Average — CMS composite of the measures below.
The next survey window likely opens around December 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 Hartford Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Food service areas had multiple sanitation and temperature control failures. Dirty shelving, utensil bins, slicer parts, and a mixer were observed with debris and buildup; several refrigeration units were at 50F with TCS foods stored above safe temps; multiple ready-to-eat items lacked date marks or were expired; food and supplies were stored under wastewater lines; a microwave had peeling and rusted surfaces; the ice machine drain line was directly connected to the sink wastewater line; the dish machine wash temp was below the required 160F; and cooling sausage was found at 74.5F with no cooling log.
Incomplete Water Management Program and Stagnant Plumbing Fixtures: Surveyors found multiple inoperable, unused, or discolored water fixtures and lines, including hoppers, sinks, and water fountains, with staff unaware of several plumbing lines and fixtures. The MD said he was still creating the WMP binder because much documentation had been lost, and the facility could not provide the required water system assessment or flow diagrams. Meeting minutes referenced flushing, but did not identify which fixtures or dead-end lines were flushed, and the chlorine test method used could not detect the stated control level.
Poor Premises Cleanliness and Maintenance: Surveyors observed multiple areas with loose, leaking, or damaged fixtures, including faucets, a toilet, cracked sink plumbing, broken floor tiles, and mop sink faucets left on with undue back pressure on the AVB. They also found widespread debris, dust, stains, pooled water, soiled shower equipment, contaminated storage areas, and dirty laundry transport bins across several units and common areas.
Staff failed to provide timely bedside water to multiple cognitively intact and cognitively impaired residents, some with significant comorbidities such as CVA, CHF, COPD, diabetes, and severe protein-calorie malnutrition. During a daytime survey window, several residents were observed without water at bedside; some reported not receiving fresh water since the prior night or since breakfast and described using alternative containers or having cups removed and not replaced. Assigned CNAs acknowledged that they had not yet passed water during their shifts, despite the DON’s expectation that fresh water be passed by mid-morning and before the end of the shift, and despite a facility policy requiring that each resident be provided bedside water.
Surveyors found that meals were not maintained at palatable temperatures when a dietary manager acknowledged that heated bases were available but not used, and plates were observed at 75–85°F without a plate warmer in operation. A test tray placed early on a meal cart with about 25 trays and delivered to a unit was later measured, showing a pot pie at 127.6°F and mixed vegetables at 104°F, despite the manager’s stated expectation that hot foods should reach residents at 135°F or higher. This resulted in decreased food consumption and potential nutritional decline for affected residents.
Failure to Provide AMD Information Before Code Status Change: A resident with vascular dementia and prior DNR status was changed to full code without documentation that the resident’s representative was given information about advance directives. The representative said they were not included in decision making and did not know the code status had changed. Records showed a prior DNR AMD signed by a guardian company representative, but the later full-code form was signed only by the SW and noted the resident could not sign due to dementia with confusion.
Failure to timely transmit an MDS discharge assessment. A resident discharged from the facility, but the MDS for discharge status had not been sent to the CMS system and was over 120 days late. The MDS coordinator stated the assessment had not yet been transmitted and noted that staff changes led to some missed transmittals. The NHA stated MDS assessments are expected to be sent timely in accordance with federal regulations.
Two residents had inaccurate MDS assessments. One resident’s MDS incorrectly indicated limb restraint use even though staff stated the facility did not use restraints and there was no EHR documentation to support restraint use. Another resident’s MDS incorrectly indicated HD despite no orders or documentation in the EHR, and the resident stated they did not receive dialysis.
A resident with paranoid schizophrenia was admitted with a Level I PASARR indicating mental illness, prior MH treatment, and routine antipsychotic use, but no Level II PASARR was completed. SW acknowledged the PASARR process fell behind due to staffing changes, and the NHA confirmed the resident had not received psychiatric services or schizophrenia medication since admission.
Medication Left at Bedside Without Self-Administration Order: A resident with no cognitive impairment and no order for self-administration was observed with three pills left in a cup on the bedside table. The resident said the nurse leaves the pills there because they cannot swallow them all at once and did not know what the medications were for. An LPN and the DON both confirmed that medications should not be left at the bedside and that oral meds should be observed until swallowed.
