Hadley Pointe Nursing Rehab & Care

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that care and treatment consistent with professional standards of practice for Congestive Heart Failure (CHF - a condition in which the heart is unable to pump blood effectively, leading to fluid buildup in the lungs and other body parts) was provided for one Resident (#1) out of a total sample of 19 residents. Specifically, the facility failed to obtain ordered weekly weights, failed to conduct respiratory and fluid status assessments consistent with the facility's own Heart Failure Protocol and Physician orders, and failed to notify the Nurse Practitioner (NP) when ordered weights were not obtained for Resident #1, a Resident admitted in March 2026 with a known diagnosis of CHF - resulting in an undetected 19.6 lb. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that sufficient nursing staff were available to provide care and services to attain the highest practicable physical, mental, and psychosocial well-being of each resident, in accordance with the facility assessment. Specifically, the facility failed to ensure that sufficient Certified Nurse Aides (CNAs) were available to provide personal care and services timely to meet the needs of the facility residents, the facility also failed to ensure that call lights were answered timely, and that CNAs were scheduled based on the acuity level of residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain current employee records to ensure that licensed nurses and other personnel have demonstrated the knowledge, competencies, and skill sets to provide care and respond to each residents' plan of care for one out of five licensed nursing staff employee files reviewed. Specifically, the facility failed to provide education and assess for nursing staff competency of Congestive Heart Failure (CHF) protocol initiated on 11/17/25, resulting in non-implementation of the CHF protocol for Resident #1 resulting in a 19.6 lb. (pound) weight gain requiring pharmacological intervention.

Inspectors wroteBased on records reviewed and interviews, the facility failed to ensure the newly hired employees' records contained evidence of the 2025 - 2026 COVID-19 vaccination for four employees (CNA #6, Nurse #4, Nurse #5, and CNA #7) out of five newly hired employees, and that five Residents (#65, #74, #7,#4 and #94) out of five residents reviewed for vaccinations, contained evidence that the 2025-2026 COVID-19 vaccination had been offered, received or declined, placing the staff and residents at increased risk of becoming infected with the Coronavirus disease (COVID-19 - infection caused by the SARS-CoV-2 virus). [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to implement the facility's Abuse Prohibition policy and conduct an investigation for one Resident (#55), out of a total sample of 19 residents, who was observed to have an injury of unknown source. Specifically, for Resident #55, the facility failed to implement their Abuse policy related to notification, reporting, protection, and investigating a suspicious injury of swelling and bruising to the Resident's right face and right eye that the cause was not directly observed, when staff identified the injury on 4/6/26 and did not initiate an investigation until 4/17/26, delaying identification whether abuse to the Resident was occurring or has occurred, and placing him/her at risk of further abuse and injury.

Inspectors wroteBased on observations, interviews and record review, the facility failed to report an injury of unknown origin within the two (2) hour requirement for one Resident (#55), out of a total sample of 19 residents. Specifically, for Resident #55, the facility failed to report the injury of unknown origin within two hours as required to the Massachusetts Department of Public Health (MA DPH) when staff observed swelling and subsequent bruising to the Resident's right eye and face on 4/6/26, and staff were unable to identify the source of the facial injury.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a thorough investigation was completed when an injury of unknown source was observed for one Resident (#55), out of a total sample of 19 residents. Specifically, for Resident #55, the facility failed to investigate the cause of swelling and subsequent bruising to the Resident's right face and around the right eye observed on 4/6/26, when staff were unable to identify an event that caused the facial injury, and failed to investigate the facial injury until 4/17/26 (11 days later).

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a person-centered care plan for Congestive Heart Failure (CHF - when the heart is unable to pump blood effectively, leading to fluid buildup in the lungs and other body parts) for one Resident (#1) out of a total sample of 19 residents. Specifically, for Resident #1, the facility failed to appropriately care plan for and implement person-centered CHF assessment and monitoring when the Resident was admitted with a diagnosis of CHF, resulting in an unidentified 19.6 lb.(pound) weight gain and the Resident requiring further pharmacological interventions.

