Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hartwell Health And Rehabilitation during CMS and state inspections, most recent first.
Improper hand hygiene and glove use in the dish room. A dietary aide handled soiled meal trays and bowls, sent them through the dish machine, and then handled clean bowls and arranged them on a tray while still wearing the same blue plastic gloves. She confirmed she did not remove the gloves or wash her hands before moving from soiled to clean dishes, and the FSM stated staff were expected to remove gloves and wash hands when going from dirty to clean dishes.
A CNA was hired and began orientation and floor work before a satisfactory criminal background check was completed. The facility policy required background and criminal history screening, but the CNA’s GCHECXS later showed an unsatisfactory result related to methamphetamine possession, while HR confirmed the check was not satisfactory until later because documents had to be repeatedly resubmitted.
Failure to Provide Needed Foot Care and Toenail Trimming: A resident with COPD, morbid obesity, lymphedema, repeated falls, CHF, and CKD had dependent ADL needs and requested toenail trimming, but the podiatrist previously declined care because of nail polish. After the polish was removed, the toenails remained long, hard, and jagged, and the LPN responsible for foot care was unsure of the podiatry schedule, lacked the provider agreement, and did not contact the podiatry provider about the resident.
A resident with CHF, CKD, respiratory failure, and dementia had an order for daily weights, but the record showed repeated missed or refused weights and no documentation that the physician was notified about the pattern of refusals or the resident’s weight changes. Staff interviews confirmed the gaps in monitoring, and the resident later developed cough, SOB, and pulmonary edema on CXR, with treatment ordered after the change in condition was identified.
A resident with severe cognitive impairment, dysphagia, hemiplegia, dementia, and poor dentition had loose-leaf chewing tobacco left accessible on the bedside table on multiple observations. The facility policy required smoking materials to be kept in a designated location, but staff interviews confirmed the tobacco was routinely kept at the bedside, and the DON and RNC stated it should be locked at the nurses' station or medication room.
A facility failed to follow infection control practices for a resident on contact precautions with MRSA and failed to prevent cross-contamination for another resident. A CNA entered the MRSA resident’s room without PPE and checked vital signs for both the resident and the roommate, despite posted contact precaution signage. In a separate observation, a CNA handled another resident’s breakfast with bare hands and did not perform hand hygiene. Records showed the first resident had a post-op wound infection with MRSA, while the second resident had severe cognitive impairment and multiple chronic conditions.
Expired insulin pens were found on two medication carts in the facility, with one Humalog pen lacking an open date and a Novolog pen past its discard date. Both pens were removed by the respective LPN and RN, who confirmed the expiration and placed them in a destruction bin. The RN reported the issue to the DON, who stated that expired medications should be discarded per protocol.
The facility failed to maintain clean exhaust fans in six shared bathrooms, leading to a buildup of dust and possible mold. Observations showed thick layers of dust on the fans, and staff interviews revealed inconsistencies in cleaning routines. The Maintenance Supervisor indicated daily cleaning was required, but Environmental Service Aides had varying practices, with some unaware of specific cleaning protocols.
The facility failed to manage elopement risks for two residents with wander guards, lacking proper assessments and documentation. One resident had a history of exit-seeking behavior, while another was preparing to leave the facility, indicating inadequate supervision. Additionally, a resident was found with unauthorized medication at her bedside, without proper assessment or physician's order, highlighting lapses in medication policy adherence.
A resident receiving oxygen therapy did not receive the prescribed flow rate, as observations showed incorrect settings on the oxygen concentrator. The resident, with conditions like heart failure, was at risk due to this discrepancy. Staff interviews revealed a lack of adherence to the physician's order, with the DON aware of the issue but no corrective actions documented.
A resident with COPD and AF was not instructed to rinse her mouth after using a steroid inhaler, as required by facility policy, during medication administration by an LPN. The resident had mildly impaired cognition and required minimal assistance with daily activities. The LPN confirmed the omission, and the DON acknowledged the policy requirement.
A facility failed to accurately document a resident's fall and injury, leading to a deficiency in maintaining medical records. The resident, with multiple diagnoses including a left tibia fracture, experienced a fall that was incorrectly recorded as a right ankle fracture in several documents. Interviews revealed that the facility's process for updating fall status was not followed, highlighting a lapse in adhering to professional standards.