Two residents were observed being pushed in wheelchairs without footrests in place. An LPN propelled one resident without leg rests, and staff later stated the resident should have them for safety. Another resident, who was dependent for wheelchair mobility and had severe cognitive impairment, was observed multiple times in a wheelchair without footrests while being transported and while seated, with feet resting or sliding on the floor. Staff, including the DON and Rehab Manager, stated dependent residents should have footrests/leg rests during wheelchair transport.
A resident with pneumonia, adult failure to thrive, and an order for continuous O2 at 2 L/min was observed in the day room without the nasal cannula while coughing, and the portable tank was empty. An LPN acknowledged the resident should have been on oxygen and later applied a new tank and cannula; the CNA said the empty tank was not reported because of distraction. The resident's care plan and Kardex did not include oxygen use.
Failure to Obtain Legal Guardian for a Resident with Dementia: A resident with vascular dementia and legal incapacity had no current LG after the prior guardian company’s paperwork expired and the company went out of business. The resident’s RR said they were not the LG and were trying to obtain guardianship through court, while the SW and NHA could not provide documentation of any facility efforts to secure a new LG. The resident’s AMD was signed by the SW because the resident could not sign due to dementia with confusion.
A resident with dysphagia and severe cognitive impairment was observed receiving a lunch tray that was labeled for a regular diet with pureed texture, but the food on the tray was not pureed and included items such as chicken pot pie and a bread roll. The resident began to eat the bread roll before an LPN was notified. Record review and staff interviews confirmed the resident had an order for pureed texture with thin liquids and ongoing chewing and swallowing difficulty.
A resident with TIA, dementia, and Alzheimer's disease lacked documentation of current influenza and pneumococcal immunizations, as well as guardian-signed refusals or contraindications. The IP reported the missing documentation, and the DON stated the guardian should have been contacted for consent or declination. Facility policy required annual influenza vaccination offers with refusal and education documented, and pneumococcal vaccination with informed consent from the resident or authorized representative when appropriate.
A resident with TIA, dementia, and Alzheimer’s disease did not have documentation of current COVID-19 immunization, a guardian-signed refusal, or a contraindication in the EHR. The IP reported the record lacked vaccine documentation, and the DON stated the guardian should have been contacted for consent or declination. Facility policy required signed consent or declination for COVID-19 vaccination.
A deficiency was cited when a facility area was not kept free from accident hazards and adequate supervision was not provided to prevent accidents. The environment did not meet safety standards, and there was a lack of appropriate measures and oversight to protect residents from potential harm.
A resident with paralysis and a high fall risk was not provided the required two-person assist during bed repositioning, as specified in their care plan and Kardex. A CNA attempted to change the resident's brief alone, resulting in the resident falling from the bed and sustaining a right hip fracture that required surgical repair. The CNA was unaware of the two-person assist requirement and did not consult the Kardex prior to care, leading to inadequate supervision and a serious injury.
The facility failed to clean and sanitize resident equipment for 14 residents on the third floor. A shower chair with dried feces and a soiled sit-to-stand machine were observed. An LPN indicated the midnight shift was responsible for cleaning, and the NHA confirmed the equipment should be cleaned after each use. The facility's policy emphasized the importance of cleaning to prevent infection transmission.
A resident's recliner was found unclean on multiple occasions, with dried food, dust, and stains, despite the facility's policy on cleaning multi-use equipment. The resident, with a history of chronic conditions and requiring assistance for daily living, was observed in the dirty recliner. The ADON noted that cleaning was assigned to aides, but this was not documented on assignment sheets.
A facility failed to complete and transmit a resident's MDS assessments within the required timeframe. The Admission MDS assessment was completed late, and the discharge assessment was not completed or submitted, resulting in inaccurate tracking of assessments. The MDS Coordinator was uncertain why the discharge assessment was missed.
A resident with hemiplegia and hemiparesis was observed with long fingernails and an unkempt beard, indicating a failure in timely ADL care. Despite receiving a bed bath, the resident's grooming needs were unmet, and no refusals of care were documented. The facility's policy requires daily grooming assistance, which was not provided as expected.
A resident with limited ROM was not included in the restorative program after therapy discharge, despite documentation indicating the need. The resident, with an acquired absence of both legs below the knee, was not receiving necessary exercises. Staff interviews revealed a lack of referral from physical therapy, contrary to facility policy.
A resident's CPAP equipment was not stored in a sanitary manner, with the mouthpiece left uncovered on a nightstand and occasionally falling on the floor. The resident, who has obstructive sleep apnea, reported that the facility did not provide a cover for the mouthpiece, and cleaning was inconsistent. The facility's policy required the mask to be stored in a clean bag, but this was not followed, leading to potential respiratory infection risks.