Inspectors wroteBased on interview, and record review, the facility failed to offer Pneumococcal and Influenza immunizations to two Residents (#65 and #4), of five applicable residents reviewed for pneumococcal and influenza immunizations, out of a total sample of 19 residents. Specifically, the facility failed to ensure that: Resident #65 was offered the updated Pneumococcal and Influenza vaccines when he/she was identified to be at high risk for pneumococcal and influenza infection complications due to diagnoses of Chronic Respiratory Failure and Chronic Obstructive Pulmonary Disease (COPD) and neither vaccine had been identified as being medically contraindicated for the Resident. Resident #4 was offered the annual Influenza vaccination when he/she had previously consented and received the Influenza vaccine in 2024.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #2), who was severely cognitively impaired, and was transferred to the hospital Emergency Department (ED) for an evaluation after hitting a staff member, the facility failed to ensure Resident #2 was allowed to return to the Facility once cleared by the hospital, and considered him/her discharged at the time of transfer.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #2), the facility failed to ensure they notified the resident and the resident's representative(s) of the intent to transfer and/or intent to discharge and the reasons for the move in writing, and failed to send a copy of the discharge notice to a representative of the Office of the State Long-Term Care Ombudsman, as required.

Inspectors wroteBased on observations (which included taking photographs), interviews and records reviewed, for one of two resident units, the Facility failed to ensure it provided a safe, clean, comfortable and homelike environment for their residents, when there were visible signs of unclean conditions on bathroom floors and PTAC Units (packaged terminal air conditioners, which are self-contained all-in-one heating and cooling units installed through a wall), located in resident rooms were heavily coated in dust, these conditions did not support that a homelike environment was being provided and/or maintained for residents.

Inspectors wroteBased on records reviewed and interviews, for two of four sampled residents (Resident #1 and Resident #2) who were both alert and oriented and dependent on staff for care, the Facility failed to ensure they were both treated in a dignified and respectful manner, when both residents reported that during the overnight shift on 08/17/25, that Certified Nurse Aide (CNA) #1 was abrupt, rude, did not respect their wishes and treated them in an undignified and disrespectful manner.

Inspectors wroteBased on records reviewed and interviews, for one of four residents (Resident #3) who reported a complaint about being neglected to staff member and requested that the staff member write and submit a written complaint on his/her behalf, the Facility failed to ensure that staff implemented and followed their abuse policy, 1) related to the need to immediately report an allegation of abuse to the Administrator and/or Director of Nurses, and 2) for one of four sampled employee files (Activity Assistant #1), the Facility failed to ensure that a Massachusetts Nurse Aide Registry (NAR) background check was conducted upon hire.

Inspectors wroteBased on records reviewed and interviews, for two of three sampled residents (Resident #1 and Resident #2), the Facility failed to ensure that after the Director of Nurses (DON) #1 was made aware on 08/17/25 at 5:50 A.M., of allegations of abuse made by both of these residents, against Certified Nurse Aide #1, that the allegations were reported to the Department of Public Health (DPH) within two hours as required.

Inspectors wroteBased on records reviewed and interviews, after being made aware on 8/17/25, of two separate allegations of resident abuse (the first by Resident #2 and the second a little later that same morning by Resident #1) by the same accused staff member (Certified Nurse Aide #1), the Facility failed to ensure that after being made aware of the second allegation, that they obtained and maintained evidence that a thorough investigation was completed, including but not limited to obtaining the accused staff member witness statement and/or an interview about the second allegation.

Inspectors wroteBased on records reviewed and interviews, for one of four sampled residents (Resident #1), who had limited movement in his/her left leg and required assistance from two staff members when turning and repositioning in bed, the Facility failed to ensure staff consistently implemented and followed his/her care plan interventions related to bed mobility, when on 08/17/25, during the overnight shift, Certified Nurse Aide (CNA) #1 turned and repositioned Resident #1 without another staff member present to assist her, which caused him/her to experience pain.

