Hadley Pointe Nursing Rehab & Care

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

mobility. CNA #1 further said that she believed she could move Resident #1 on her own if he/she helped.

CNA #1 said that during rounds on 08/17/25, before 5:00 A.M. (exact time unknow), she rolled Resident #1

in bed, without assistance from another staff member because she was too busy to get help. CNA #1 said that Resident #1 stopped helping while she was rolling him/her and that she (CNA #1) would have stopped rolling him/her when asked but continued because she did not want to hurt her own back. CNA #1 said she did not mean to hurt Resident #1 during care.Nurse #1 said that when she administered a medication to Resident #1, on 08/17/25 at 5:30 A.M., Resident #1 told her that CNA #1 hurt his/her left leg during care that morning. Nurse #1 said there were no visible injuries, and that Resident #1 complained of mild pain in

the left leg. Nurse #1 said she administered acetaminophen to Resident #1 with good effect.During an

interview on 09/16/25 at 4:30 P.M., the Administrator said that in response to the incidents involving Resident #1 and Resident #2, the Staffing Agency was informed that CNA #1 should no longer be assigned to their Facility. The Administrator further said that all residents deserved to be treated with dignity and respect.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/16/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Hadley Pointe Nursing Rehab & Care

20 North Maple Street Hadley, MA 01035

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Level of Harm - Minimal harm or potential for actual harm

Based 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.

Findings include:Review of the Facility Policy titled Abuse Prohibition, dated as revised 10/24/22, indicated that anyone who witnesses an incident of suspected abuse, neglect, involuntary seclusion, injuries of unknown origin, or misappropriation of patient property is to tell the abuser to stop immediately and report

the incident to his/her supervisor immediately, regardless of what shift worked.Further review of the Policy indicated that potential employees would be screened for a history of abuse, neglect or misappropriation, including checking with the appropriate licensing boards and registries.1) Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 08/18/25, indicated that Resident #3 accused Certified Nurse Aide (CNA )#2 of neglect. The Report indicated that Resident #1 alleged that after he/she asked CNA #2 for incontinence care, he/she waited three hours for assistance.Review of a Handwritten Statement, (written by an unidentified staff member at Resident #3's request) signed and dated by Resident #3 on 08/15/25, indicated that he/she sat in an incontinence brief that was soiled with feces for three hours, despite asking CNA #2 for assistance.Resident #3 was admitted to the Facility in June 2025, diagnoses included depression and unsteadiness on feet. Review of Resident #3's admission Minimum Data Set (MDS) Assessment, dated 07/04/25, indicated Resident #3 was cognitively intact with a score of 15 out of 15 on the Brief Interview for Mental Status. (BIMS, scores indicate: 0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, and 13-15 cognitively intact). Further review of the Assessment indicated Resident #3 required substantial assistance from staff with Activities of Daily Living (ADLs) and mobility.During an interview on 09/16/25 at 11:23 A.M., Resident #3 said he/she did not remember all the details of the incident involving CNA #2 but said he/she asked a CNA (exact name unknown) to write a complaint describing the incident and to give it to the Administrator.

Resident #3 said he/she had the CNA write the statement because his/her own handwriting was atrocious.

During an interview on 09/16/25 at 4:30 P.M., the Administrator said that he was not aware of Resident #3's allegation of neglect involving CNA #2, until he found a Handwritten Statement (that was signed and dated 8/15/25) under his door on 08/18/25 (three days later). The Administrator said the incident was reported to DPH on 08/18/25 when he discovered Resident #3's Statement. The Administrator said he was unable to identify who completed the statement for Resident #3 and left it for him. The Administrator said the expectation was for staff to report any allegations of abuse immediately to their supervisor and/or administration. 2) Review of Activity Assistant #1's personnel file indicated that he was hired on 08/04/25.

Further review of the File indicated that there was no documentation to support that a Massachusetts NAR background check was conducted upon hire.During an interview on 09/16/25 at 4:00 P.M., the Human Resource (HR) Representative said that he was new to his HR role, having started in May 2025. The HR Representative said he had only performed NAR checks on nurses and CNAs upon hire and did not realize

they were required for all potential employees. During an interview on 09/16/25 at 4:30 P.M., the Administrator said there was no documentation to support that an NAR check was conducted on Activity Assistant #1.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/16/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Hadley Pointe Nursing Rehab & Care

20 North Maple Street Hadley, MA 01035

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Based 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.Findings include:Review of the Facility Policy titled Abuse Prohibition, dated as revised 10/24/22, indicated that immediately upon receiving information concerning a report of suspected or alleged abuse, mistreatment or neglect, the Administrator or designee will Report allegations [to the appropriate state and local authorities] involving abuse (physical, verbal, sexual, mental) not later than two hours after the allegation is made.Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated as submitted on 08/17/25 at 10:08 A.M., indicated that Resident #1 alleged that Certified Nurse Aide, (CNA) #1 was rough while providing incontinence care. The Report indicated that CNA #1 took hold of Resident #1's left leg and rolled him/her onto his/her side, which caused pain in his/her left hip. The Report further indicated that when Resident #1 asked CNA #1 to stop, CNA #1 began yelling at him/her. Review of HCFRS indicated a second abuse allegation, involving CNA #1 and Resident #2, was included in the Report submitted on 8/17/25 at 10:08 A.M., and the Department of Public Health (DPH) directed the Facility to resubmit the second incident separately as required. Review of the Report submitted by the Facility via HCFRS, dated as submitted on 08/18/25 at 6:54 P.M., indicated that on 08/17/25 at 5:45 A.M., Resident #2 alleged that Certified Nurse Aide (CNA) #1 directed profanity at him/her during care and that his/her roommate witnessed the incident. Review of a Facility Investigation Summary, dated 08/22/25, indicated the Former DON #1 (hereby referred to as DON #1) received a call at 5:50 A.M., about the incident involving CNA #1 and Resident #1.Review of a Facility Investigation Summary, dated 08/23/25, indicated DON #1 received a call at 7:30 A.M., about the incident involving CNA #1 and Resident #2.During

