Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
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 Sanfield Rehab & Living Center during CMS and state inspections, most recent first.
The facility failed to complete significant change MDS assessments within the required timeframe for two residents after hospice admission. One resident’s MDS was initiated but left incomplete, and another resident’s MDS was signed by the RN 11 days late; the President of Clinical Services acknowledged the assessments were not completed timely.
Late Submission of Discharge MDS Assessments: The facility failed to timely electronically submit discharge MDS assessments to the State MDS database for four residents. Two discharge MDSs were not submitted by the required deadline, and two others were submitted 33 and 90 days late. The President of Clinical Services and the DON confirmed the late submissions.
The facility failed to develop comprehensive hospice care plans with goals and interventions for two residents receiving hospice services. One resident was admitted to hospice and another resident was also admitted to hospice, but both clinical records lacked evidence of a hospice care plan. The DON confirmed the findings during interview.
A resident’s annual MDS with CAAs was not completed on time for an Accident Hazards review. The annual assessment was due within 14 days of the ARD, but the CAA completion was 12 days late, and a surveyor confirmed the finding with the DON.
Late Quarterly MDS Assessments: The facility failed to complete quarterly MDS assessments on time for two residents. One resident’s quarterly MDS was overdue when reviewed by the surveyor, and the President of Clinical Services confirmed it was late. Another resident’s quarterly MDS was also overdue, and the DON later confirmed it was late.
Failure to complete annual performance evaluations for a CNA. The facility could not provide evidence of a completed annual performance evaluation for one CNA, and the Administrator confirmed the CNA did not receive one in 2024 during a surveyor interview.
Failure to Use Gloves During Insulin Injection: A Charge Nurse prepared a resident's 25-unit Lantus dose, entered the resident's room, cleaned the abdominal area with an alcohol prep pad, and administered the subcutaneous injection without wearing gloves. The Charge Nurse acknowledged she did not wear gloves during the insulin injection and stated she should have been wearing gloves.
A resident’s bed had a 5-inch gap between the mattress and foot board that was stuffed with blankets instead of a bumper pad. The Administrator stated a bumper pad should have been in place and suggested it may have been sent for cleaning.
A resident with Parkinson's Disease and hallucinations had PRN orders for Seroquel and Lorazepam that exceeded the 14-day limit without proper reassessment or stop dates. Despite recommendations from the consultant pharmacist, the physician declined to discontinue or reassess the orders, citing the resident's hospice status. The orders were eventually changed to scheduled dosing after several months.
Late Completion of Significant Change MDS Assessments After Hospice Admission
Penalty
Summary
The facility failed to complete significant change MDS 3.0 assessments within 14 days after residents entered hospice services for 2 of 3 sampled residents. R10 was admitted to hospice on 6/27/25, and a significant change MDS was initiated with an ARD of 7/3/25, but it was not completed by the required completion date of 7/11/25 and remained incomplete as of 7/22/25. R9 entered hospice on 6/22/25, and the significant change MDS was due by 7/6/25, but it was not signed by the RN indicating completion until 7/17/25, 11 days late. During interviews on 7/22/25, the President of Clinical Services reviewed the records and stated the MDSs had not been completed timely, and a surveyor confirmed the finding for R9.
Late Submission of Discharge MDS Assessments
Penalty
Summary
The facility failed to electronically submit discharge MDS assessments to the State MDS database within 14 days after completion for 4 of 12 residents reviewed. Resident #2 was discharged on 6/5/25, and the discharge MDS with an ARD date of 6/5/25 was due to be completed by 6/19/25 and submitted by 7/3/25, but it had not been submitted at the time of review. Resident #3 was discharged on 6/6/25, and the discharge MDS with an ARD date of 6/6/25 was due to be completed by 6/20/25 and submitted by 7/4/25, but it also had not been submitted at the time of review. Resident #19's discharge record showed a discharge date of 6/4/25, and the discharge MDS was completed on 6/5/26. It was required to be submitted by 6/19/25, but was not submitted until 7/22/25, 33 days late. Resident #21's discharge record showed a discharge date of 4/9/25, and the discharge MDS was not completed until 7/14/26. It was required to be submitted by 4/23/25, but was not submitted until 7/22/25, 90 days late. During interviews, the President of Clinical Services and the DON confirmed the MDSs were not submitted timely.
Missing Hospice Care Plans for Two Residents
Penalty
Summary
The facility failed to ensure that comprehensive care plans were developed for hospice care for 2 of 3 residents reviewed for hospice services, including Resident #10 and Resident #9. Resident #10 was admitted to hospice on 6/27/25, but the clinical record lacked evidence of a hospice care plan with goals and interventions. Resident #9 was admitted to hospice on 6/22/25, and the clinical record also lacked evidence of a comprehensive hospice care plan with goals and interventions. On 7/22/25 at 12:30 p.m. and 12:31 p.m., the surveyor interviewed the DON, who confirmed the findings.