The facility failed to maintain an eyewash station properly, resulting in water flowing from an open pipe onto the floor and staff's feet. The Maintenance Director used a bucket to catch the water, but the Administrator acknowledged the potential slip hazard.
Improper Hand Hygiene and Glove Use in Dish Room
Penalty
Summary
Dietary staff failed to follow hand hygiene and glove-use practices in the dish room while handling soiled and clean dishes. The facility policy titled Food Preparation and Distribution stated that hand washing should occur before putting on gloves and after removing gloves, and that gloves should be changed between tasks such as handling raw meats or ready-to-eat foods and between handling soiled and clean dishes. During observation on 02/07/2026 at 12:35 PM, Dietary Aide EE was washing soiled dishes in the dish room while wearing blue plastic gloves. The dietary aide placed soiled meal trays and six soiled small gray bowls onto a dish rack and sent them through the conveyor-style dish machine. After the items came out clean, she handled the clean small gray bowls and placed them on a large tray with other clean bowls while still wearing the same blue plastic gloves used for the soiled dishes. She continued arranging and organizing the tray of clean bowls without removing the gloves or washing her hands. In interview, Dietary Aide EE confirmed she did not remove her gloves or wash her hands after touching the soiled dishes and before touching the clean dishes. The Food Service Manager stated the aide was assigned to the dirty side of the dish machine and should have removed gloves and washed hands when moving from dirty dishes to clean dishes.
Unsatisfactory Background Check Not Completed Before CNA Began Working
Penalty
Summary
The facility failed to complete and receive a satisfactory background check for one of 11 nursing staff reviewed. Review of the facility policy titled "Abuse Prohibition-Screening, Hiring, And Training Practices" stated that prospective associates must undergo a background and criminal history investigation, and that the center will not employ individuals with an unsatisfactory criminal records check or a finding related to abuse, neglect, mistreatment, or misappropriation of property. Despite this policy, Certified Nursing Assistant (CNA) II was hired with an unsatisfactory background check status and later had a Georgia Criminal History Check System report showing an unsatisfactory determination related to possession of methamphetamine. The employee file review showed CNA II was hired on 12/22/2025 and had clock events from 12/21/2025 to 01/03/2026, including seven days of active check-ins and check-outs. The facility noted that from 12/21/2025 to 12/27/2025, CNA II was in orientation and in-service training and began providing care to residents on the floor on 12/29/2025. During interview, the HR Director stated CNA II was hired on 12/22/2025 and officially began working on the floor on 12/27/2025, and confirmed the GCHEX was not satisfactory until 01/16/2026 because documents had to be repeatedly submitted for review.
Failure to Provide Needed Foot Care and Toenail Trimming
Penalty
Summary
The facility failed to adequately provide ADL care related to foot treatment for one resident, R11, who had diagnoses including COPD, age-related physical debility, morbid obesity, lymphedema, repeated falls, iron deficiency anemia, diastolic CHF, and CKD stage 3b. Her MDS showed a BIMS score of 15 with lower extremity impairment on both sides and dependence for toileting hygiene, showering/bathing, upper body dressing, putting on/taking off footwear, and rolling in bed. Her care plan identified limited mobility and the need for assistance with functional ADLs, with interventions to assist with ADLs as needed and provide the appropriate level of assistance to promote safety. R11 told surveyors that she wanted her toenails trimmed and said the podiatrist had not done so during a prior visit because nail polish was on her toes. She stated the polish had since been removed, but no one had returned to trim the nails. The podiatry record showed that on 12/30/2025 the nails could not be filed because of nail polish, and the podiatry resident visit list showed R11 was seen on that date but not listed or seen on 01/15/2026. The LPN responsible for foot care was unsure of the podiatry schedule, did not have a copy of the podiatry provider agreement, could not explain the refusal of care, and confirmed she did not email the podiatry provider about R11. Surveyors observed that R11’s toenails were long, hard, and jagged after the nail polish had been removed.
