,” Mollot said.

The repeated mistreatment isn’t just the fault of “bad apple” nurse aides, but also leaders at the facility, including nursing supervisors and the administrator, Mollot said. 

Dr. Charlene Harrington, a registered nurse and professor emeritus at the University of California San Francisco who has studied long-term care, said these incidents could have been prevented if a supervisor had been on duty that night. 

“They don’t have enough supervision,” she said. “That’s why you have to have registered nurses there.”

Massachusetts nursing homes aren’t required by law to have registered nurses onsite 24/7, though advocates have called for such a rule.

Symptoms like constipation or trouble breathing should have been brought to the attention of a registered nurse, Harrington added.

Sam Brooks, director of public policy for the advocacy group National Consumer Voice for Quality Long-Term Care, pointed out another way understaffing could have contributed to the cruelty.

“It puts a huge burden on the existing staff,” he said. “It’s not an excuse, but you can understand how when you have an overworked, stressed-out staff, these incidents might occur more.”

Scrutiny from regulators

Next Step Healthcare has faced scrutiny from federal regulators for years.

The Centers for Medicare and Medicaid Services has fined the chain over $1.4 million for health violations at multiple facilities, including Fall River Healthcare, since 2022. The agency rates most of the chain’s 15 facilities as below-average, based on health inspections, staffing, and quality metrics.

In 2022, the chain reached a settlement with federal prosecutors to resolve allegations that it illegally discriminated against patients with substance use disorder by turning them away.

Then, in late 2023, the U.S. Department of Labor filed a lawsuit against the chain for allegedly withholding wages from 600 workers. In court filings, the chain denied the department’s allegations that it failed to pay employees for working through their breaks. That case is still open.

In June 2024, Next Step Healthcare reached a settlement with Massachusetts Attorney General Andrea Campbell to resolve allegations that the company deliberately understaffed 14 of its nursing homes, “resulting in resident harm and neglect.”

Next Step agreed to invest $3.25 million into staffing and to “make diligent efforts” to reach a certain staff-to-resident ratio, a measure known as “hours per patient per day,” or HPPD.

The agreed-upon ratio was 3.58 HPPD — a standard that all Massachusetts nursing homes are already required to reach. But 11 of Next Step’s 15 Massachusetts facilities were below that staffing benchmark in September,  Medicare data shows.

Fall River Healthcare had a staffing ratio of 3.40 HPPD. One facility in the chain had a ratio just below 3 HPPD. 

Next Step facilities have improved their staffing ratios since the settlement was reached, and the chain is in compliance with the settlement, according to the Attorney General’s office. The office cited data showing the staff ratio at Fall River Healthcare has improved from 3.32 HPPD in 2024.

Facilities with a long history of problems often take a long time to improve staffing because they have earned a bad reputation among health care workers, making it harder to hire new staff, according to the attorney general’s office.

“Unfortunately, we have very weak enforcement in this country, which is why we have a lot of abuse and neglect in our nursing homes,” Mollot said.

On an average day, about 1,100 people live in the Next Step facilities that have staffing ratios below state standards, according to Medicare data.

Residents hurt by substandard medical care

Residents at Fall River Healthcare didn’t always get the medical treatment they needed, according to inspection reports.

In May 2024, the nursing home was cited for failing to follow doctor’s orders to treat bedsores and other wounds for at least five residents, causing “actual harm,” inspection reports said.

A bedsore on one resident’s foot quadrupled in size and built up necrotic tissue as a result of these failures, but, according to the inspection reports, medical records showed no sign that staff told the resident’s doctor that the wound was worsening. The resident was hospitalized with sepsis related to the wound, according to the inspection. 

Bedsores can develop when a person is confined to a bed and isn’t moved often enough. The pressure on bony areas starves the skin of blood flow, which causes tissue to die and develop into a crater-like wound.

Research shows that these wounds are usually preventable, experts said.

“You shouldn’t have any pressure sores, let alone to let a pressure sore get so bad that it would become necrotic,” said Harrington, the UC San Francisco professor emeritus.

The bedsores are another sign of poor staffing, she said.

The facility also sometimes failed to give medications to residents, according to reports.

Morning medication came late for dozens of residents on one day in February — by as much as 8½ hours —  and some residents didn’t receive their morning medication at all that day, according to inspection reports.

The nurse responsible for medications that morning didn’t finish her rounds, and the nurse who took over at noon had no way of knowing who had received medications already — it was “just chaos,” she told an inspector.

That one day wasn’t an isolated incident, according to the inspection report. 

A resident with epilepsy received their medications more than an hour late on most days in a 28-day period in January 2025, according to medical records reviewed by an inspector. 

The resident’s eyes filled with tears while talking to the inspector. “It’s my life,” they said, according to the inspection report.

‘That doesn’t seem safe’

One nurse said managers at Fall River Healthcare asked her to pass out medications with no supervision before her training was done.

