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F0607
D

Failure to Follow Abuse Reporting Policy and Conduct Required Background Checks

Hadley, Massachusetts Survey Completed on 09-16-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement and follow its abuse policy in two key areas. First, when a resident who was cognitively intact and required substantial assistance with activities of daily living reported being left in a soiled incontinence brief for three hours after requesting help from a CNA, the staff member who assisted the resident in writing a complaint did not immediately report the allegation to the Administrator or Director of Nursing as required by facility policy. The Administrator only became aware of the incident three days later when he found the resident's written statement under his door, at which point the incident was reported to the Department of Public Health. Second, the facility did not conduct a required Massachusetts Nurse Aide Registry (NAR) background check for an Activity Assistant upon hire. The personnel file for the Activity Assistant lacked documentation of the NAR check, and the Human Resources representative stated that he was unaware that NAR checks were required for all potential employees, not just nurses and CNAs. The Administrator confirmed that there was no evidence of an NAR check for this employee.

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