Federal inspectors found that Resident 65 at Hadley Pointe Nursing Rehab & Care lost 24.5 percent of his body weight between October 2024 and January 2025. His body mass index fell to 15.5, classified as underweight. When inspectors observed him on January 15, the resident was "very thin" with "both sides of his neck sunken in behind his collar bone" and "thin and boney" exposed arms and legs.
The facility's nurse practitioner told inspectors she wished staff had notified her months earlier about the weight loss. "I wished the facility had notified me a couple of months ago that the resident's weight was trending down," she said during the inspection.
Staff documented the resident's significant 7.8 percent weight loss on October 1, 2024, but failed to assess him or implement interventions before he was hospitalized nine days later with a hip fracture. After his readmission on October 14, facility policy required weekly weights, but none were obtained. The resident went unweighed for the entire month of December.
The dietician didn't reassess the resident until October 18, four days after his return from the hospital. When she recommended dietary supplements on that date, the physician didn't order them until six days later. Staff failed to record meal consumption percentages for dozens of meals throughout October, November, and December.
Unit Manager 2 summed up the facility's handling of the case bluntly: "The process is broken. Let's just say that."
Multiple Grooming Failures
Inspectors also found two residents went unshaven for days despite care plans requiring daily grooming assistance.
Resident 59, who has severe cognitive impairment and cannot shave himself, was observed with facial hair on his chin, upper lip, and cheeks for three consecutive days during the inspection. His family member said the resident "has always preferred not to have facial hair" and complained that "shaving has not been getting done as often as it should be."
A nursing assistant who finally shaved the resident on January 15 told inspectors he "should have been shaved days prior because he had significant hair growth on the face, and it appeared he had not been shaved for several days."
Resident 33 faced similar neglect. His healthcare proxy had specifically requested he be shaved before Christmas visitors on December 26, 2024, but staff failed to do so. The resident had visible facial hair "approximately one quarter inch long" when inspectors interviewed him on January 14. When asked about his preference, the resident "ran his hand over his chin and cheeks and said he had more facial hair lately" and that "it was not his preference to have facial hair."
A nursing assistant confirmed that "residents with facial hair remained unshaven for several days" was "a regular occurrence" and that the facility needed to offer grooming assistance because residents "did not always ask to be shaved."
Unit Manager 2 acknowledged that "grooming and shaving had been an ongoing issue with not only Resident 59 and 33, but many other residents who also requiring assistance with shaving."
Missing Physician Visits
Two residents hadn't seen their physician since July 2024, violating federal requirements for alternating 60-day visits between physicians and nurse practitioners.
Residents 65 and 79 were both last seen by their physician on July 17, 2024. Since then, only the nurse practitioner had conducted their routine visits. The nurse practitioner told inspectors she received notification in October 2024 that she could complete all routine visits, but federal regulations require alternating between physicians and nurse practitioners every 60 days.
COVID-19 Testing Lapses
During a COVID-19 outbreak on one nursing unit, the facility failed to test residents every 48 hours as required by state guidelines. After a staff member tested positive on January 10 and another on January 15, residents should have been tested on January 15. The infection preventionist admitted the testing "should have been" completed but wasn't.
Emergency Equipment Covered in Dust
Inspectors found emergency code carts on two nursing units covered with "thick coating of gray dust." The carts contained life-saving equipment including automatic external defibrillators used during medical emergencies. Nurses acknowledged the equipment "should not be covered in gray dust" and "needed to be cleaned."
Laundry Problems Persist Despite Quality Initiative
All 14 residents attending a council meeting said their "major concern was having their personal clothing returned to them after it was sent out to be laundered." One resident said family members "had to repeatedly purchase socks" because items kept disappearing.
The facility had launched a quality improvement project tracking missing clothing complaints, documenting 60 incidents across four quarters. Despite the ongoing project, the administrator admitted she was "unable to evaluate" whether the missing clothing issue had improved and that there was no formal system to track items sent to the contracted laundry company.
Family Member 1 told inspectors he was "tired of buying new clothing every week" for his relative and that facility staff consistently blamed the outside laundry contractor for missing items.
Additional Violations
The facility also failed to:
- Maintain a written transfer agreement with an area hospital until inspectors inquired about it on January 17 - Obtain proper consent for influenza vaccination from a resident's healthcare proxy - Complete bed safety inspections when mattresses were changed - Maintain communication with a dialysis center for a resident requiring three-times-weekly treatment
The inspection covered 19 residents and found violations affecting multiple residents across several areas of care. The facility, located at 20 North Maple Street, operates as the Elaine Center at Hadley.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Hadley Pointe Nursing Rehab & Care from 2025-01-17 including all violations, facility responses, and corrective action plans.