Failure to Follow Daily Weight Orders and Report Changes in Condition
Penalty
Summary
The facility failed to follow physician orders for daily weights and failed to contact the physician for a change in condition for a resident with multiple diagnoses including chronic diastolic congestive heart failure, chronic kidney disease, atrial fibrillation, Parkinson’s disease, dementia, and respiratory failure with hypoxia. The resident’s care plan included monitoring vital signs, notifying the physician of changes, and monitoring weight because of heart failure. The physician’s orders included daily weights before breakfast, chest x-rays for shortness of breath and cough, and a short course of furosemide for congestive heart failure. The resident’s record showed multiple missed or undocumented daily weights over time, with repeated gaps in the weight record and several entries marked as refused or not documented. The record also showed a documented weight increase from 149 pounds to 168 pounds, followed by additional fluctuating weights and further missed entries. Staff interviews confirmed that the resident sometimes refused weights, that refusals occurred in patterns, and that there was no documentation that the physician had been contacted about the repeated refusals or the weight pattern. The DON also stated she was not sure whether the physician had been contacted. The resident later developed respiratory symptoms and pulmonary edema. Notes documented decreased participation in therapy, nasal drainage, watery eyes, a congested cough, and a chest x-ray showing central pulmonary vascular congestion with mild cardiogenic pulmonary edema. The resident was treated with Lasix and potassium after the x-ray results were reported. During observation, the resident stated he had a dry cough and that it was hard to breathe. The NP stated she expected physician orders to be followed and wanted to know about refusals so the plan of care could be adjusted, but she also stated the EMR did not prompt her about refusals and she depended on staff to notify her.
Chewing tobacco left at resident bedside
Penalty
Summary
The facility failed to keep the area free from accident hazards for one of three sampled residents, R22, by allowing chewing tobacco to remain at the bedside. The facility policy titled Patient Smoking Guidelines stated that no patient was allowed to possess smoking paraphernalia in their room or elsewhere in the center except in a designated location, and that all smoking materials were to be kept in a designated location and dispensed at smoke break. Despite this, observations on 02/06/2026 and 02/07/2026 showed loose-leaf chewing tobacco accessible on R22's bedside table, including two packages at one observation and one bag at later observations. R22's record showed diagnoses including unspecified sequelae of cerebral infarction, right-sided hemiplegia, dementia, dysphagia, chronic kidney disease stage 4, bilateral hand contractures, anxiety disorder, and poor dentition. The MDS documented severe cognitive impairment, dependence for oral hygiene and other personal care, swallowing problems including holding food in the mouth or cheeks and coughing or choking, and broken or decayed natural teeth. The care plan identified cognitive impairment, behavioral symptoms, tobacco use, and altered nutrition risk, and allowed R22 to keep chewing tobacco and a dip spit cup on the bedside table. Staff interviews confirmed that R22's tobacco products were routinely kept at the bedside, while the DON and RNC stated tobacco products were not to be kept there and should be locked at the nurses' station or medication room.
Infection Control Failures With Contact Precautions and Cross-Contamination
Penalty
Summary
The facility failed to maintain effective infection control practices related to contact precautions for a resident with MRSA and failed to prevent cross-contamination for another resident. The facility’s Infection Prevention Plan and Transmission-Based Precautions policy stated that contact precautions required gown and glove use for interactions involving the resident or the resident’s environment, with PPE donned on room entry and removed before exiting the room. R78’s record showed diagnoses including post-amputation aftercare, diabetes, peripheral vascular disease, and chronic kidney disease, and the care plan documented a post-op surgical wound infection with purulent drainage and MRSA heavy growth. A physician order placed R78 on contact isolation for orthopedic aftercare following surgical amputation. During observation, the door to R78’s room had contact precaution signage posted, but a CNA entered the room without PPE and checked the vital signs of R78 and the roommate before leaving. The CNA confirmed assessing both residents and stated that R78 had a wound/MRSA and that gloves should have been worn. This interaction occurred while the resident was identified as requiring contact isolation, and the CNA did not use the required PPE when entering the room or when providing care in the resident’s environment. The facility also failed to prevent cross-contamination risk for R16. R16’s record showed diagnoses including sequelae of cerebral infarction, hemiplegia, dysphagia, dementia, constipation, and anemia, with a BIMS score of 5 indicating severe cognitive impairment. During breakfast observation, a CNA used bare hands to tear apart R16’s pancakes and did not perform hand hygiene. Although the nurse supervisor later stated that R16 was no longer under contact precautions and that treatment had ended, she also noted that the precaution sign remained on the door and that staff should have clarified the resident’s status. The DON and clinical standard quality nurse stated that staff should use gowns and gloves for enhanced barrier precautions during direct contact care, but the observed care for R16 was provided with bare hands and no hand hygiene.