a telephone interview on 09/17/25 at 12:20 P.M., the Director of Nurses (DON) #1 said that he did not recall

the exact time he was notified of both abuse allegations.During an interview on 09/16/25 at 4:30 P.M., the Administrator said that staff are expected report any allegations of abuse to Administration immediately, and that administration, in turn, must report those allegations to DPH within two hours as required.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/16/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Hadley Pointe Nursing Rehab & Care

20 North Maple Street Hadley, MA 01035

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610

Respond appropriately to all alleged violations.

Level of Harm - Minimal harm or potential for actual harm

Based 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. Findings include:Review of the Facility Policy titled Abuse Prohibition, dated as revised 10/24/22, indicated that anyone who witnesses an incident of suspected abuse, neglect, involuntary seclusion, injuries of unknown origin, or misappropriation of patient property is to tell the abuser to stop immediately and report the incident to his/her supervisor immediately, regardless of what shift worked.The Policy indicated that an initial investigation would be initiated within 24 hours and would be thoroughly documented within the risk management portal and would ensure that documentation of witness interviews is included.Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 08/18/25, indicated that on 08/17/25 at 5:45 A.M., Resident #2 alleged that Certified Nurse Aide (CNA) #1 was directing profanity at him/her during care and that his/her roommate witnessed the incident. Review of the Facility Investigation file indicated there was no documentation to show that the accused CNA (#1) was interviewed about the incident involving Resident #2 on 08/17/25, and/or that a written witness statement was obtained and maintained by the Facility. During

a telephone interview on 09/08/25 at 4:23 P.M., Certified Nurse Aide (CNA) #1 said she worked a double shift at the Facility through a Staffing Agency, beginning on 08/16/25 at 3:00 P.M. and ending on 08/17/25 at 5:30 A.M. CNA #1 said that said that around 5:30 A.M. on 08/17/25, Nurse #1 asked her to complete a written statement regarding an allegation of abuse that had been made by a resident she had on her assignment, and she was directed to leave the Facility. CNA #1 said that later that morning the Agency informed her of a second abuse allegation involving another resident on her assignment. CNA #1 said that although a Police Sergeant contacted her about the second allegation, no one from the Facility reached out for a statement regarding the second allegation.During an interview on 09/16/25 at 08:20 A.M., Nurse #1 said an allegation of abuse involving Resident #1 and CNA #1 was reported to her around 5:30 A.M. on 08/17/25. Nurse #1 said she instructed CNA #1 to complete a witness statement and to leave the Facility, pending investigation. Nurse #1 said that a second allegation of abuse involving CNA #1 was reported at 5:45 A.M., after she (CNA #1) had left the Facility therefore, she was unable to obtain a written statement from CNA #1, about the second allegation. During a telephone interview on 09/17/25 at 12:20 P.M., the Former Director of Nurses (hereby referred to as DON #1) said that he notified the Staffing Agency of the second allegation of abuse involving CNA #1 and asked that she no longer be assigned to the Facility. DON #1 said he did not reach out to CNA #1 for a statement as part of his investigation. During an interview on 09/16/25 at 3:50 P.M., the Current Director of Nurses (DON #2) said there was no documented evidence that a statement was obtained from the accused CNA (CNA #1) regarding the verbal abuse allegation, or that she was interviewed, as required.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/16/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Hadley Pointe Nursing Rehab & Care

20 North Maple Street Hadley, MA 01035

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

member because she was too busy to get help. CNA #1 said that Resident #1 stopped helping while she was rolling him/her and that she (CNA #1) would have stopped rolling him/her when asked but continued because she did not want to hurt her own back. CNA #1 said she did not mean to hurt Resident #1 during care.During an interview on 09/16/25 at 4:30 P.M., the current Director of Nurses (DON) #2 said that CNAs have access to reference the care plan interventions in the electronic medical record where they document.DON #2 said that Resident #1's Care Plan indicated that he/she required assistance from two staff members for bed mobility, and that CNA #1 should not have rolled Resident #1 without assistance from a second staff member.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/16/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Hadley Pointe Nursing Rehab & Care

20 North Maple Street Hadley, MA 01035

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0943 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

Based 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.Findings include: Review of the Facility Policy titled Abuse Prohibition, dated as revised 10/24/22, indicated that abuse prohibition training and reporting obligations would be provided to all employees at orientation and a minimum of annually.Review of Certified Nurse Aide (CNA) #2's personnel file indicated that she was hired on 07/07/24. Further review of the File indicated that there was no documentation to support CNA #2 had received education on abuse during orientation, in accordance with the Facility's Abuse Prohibition Policy.Review of Certified Nurse Aide (CNA) #4's personnel file indicated that she was hired on 08/12/25. Further review of the File indicated that there was no documentation to support CNA #2 had received education on abuse during orientation, in accordance with the Facility's Abuse Prohibition PolicyDuring an interview on 09/16/25 at 4:30 P.M., the Administrator said that he had no documentation to support that CNA #2 and CNA #4 had received education on Abuse Prohibition, in accordance with the Facility's Policy.

Event ID:

Facility ID:

If continuation sheet