A resident in the facility for two months, who was cognitively intact and required assistance with daily activities, did not receive necessary dental care despite having only two teeth and expressing difficulty chewing. The resident requested to have the teeth pulled to obtain dentures, but the facility failed to coordinate or provide dental services, resulting in unmet oral health needs. Interviews with the DON and SSD revealed a lack of awareness and documentation regarding the resident's dental needs, despite a physician's order and care plan noting dental concerns.
Food Storage, Equipment Sanitation, Temperature Control, and Cooling Deficiencies
Penalty
Summary
The facility failed to maintain food service equipment and storage areas in a clean condition. During observation of the walk-in cooler, black spotted debris was seen on the top surfaces of hard plastic shelving used to store food. The Dietary Manager stated the shelves are power washed, but they had not been taken outside because of cold weather. In the clean utensil bin, clean utensils were stored among food crumbs and debris, and wiping the inside of the bin revealed it was greasy. The tabletop slicer, used about once a week, had dried meat debris on the backside, bottom, and top portions of the blade after the plastic cover was removed. A stand-up floor mixer that was used about once a month was observed covered with a plastic bag and had yellow and white debris caked on the under arm of the unit. The facility also failed to maintain proper cold holding temperatures in multiple refrigeration units. The three-door Traulson cooler in the serving room had an ambient temperature of 50F, and a container of tuna salad and a packet of cream cheese inside measured 47.3F. The C unit nourishment room refrigeration unit also had an internal temperature of 50F. In the A and B nourishment room refrigeration unit, several items were observed without proper date marking, including chicken wings with no discard date, leftover pizza with a receipt dated 1/21/26, and yogurt with a best by date of 1/22/26. In the walk-in cooler, two containers of whipped topping were past their best by date, and an open package of sliced smoked ham had no date to indicate discard. Additional observations showed multiple food storage and sanitation issues in nourishment rooms and kitchen equipment. In the Homebound nourishment room, rice, a leftover sub, and a peanut butter and jelly sandwich were not dated, and a nutritional supplement was present without clear tracking of when it had thawed. Disposable cups and thickened juices were stored underneath wastewater lines to hand sinks. The C unit nourishment room microwave had bubbled, peeling, brown, and rusted interior surfaces. The Cardiac nourishment room ice machine drain line was directly connected to the wastewater line of the sink through a condensate pump. The facility also observed a high temperature dish machine operating below the required wash solution temperature, with the wash gauge ranging from 148F to 152F on one observation and around 140F on another, while the machine data plate required a minimum wash water temperature of 160F. Finally, ground turkey sausage placed in the walk-in cooler for cooling was found at 74.5F, and the Dietary Manager stated there was no cooling log and was unsure when cooling had started.
Incomplete Water Management Program and Stagnant Plumbing Fixtures
Penalty
Summary
The facility failed to provide and implement an active and ongoing infection prevention and control program for reducing the risk of legionella and other opportunistic pathogens of premise plumbing. During observations, surveyors found multiple water fixtures and lines that appeared stagnant, inoperable, or discolored, including a possible stagnant water line in the kitchen serving room near the steam tables, brownish yellow water coming from the hopper fixtures and sprayer in the Homebound unit soiled linen room, a sink and hopper fixture with no water flow in the C unit soiled linen room, a hopper in a soiled utility room with low water level and slow, discolored flow, and an inoperable utility sink in the B unit soiled utility room. Additional observations included an inoperable water fountain in the B unit hallway, an inoperable water fountain in the A unit hallway, and a water line extended through the wall in the Homebound unit A hallway that had been shut off and produced milky, discolored water when opened. Interviews showed staff were unaware of several of these water lines and fixtures, including the Maintenance Director, Dietary Manager, housekeeping manager, and CNA, and the housekeeping manager stated the hopper was not used and that he did not have responsibilities for the Water Management Plan. The Maintenance Director stated he was in the process of creating a Water Management Program binder because much of the documentation had been lost. The facility policy stated the water management program would include an assessment of where Legionella and other opportunistic pathogens could grow and spread, along with a description of the building water systems using text and flow diagrams, but no such assessment or system description was provided. The Water Management Team meeting minutes referenced flushing, but the documentation did not identify which sinks, fixtures, or dead-end piping were being flushed, and the testing method described for free chlorine was insufficient for the stated control level being monitored.