Expired Insulin Pens Found on Medication Carts
Penalty
Summary
The facility failed to remove expired insulin pens from two of the three medication carts observed, which could potentially lead to the administration of expired medications to residents. During an observation, a Humalog insulin pen with a discard date of 10/21/2024 was found on a medication cart managed by an LPN. The pen did not have an identifiable open date, and the LPN confirmed the expiration and removed the pen, placing it in a destruction bin. Another observation revealed a Novolog insulin pen on a different medication cart, managed by an RN, with an open date of 9/23/2024 and a discard date of 10/21/2024. The RN confirmed the expiration and removed the pen, also placing it in a destruction bin. The RN stated that this issue would be reported to the Director of Nursing (DON), who later confirmed that all expired medications should be removed and discarded according to the manufacturer's instructions or facility policy.
Failure to Maintain Clean Exhaust Fans in Shared Bathrooms
Penalty
Summary
The facility failed to maintain clean exhaust fans in six shared bathrooms out of 35, which could compromise the hygiene and safety of the shared bathroom environments. Observations revealed that the exhaust fans in several shared bathrooms were covered with a thick layer of white, fuzzy substance, indicating a significant buildup of dust and possible mold. The facility's policy on housekeeping intended to maintain a clean and sanitary environment, but the guidelines were not consistently followed, as evidenced by the unclean exhaust fans. Interviews with staff revealed inconsistencies in the cleaning routines and awareness of the facility's cleaning protocols. The Maintenance Supervisor noted that exhaust fans should be cleaned daily, but the Environmental Service Aides (ESAs) had varying practices, with one dusting every two weeks and another checking twice a week without specific knowledge of the cleaning frequency. The Environmental Service Supervisor confirmed that ESAs were expected to inspect the exhaust fans daily and clean them approximately three times a week, but acknowledged that some aides, particularly newer staff, required frequent reminders about their tasks.
Deficiencies in Elopement Risk Management and Medication Administration
Penalty
Summary
The facility failed to properly assess and manage the elopement risk for two residents, R54 and R68, who were equipped with wander guards. R54, diagnosed with Alzheimer's disease and dementia, had a history of exit-seeking behavior and had left the property twice on a previous occasion. Despite this, there were no physician orders for behavior monitoring, wander guard use, or skin checks under the wander guard bracelet. The care plan indicated a moderate risk for elopement, but the necessary interventions and documentation were not adequately implemented. Similarly, R68, who was admitted with cognitive impairments and a history of delusions and behavioral symptoms, was also at risk for elopement. The resident's care plan noted the risk due to confusion and frequent requests to go home, yet there were no orders for behavior monitoring or skin checks related to the wander guard. Observations revealed that R68 was preparing to leave the facility, indicating a lack of effective supervision and intervention to prevent potential elopement. Additionally, the facility failed to assess R32 for self-administration of medication properly. R32, with a history of dementia and cerebrovascular accident, was found with an unauthorized topical analgesic rub at her bedside. The resident was unable to demonstrate the necessary understanding and skills for self-administration, and there was no physician's order for the medication. Despite staff awareness of the ointment's presence, it was not addressed until observed by a surveyor, highlighting a lapse in adherence to the facility's medication policies.
Oxygen Therapy Administration Deficiency
Penalty
Summary
The facility failed to administer oxygen therapy to a resident, R33, in accordance with the physician's order, which specified a flow rate of 2 liters per minute (LPM) via nasal cannula as needed. Observations revealed that the oxygen concentrator flow rate was set at 2.5 LPM and 1.75 LPM on different occasions, deviating from the prescribed rate. The resident, who was admitted with conditions including paroxysmal atrial fibrillation and heart failure, was at risk of respiratory complications due to this discrepancy. The facility's policy on oxygen therapy intended to ensure optimal oxygenation was not adhered to, as evidenced by the incorrect flow rates. Interviews with staff, including an LPN and the DON, confirmed that the oxygen flow rates were not consistently set as ordered. The LPN admitted to not checking the flow rate during her shift, while the DON acknowledged awareness of the issue, noting that it was a common problem and had been discussed in meetings. The DON also mentioned that the corporate RRT had previously identified the issue and recommended contacting the physician to adjust the order and conducting self-audits to ensure compliance. Despite these recommendations, there was no documentation of staff education or audits being conducted prior to the survey.
