Hadley Pointe Nursing Rehab & Care

In the surveyor’s words

From the most serious findings on record at Hadley Pointe Nursing Rehab & Care, in the surveyor’s own words.

• Actual harm, isolatedF684Apr 22, 2026

  Based 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… […]

• Actual harm, isolatedF600Jan 22, 2025

  Based 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. […]

• Actual harm, isolatedF580Jan 17, 2025

  Based 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. […]

• Actual harm, isolatedF692Jan 17, 2025

  Based 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 readmitted to the facility. -implement and monitor dietary interventions timely when dietary supplements, additional nourishment, and weekly weights were recommended. […]

• Actual harm, isolatedF689Aug 22, 2024

  Based 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. […]