Kristen, who asked to be identified only by her first name, said she was hired last spring, but the facility was so short-staffed for a full month that there weren’t enough employees around to train her. That meant she didn’t know how to work the medical records system she needed to use for patient charts and medication rounds, she said.

“If they were going to throw me onto the floor to work and I wasn’t fully trained, that doesn’t seem safe to me,” she said. “They didn’t know if I knew how to do the job or not.”

The nursing home wasn’t clean, and it was hot because the air conditioning didn’t work, she said. Other staff warned her not to leave her purse on the floor because of cockroaches.

Longtime employees often complained about how much they hated working there, Kristen said.  She said she has worked for nursing homes where residents are treated like family, but Fall River Healthcare’s staff was different.

“It just seemed like they were there basically just to get a paycheck,” she said. “There wasn’t a lot of really good taking care of the residents.”

Workers and supervisors were quitting constantly, Kristen said. The lack of supervision and training led her to quit in June, only a month after she was hired.

“I’m not going to put my license on the line,” she said.

Experts and advocates who reviewed the most serious citations at Fall River Healthcare repeatedly cited understaffing and poor management as the likely culprit. 

Fall River Healthcare has a nurse turnover rate of 47%, meaning that nearly half of its nurses leave in a given year, according to Medicare data. The state average is 42%.

The data shows the nursing home lost two administrators — the facility’s top manager — in one year. Most nursing homes in the state didn’t see any turnover in this role, and just 12% had turnover as high as Fall River Healthcare.

Industry groups say it’s hard to hire and retain staff, despite the industry’s best efforts, because of a shortage of health care workers.

“That’s what they say, but we don’t believe that,” said Brooks, the Consumer Voice advocate. “When you pay proper wages and you invest in staff, there isn’t necessarily a job crisis.”

Brooks said nursing homes with high staffing levels exist in the same communities as nursing homes with low staffing, suggesting that providing good pay, benefits, and training can help attract and retain nurses.

Indeed, dozens of nursing homes throughout Massachusetts had nursing turnover under 33%, data shows.

Residents face indignities

For three weeks in January 2025, staff failed to stop a resident from abusing another resident with racial slurs and stereotypes, inspection reports said.

Resident #105 called their roommate Resident #141 “the N word” and yelled that Resident #141 smelled “like shit,” according to the inspection. The residents were separated, but the abuse went on for weeks after that, the inspection said.

The facility was cited seven times for failing to respond appropriately. Inspectors also cited the facility for having no trauma-informed care plan that reflected Resident #141’s history as a veteran injured in combat and no interventions in place to address Resident #105’s active substance use.

Inspections say Resident #105 returned to the facility intoxicated at 7 p.m. on New Year’s Eve. Yelling with slurred speech, they threatened to punch staff, threw furniture around, and exposed themself until staff called 911 to send the resident to the hospital, according to the inspection. In February, the resident was sent to the hospital for stroke-like symptoms after taking pills from a visitor, according to the reports.

(It’s unknown whether Resident #105 still lives at the facility; records show they were there for short-term rehab.)

Reports from May 2024 document more indignities.

One resident was served breakfast on an overbed tray with the resident’s urinal, containing a “yellow clear fluid,” sitting right next to their cereal, according to another inspection report.

“I don’t know why but I guess I have to keep it there and look at my pee while I eat,” the resident told an inspector.

The resident’s roommate told the inspector that staff always leave the urinal there during meals, saying it was “disgusting” and “the staff just don’t care.” The unit manager told the inspector she was “working on breaking this habit the staff have” of leaving the urinal on the resident’s table with their food.

An inspector watched Resident #106 wait 30 minutes for help using the bathroom, the inspection report said. They had to ask nurses twice to provide this help.

The next day, the inspector found Resident #106 “visibly in distress” waiting for help using the bathroom again. The resident said they thought they already soiled themself.

“Someone came in a while ago, but they don’t believe me,” the resident told the inspector. “They did not even check, they just left.”

The inspector went to get help from a nurse, the report said, but staff didn’t enter Resident #106’s room for another 15 minutes.

Resident #106 told the inspector that they have fallen in the bathroom using it by themself because staff took too long to help. Nurses told the inspector that waiting 15 to 30 minutes to use the bathroom wasn’t acceptable.

‘I won’t get over it’

In August 2024, Sheila Lambert was close to moving her father, Edward Pereira, out of Fall River Healthcare. On a Friday a few days after Lambert discovered the mess in his bathroom, a social worker called her to say a bed might open up at another facility in the area.

Pereira died that weekend.

He fell and hit his head in the middle of the night while trying to use the bathroom by himself, Lambert said. The injury sent Pereira to the hospital, but she said the head injury probably wasn’t what killed him. His prostate cancer was very advanced by that point, she said.

Lambert said she wonders how Fall River Healthcare is still open.

“I won’t get over it, knowing my father had to spend the last few months of his life there,” she said.

Email Grace Ferguson at gferguson@newbedfordlight.org.

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