Failure to Instruct Resident on Proper Inhaler Use
Penalty
Summary
The facility failed to properly administer an oral steroid inhaler to a resident, identified as R6, during medication administration. The facility's policy on Oral Inhalation and Nebulizer Administration requires that after using a steroid inhaler, the patient should thoroughly rinse their mouth with water and spit it out to minimize the risk of oral pharyngeal candidiasis (thrush). However, during an observation on October 23, 2024, it was noted that the Licensed Practical Nurse (LPN) administering the medication did not instruct or educate R6 to rinse her mouth after using the inhaler. R6, who was admitted with chronic obstructive pulmonary disease (COPD), atrial fibrillation (AF), and peripheral vascular disease (PVD), had a physician's order for fluticasone furoate/vilanterol trifenatate inhaler to be administered twice daily. The resident had mildly impaired cognition with a Brief Interview for Mental Status (BIMS) score of eight and required minimal assistance with activities of daily living due to lower body weakness. During an interview, the LPN confirmed the omission, and the Director of Nursing acknowledged that inhalers should be administered according to physician's orders and facility policy.
Inaccurate Documentation of Resident Fall and Injury
Penalty
Summary
The facility failed to maintain accurately documented resident records in accordance with accepted professional standards and practices regarding falls for one resident, identified as R32. The deficiency was identified through observation, record review, resident and staff interviews, and a review of the facility's policies on Fall Management and Documentation in the Medical Record. The facility's policy requires that each resident's risk for falls be evaluated by the interdisciplinary team, with a plan of care developed and implemented based on this evaluation. However, the facility did not adhere to these standards, as evidenced by the inaccurate documentation of R32's fall and subsequent injury. R32 was admitted to the facility with multiple diagnoses, including a displaced fracture of the medial malleolus of the left tibia, unsteadiness on feet, and unspecified dementia. The resident's quarterly Minimum Data Set indicated a fall with major injury since admission. Despite this, the facility's incident report fall list documented a fall on 8/2/2024 with no apparent injury, contradicting the nurse's notes that indicated a probable fracture of the medial malleolus. The facility incorrectly recorded the fracture as being on the right ankle in multiple documents, including the Event Follow-Up and Therapy Referral, despite the diagnosis clearly indicating a left ankle fracture. Interviews with the Director of Nursing and the Administrator revealed that the facility's process for updating the status of falls was not followed. The Director of Nursing acknowledged that the charting should have been updated to reflect a fall with major injury and that it was the responsibility of the first nurse noting the fall to change the status. The Administrator emphasized the clinical team's responsibility to ensure accurate and comprehensive documentation. The failure to accurately document the resident's fall and injury status represents a deficiency in maintaining medical records according to professional standards.
Eyewash Station Maintenance Deficiency
Penalty
Summary
The facility failed to maintain an eyewash station in a safe and functional manner, as observed during a survey. Specifically, water flowed from an open pipe below the eyewash station onto the floor and onto the feet of staff using the sink. This issue was identified during a tour of the laundry department, where water was seen flowing from under the eyewash station onto the feet of the surveyor and a Laundry Aide. The Laundry Aide confirmed that the pipe under the eyewash station was always open, causing water to flow onto the floor whenever the station was used. The Maintenance Director acknowledged that the open pipe had been present since before his tenure at the facility, which began five years ago. He stated that he checked the eyewash station monthly and used a bucket to catch the water to prevent it from flowing onto the floor. However, he believed that as long as the eyewash station was operational, it was sufficient, despite the potential hazard. The Administrator expressed that her expectation was for the water to drain properly and not spill onto the floor, as the current situation posed a slip and fall hazard.
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Illustrative
What surveyors actually found near you
We read the 41 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Hartwell
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hart Care Center | 1.2 mi | ★★★★★ | 0 | 0 |
| Brown Health And Rehabilitation | 11.1 mi | ★★★★★ | 7 | 0 |
| Iva Post-acute | 15.8 mi | ★★★★★ | 5 | 0 |
| Comer Health And Rehabilitation | 17.1 mi | ★★★★★ | 4 | 0 |
| Pruitthealth - Spring Valley | 17.2 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.