Late Annual MDS and CAA Completion
Penalty
Summary
The facility failed to complete an annual Comprehensive MDS 3.0 with CAAs in a timely manner for one resident reviewed for Accident Hazards. The resident’s annual MDS had an ARD of 4/2/25 and was due to be completed by 4/16/25, 14 days from the ARD date, but the CAA completion date was 4/28/25, which was 12 days late. On 7/22/25, the resident’s clinical record was reviewed, and on 7/23/25 at 10:48 a.m., a surveyor confirmed the finding with the DON.
Late Quarterly MDS Assessments
Penalty
Summary
The facility failed to complete quarterly MDS 3.0 assessments in a timely manner for 2 of 12 sampled residents. R11’s quarterly MDS had an ARD of 7/3/25 and was due by 7/17/25, but it was not completed at the time of review on 7/21/25. R7’s quarterly MDS had an ARD of 7/8/25 and was due by 7/22/25, but it was not completed at the time of review on 7/22/25. During interviews, the President of Clinical Services confirmed that R11’s quarterly MDS was late, and the DON later confirmed that R7’s quarterly MDS was now late.
Failure to Complete Annual CNA Performance Evaluation
Penalty
Summary
The facility failed to complete annual performance evaluations at least every 12 months for 1 of 5 sampled employees, Certified Nursing Assistant #1. CNA1 was hired on 8/3/2004, and the facility was unable to provide evidence of a completed annual performance evaluation for 2024. During an interview with a surveyor on 7/23/25 at 12:45 p.m., the Administrator confirmed that CNA1 had not received an annual performance evaluation in 2024.
Failure to Use Gloves During Insulin Injection
Penalty
Summary
The facility failed to maintain an Infection Control Program designed to help prevent the development and transmission of disease and infection when a Charge Nurse administered R12's Lantus insulin injection without wearing gloves. On 7/22/25 at 7:50 a.m., the Charge Nurse was observed preparing R12's 25-unit Lantus dose at the nurse's station with no infection control concerns, then entered the resident's room, asked where the resident wanted the injection, cleaned the abdominal area with an alcohol prep pad, and administered the subcutaneous injection without gloves. The Charge Nurse acknowledged at the time that she did not wear gloves during the insulin injection and stated that she should have been wearing gloves, which the surveyor confirmed.
Bed Gap Filler Not in Place at Foot of Bed
Penalty
Summary
The facility failed to ensure that a bed gap filler, or bumper pad, was in place between the mattress and the foot of the bed frame for Resident #17. During observation, surveyors found a gap stuffed with blankets between the foot board of the bed frame and the mattress, and the gap measured 5 inches between the end of the mattress and the foot board. During a later observation, the Administrator stated that there should have been a bumper pad in place rather than blankets, and indicated it may have been soiled and sent for cleaning.
Failure to Limit PRN Psychotropic Medication Orders to 14 Days
Penalty
Summary
The facility failed to ensure that PRN psychotropic medication orders were limited to 14 days for a resident with Parkinson's Disease and hallucinations. The resident had a PRN order for Seroquel, an antipsychotic medication, which was initially prescribed without a 14-day stop date. This order remained active beyond the required period, allowing staff to administer the medication without a valid order. Despite recommendations from the consultant pharmacist to discontinue or reassess the need for the medication, the physician declined, citing the resident's hospice status and need for the medication due to hallucinations. The PRN order was eventually changed to scheduled dosing after several months. Additionally, the resident had a PRN order for Lorazepam, an antianxiety medication, which also lacked a stop date. This order was similarly left active beyond the 14-day limit, resulting in administration without a valid order. The consultant pharmacist recommended discontinuation or reassessment, but the physician again declined, referencing the resident's hospice care and anxiety related to hallucinations. The order was eventually changed to scheduled dosing, but not before the medication was administered without a valid order.
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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.
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Nursing homes near Hartland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Dexter Health Care | 13 mi | ★★★★★ | 22 | 0 |
| Cedar Ridge Center | 14.2 mi | ★★★★★ | 12 | 0 |
| Woodlawn Rehabilitation & Nursing Center | 15.7 mi | ★★★★★ | 6 | 0 |
| Maplecrest Rehab & Living Center | 21.6 mi | ★★★★★ | 0 | 0 |
| Hibbard Skilled Nursing & Rehabilitation Center | 22.9 mi | ★★★★★ | 4 | 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.