Inspectors wroteBased on records reviewed and interviews, for two of four sampled employee personnel files (Certified Nurse Aide, (CNA) #2 and CNA #4), the Facility failed to ensure CNA #2 and CNA #4 received training upon orientation that included the prohibition of all forms of abuse, neglect, exploitation and misappropriation of resident property as required by Federal Regulations, and in accordance with Facility Policy.

Inspectors wroteBased on record review and interviews, for one of three sampled residents (Resident #3), who required medication to treat hypotension (low blood pressure) and had a Physician's order to hold (not administer) the medication for a systolic blood pressure (SBP-top number, represents the pressure in arteries when the heart contracts) greater than 115, the Facility failed to ensure the resident was free from significant medication errors when he/she was administered the medication outside of the prescribed parameter, placing him/her at risk for high blood pressure.

Inspectors wroteBased on records reviewed and interviews for two of three sampled residents (Resident #1 and Resident #2) who although they were cognitively impaired, were able to make themselves understood by staff, the Facility failed to ensure they were free from physical abuse, in the form of unwanted and inappropriate physical contact by a contracted employee (consulting Podiatrist). On 01/02/25, both residents reported that the Podiatrist had touched them in a sexually inappropriate manner and their recounting of the incidents to facility administrative staff and the police remained consistent. Both Resident #1 and Resident #2 reported being shocked after the incidents occurred. [...]

Inspectors wroteBased on records reviewed and interviews, for one of one sampled employee/contracted employee files (consultant Podiatrist) the Facility failed to ensure they developed and implemented Abuse policies that included prescreening and training for prospective consultants, contractors, volunteers, caregivers and students, When a Massachusetts Nurse Aide Registry (NAR) check was not conducted on the Podiatrist as required, prior to providing services at the Facility, and there was no evidence he received annual abuse prohibition training.

Inspectors wroteBased on records reviewed and interviews, for two of three sampled residents (Resident #1 and Resident #2), the Facility failed to ensure that after the Director of Nurses (DON) was made aware on 01/02/25, of allegations of sexual abuse made by both of these residents, against the Podiatrist, that the allegations were reported to the Department of Public Health (DPH) within two hours as required, when they were reported to DPH over four hours later.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the Physician/Nurse Practitioner (NP) of changes in condition for two Residents (#65 and #85) out of a total sample of 19 residents. Specifically: 1. For Resident #65, facility staff failed to: -notify the Physician/NP timely of significant weight loss which resulted in delayed treatment and monitoring of the Resident, and continued significant weight loss. -notify the Resident's Legal Guardian of a change in treatment relative to significant weight loss prior to initiating medication treatment which required the Guardian's consent. 2. For Resident #85, facility staff failed to: -notify the Physician/NP of significant weight loss identified with weekly weights, resulting in inadequate treatment and monitoring of the Resident's nutritional status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain acceptable parameters of nutritional status for two Residents (#65 and #85) out of a total sample of 19 total residents. Specifically, the facility failed to: 1. For Resident #65, A.-address significant weight loss and implement effective interventions when the Resident was identified to have greater than 7.5 percent (%) weight loss prior to a hospitalization. -adhere to Physician orders for monthly weight monitoring. B.-implement and monitor weekly weights as required after the Resident was hospitalized and re-admitted to the facility. -implement and monitor dietary interventions timely when dietary supplements, additional nourishment, and weekly weights were recommended. -adequately monitor meal and dietary supplement intakes after significant weight loss was identified by facility staff. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide evidence of a written transfer agreement in effect with a hospital approved for participation under the Medicare and Medicaid Programs. Specifically, the facility failed to provide a written transfer agreement between the facility and the identified area hospital that would ensure timely and appropriate hospital admissions and appropriate care and services for the facility residents.

Inspectors wroteBased on record review and interview, the facility failed to resolve a grievance timely for one Resident (#32) out of a total sample of 19 residents. Specifically, for Resident #32, the facility failed to ensure that reported grievances by the Resident's family regarding missing clothing was documented and the grievance process intiatied to resolve the grievance within a reasonable time period.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two Residents (#59 and #33) out of a total sample of 19 residents, were provided assistance with personal hygiene. Specifically, the facility failed to ensure Resident #59 and Resident #33 were offered and/or provided with grooming assistance when the Resident required the assistance of staff for grooming activities.

