The Director of Nurses at Hadley Pointe Nursing Rehab & Care learned of the first abuse allegation at 5:50 a.m. on August 17. The facility didn't submit its report to the Department of Public Health until 10:08 a.m. that same day.
Resident #1 told staff that Certified Nurse Aide #1 had been rough during incontinence care. The aide grabbed the resident's left leg and rolled them onto their side, causing pain in their left hip. When the resident asked the aide to stop, the aide began yelling at them.
The second incident involved the same aide and another resident. At 5:45 a.m. on August 17, Resident #2 alleged that CNA #1 directed profanity at them during care. The resident's roommate witnessed the incident.
The Director of Nurses received a call about the second incident at 7:30 a.m., according to facility investigation summaries. But the facility's own policy, revised in October 2022, requires reporting abuse allegations "not later than two hours after the allegation is made."
During a telephone interview on September 17, the Director of Nurses said he did not recall the exact time he was notified of both abuse allegations. The administrator told inspectors that staff are expected to report any allegations of abuse to administration immediately, and that administration must report those allegations to the Department of Public Health within two hours.
The state directed the facility to resubmit the second incident as a separate report. That second report wasn't filed until 6:54 p.m. on August 18 — more than 35 hours after the incident occurred.
Federal inspectors found the facility failed to meet reporting requirements for both residents during their September 16 complaint investigation. The violation carried a determination of minimal harm or potential for actual harm, affecting few residents.
The facility's abuse prohibition policy states that immediately upon receiving information concerning suspected or alleged abuse, the administrator or designee will report allegations to appropriate state and local authorities within the two-hour window. The policy covers physical, verbal, sexual, and mental abuse.
Both incidents involved the same certified nurse aide during morning care routines. In the first case, the resident experienced physical pain from the aide's handling. In the second, profanity was directed at a resident in front of their roommate.
The facility submitted both incidents through the Health Care Facility Reporting System, but the timing violated state requirements. The first report came over four hours after the Director of Nurses was notified. The second report came over a day late.
State regulations require immediate reporting to protect residents and ensure proper investigation of abuse allegations. The two-hour window allows authorities to respond quickly and preserve evidence while incidents remain fresh.
The Director of Nurses who received both calls was identified in facility documents as "Former DON #1," suggesting staffing changes occurred between the incidents in August and the inspection in September. Investigation summaries from August 22 and August 23 documented the timeline of notifications.
Resident #1's allegation involved both physical roughness and verbal abuse. The aide's grabbing and rolling motion caused hip pain, and the yelling continued after the resident asked for gentler treatment. Resident #2's allegation focused on profanity during care, with a roommate present to witness the verbal abuse.
The facility's investigation summaries show administrators documented the incidents but failed to meet state reporting deadlines. The first call to the Director of Nurses came at 5:50 a.m., but the state report wasn't filed until 10:08 a.m. The second call came at 7:30 a.m. on August 17, but that report didn't reach the state until the following evening.
During the September inspection, the administrator acknowledged the two-hour reporting requirement and confirmed that staff are expected to report abuse allegations immediately to administration. The administrator's statement suggested awareness of proper procedures, making the delayed reporting more significant.
The Health Care Facility Reporting System tracks when facilities submit abuse allegations to state authorities. The timestamps show the facility missed deadlines for both incidents involving CNA #1. State authorities had to direct the facility to resubmit the second incident separately, adding further delay.
Both residents made their allegations on the same day, August 17, within two hours of each other. Resident #2's incident occurred at 5:45 a.m., and Resident #1's allegation was reported to the Director of Nurses at 5:50 a.m. The proximity in timing suggests a pattern of behavior during the aide's morning shift.
The inspection found the facility failed to ensure timely reporting after the Director of Nurses was made aware of both allegations. Federal regulations require facilities to report suspected abuse, neglect, or theft to proper authorities and report investigation results.
The facility's policy revision from October 2022 clearly outlined the two-hour reporting requirement for abuse allegations. The policy covered the exact type of incidents that occurred in August 2025, leaving no ambiguity about reporting deadlines.
Resident #1 experienced physical pain from the aide's rough handling during personal care. The hip pain resulted from being grabbed and rolled onto their side. When they asked the aide to stop the rough treatment, the aide responded with yelling rather than adjusting their approach.
The roommate who witnessed Resident #2's incident provides corroboration for the profanity allegation. Having a witness present during the verbal abuse strengthens the resident's account and demonstrates the aide's behavior occurred in front of others.
Investigation summaries from late August show the facility documented both incidents but struggled with proper reporting procedures. The summaries were dated August 22 and August 23, suggesting the facility's internal investigation continued even after the delayed state reports.
The former Director of Nurses' inability to recall exact notification times during the September interview raises questions about record-keeping and attention to reporting requirements. Clear documentation of notification times is essential for meeting state deadlines.
Both residents faced abuse from the same aide during vulnerable moments of personal care. The incidents occurred during incontinence care and other personal assistance, when residents depend on aides for dignity and comfort rather than rough treatment and verbal abuse.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Hadley Pointe Nursing Rehab & Care from 2025-09-16 including all violations, facility responses, and corrective action plans.
Additional Resources
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