Inspectors wroteBased on interview, and record review, the facility failed to provide Physician visits at the required frequency for two Residents (#65 and #79) for an applicable sample of four residents, out of a total sample of 19 residents. Specifically, the facility failed to provide alternating routine 60-day visits between the Physician and the Nurse Practitioner (NP) for Resident's #65 and #79, resulting in both Residents not being seen by the Physician since July 2024.

Inspectors wroteBased on interview, and record review, the facility failed to evaluate and revise performance activities for a Quality Improvement Project (QAPI) and Performance Improvement Plan (PIP) when it was identified that residents were consistently missing clothing items after clothing was sent to an outside contracted company to be laundered. Specifically, the facility failed to ensure that an effective QAPI system was maintained to analyze the cause for the identified concern, demonstrate changes implemented as part of the PIP, monitor performance, and obtain feedback from residents and representatives relative to the residents concerns of frequently missing clothing items from the contracted laundry company.

Inspectors wroteBased on observation, and interview, the facility failed to adhere to infection control practices and standards increasing the risk of contamination and spread of infection for residents in the facility. Specifically, the facility failed to: 1. conduct testing of residents for COVID-19 infection, every forty-eight hours as required, when the [NAME] Nursing Unit was experiencing an outbreak of COVID-19 infections. 2. maintain the facility code carts (mobile carts containing life saving equipment used during an emergency) in a clean and sanitary manner.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two Residents (#59 and #85), out of a total sample of 19 residents, were provided with a dignified dining experience. Specifically, the facility failed to: 1. Provide Resident #85 timely assistance with feeding, after leaving a tray of food in front of the Resident and out of reach of the Resident, which resulted in an undignified dining experience. 2. Provide Resident #59 with an uninterrupted meal, when staff removed the Resident from the meal to provide wound care and treatment, which resulted in the Resident missing a meal.

Inspectors wroteBased on interview, and record review, the facility failed to uphold resident rights for one Resident (#65), out of a total sample of 19 residents, relative to rights exercised by the Resident's Representative. Specifically, the facility failed to provide Resident #65's Representative with the right to make an informed decision relative to the administration of a new medication (Remeron [Mirtazapine]- antidepressant medication requiring informed consent for administration) when: -The Resident had been deemed incapacitated by the Court. -The Resident had a court appointed Legal Guardian. -The facility initiated administration of Mirtazapine to the Resident without consent from the Resident's Legal Guardian.

Inspectors wroteBased on observation, and interview, the facility failed to provide a clean and homelike environment for two Residents (#3, and #32) out of a total sample of 19 residents. Specifically, the facility failed to: 1. for Resident #3, ensure that personal clothing was kept safe from loss when clothing items was consistently lost and/or not delivered from laundry services back to the Resident. 2. for Resident #32, ensure that personal clothing was returned to the Resident after being laundered by a facility contractor to mitigate the Resident's family needing to frequently purchase and replace his/her clothing.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that Significant Change in Minimum Data Set (MDS) Assessments (SCSA) were completed for one Resident (#59), out of a total sample of 19 residents. Specifically, the facility failed to ensure a SCSA was completed when the Resident #59 experienced a decline in activities of daily living (ADLs) and skin condition.

Inspectors wroteBased on interview and record review, the facility failed to complete a Level I Preadmission Screening and Resident Review (PASRR) for one Resident (#58) out of a total sample of 19 residents. Specifically, the facility failed to completed a Level I PASRR Screening for Resident #58 in a timely manner which resulted in the Resident's admission to the facility without determination whether the Resident screened positive for intellectual disability (ID)/developmental disability (DD) or serious mental illness (SMI) requiring further evaluation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to review and revise the care plan for one Resident (#65), with the participation of the Resident's Representative, following the completion of one comprehensive assessment. Specifically, facility staff failed to review and revise the care plan when Resident #65 sustained a fall with fracture, experienced a significant change in condition, and a comprehensive assessment for significant change in status (SCSA) was completed.

Inspectors wroteBased on record review, and interview, the facility failed to provide care and services consistent with professional standards of practice for one Resident (#49) for one applicable resident, out of a total sample of 19 residents, who required renal dialysis (a procedure to remove waste products and excess fluid from the body when the kidneys stop functioning properly). Specifically, the facility failed to communicate and maintain ongoing documentation with the dialysis center to ensure that the dialysis center and facility received the most current information pertaining to Resident #49.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that an Influenza (Flu) vaccine was administered to one Resident (#49), out of five applicable residents, out of a total sample of 19 residents. Specifically, the facility failed to obtain consent and/or provide education to Resident #49's Health Care Proxy (HCP), when the Resident's HCP was invoked (evaluation of capacity by a Physician that a resident is unable to make medical decisions).

Inspectors wroteBased on observation, record review, and interview, the facility failed to complete an inspection of the bed rails, to identify areas of possible entrapment for one Resident (#292) out of a total sample of 19 residents. Specifically, for Resident #292, the facility failed to complete a new assessment of the bed, side rails and mattress in active use for potential entrapment when the bed mattress was changed from the previously assessed mattress, placing the Resident who had limited mobility and utilized bilateral side rails, at risk for possible entrapment.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who on 11/14/24, was found with a dressing on his/her right heel, dated 11/12/24, which concealed a suspected deep tissue injury (DTI) , the Facility failed to ensure he/she was provided with nursing care and treatment that met professional standards of quality, when there was no nursing documentation to support when the wound was initially found, who applied the dressing on 11/12/24, and what if any, treatment orders were obtained from the provider.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who was assessed by nursing as being at risk for falls, with interventions for safety that included the assistance of one staff member with toileting, transfers and mobility, the Facility failed to ensure he/she was provided with an adequate level of staff supervision to maintain his/her safety, when on 06/26/24, Certified Nurse Aide (CNA) #1 left Resident #1 unsupervised and unattended standing with his/her walker in the bathroom, Resident #1 fell backwards to the floor, complained of pain, and was transferred to the Hospital Emergency Department where he/she was diagnosed with a fractured left scapula (shoulder blade), and was also noted to have a right elbow skin tear.

Inspectors wroteBased on interview, policy review, and record review the facility failed to ensure a flow diagram was created identifying the areas at risk for Legionella (a bacteria that can cause a serious type of Pneumonia called Legionnaires' Disease that is often found growing in building water systems and other areas that remain continually wet) growth and demonstrate controls measures identified by the facility were checked per facility policy to reduce the risk of Legionella growth.

Inspectors wroteBased on interview and records reviewed for one Resident (#52) out of a total sample of three residents, the facility failed to ensure that a Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNFABN - notice issued to inform a resident and/or resident representative of his/her financial liability to the facility when he/she transitioned off Medicare benefits and remains in the facility) was issued to Resident #52 .

Inspectors wroteBased on record review and interviews, the facility failed to develop a baseline care plan relative to falls within 48 hours of admission for one Resident (#75) out of a total sample of 19 residents.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure that staff stored, labeled and dated food used for resident consumption, in accordance with professional standards for food safety within the main kitchen and on one unit kitchenette ([NAME] Unit) out of two unit kitchenettes observed.

Inspectors wroteBased on record review and interviews, the facility failed to maintain accurate medical records for one Resident (#10) out of a total sample of 19 residents. Specifically, the facility failed to ensure that accurate information relative to Advanced Directives were documented and consistent across all active medical records for the Resident.

Inspectors wroteBased on record review and interviews, the facility failed to maintain a communication process relative to Hospice services for one Resident (#44) out of a total sample of 19 residents. Specifically, for Resident #44 the facility failed to maintain documented communication that was readily accessible to all staff and providers, between the Hospice agency and the facility.