Poor Premises Cleanliness and Maintenance
Penalty
Summary
The facility failed to maintain general cleanliness and repair of the premises during multiple environmental tours of the homebound, C, New Center, laundry, cardiac, and other units. Observations included loose and leaking faucets in resident rooms, shower rooms, soiled utility rooms, and janitor closets; mop sink faucets left on with undue back pressure on the faucets' internal atmospheric vacuum breakers; a loose toilet unattached to floor caulk; broken and crumbled floor tiles; and a cracked hand sink fixture leaking heavily when turned on. In several shower rooms, surveyors observed black residue, brown smears, pooled water, crumbs, lint balls, a loose screw near the drain, a shower curtain touching the floor with black residue, and shower bed mats with visible accumulation of moisture, debris, and stains. Additional observations showed poor housekeeping and storage conditions throughout the facility. Clean sorting bins used to transport linen contained debris including packaged cookies, plastic wrappers, used gloves, a metal hanger, and dirty socks and gloves; laundry storage had inoperable and unshielded lights and loose floor tiles. Storage and utility areas contained dust, dirt, razors, used gloves, straws, and debris on floors and around shelving. Other areas included a nourishment room with napkins stored beneath the sink with visible brown and black wastewater on the packaging, an open and exposed wastewater line with thick black substance inside, a spa shower chair with a brown smear, and resident/common area furniture with food crumbs and stains.
Failure to Provide Timely Bedside Water to Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide timely bedside water to multiple residents, as required to maintain adequate hydration. During the initial screening on 1/27/2026 between 10:00 a.m. and 2:00 p.m., several residents were observed without water in their rooms or at bedside, despite the facility’s oral hydration policy stating that each resident will be provided bedside water. One resident (R94), who was cognitively intact with a BIMS score of 14/15 and had diagnoses including hemiplegia/hemiparesis after cerebral infarction and hypertension, reported that no fresh water had been passed since about 9:00 p.m. on the midnight shift and showed a small iced tea bottle they were using to obtain water from the sink. Another cognitively intact resident (R76), with diagnoses including cerebral infarction, hypertension, and venous insufficiency, was observed in bed with an empty Styrofoam cup out of reach and stated that no cold water had been passed since the midnight shift. A third resident (R18), who had severe protein-calorie malnutrition, dementia, anemia, type 2 diabetes mellitus, and cerebral infarction and was severely cognitively impaired with a BIMS score of 3/15, stated that no one had brought any fresh water at all that day and expressed a desire for cold water. Another resident (R156), cognitively intact with a BIMS score of 15/15 and diagnoses including congestive heart failure, chronic respiratory failure, type 2 diabetes mellitus, and COPD, reported that staff had picked up their water cup around breakfast time and had not brought any fresh water back. A further resident (R62), cognitively intact with a BIMS score of 15/15 and diagnoses including ETOH use, left femur fracture, hypertension, history of falls, carotid artery disease, and COPD, was observed at 1:30 p.m. with no water cup in the room or at bedside and declined interview. Review of staffing assignments showed that CNA T was assigned to several of the affected residents (R62, R76, and R18) on the 7:00 a.m. to 3:00 p.m. shift. At 3:00 p.m., CNA T acknowledged that water had not been passed and stated they planned to pass water later, adding that residents should have had water at the start of the shift. Another CNA (CNA U), assigned to other affected residents (R156 and R94) and working an additional four hours, stated at 4:16 p.m. that they had been very busy and were only then passing water, acknowledging that residents should have received fresh water earlier. The DON later confirmed that staff are expected to pass fresh water multiple times on 12-hour shifts and that on 8-hour shifts fresh water should be passed before 3:00 p.m. and 5:00 p.m., usually by 10:00 a.m., and that fresh water should be passed before 3:00 p.m. regardless, which had not occurred for these residents on the day in question.
Failure to Maintain Palatable and Safe Food Temperatures During Meal Service
Penalty
Summary
The facility failed to ensure meals were served at palatable temperatures, as identified in two intakes related to concerns that food served to residents was not at palatable temperatures. During an interview, the Dietary Manager stated the facility has heated bases but confirmed they were not in use for the observed meal, and surveyors observed plates measuring between 75°F and 85°F with no plate warmer in use. The Dietary Manager reported that hot food on the steam table should be at least 150°F so residents receive food at 135°F or higher. A regular test tray was plated and placed as one of the first meals on the C unit cart, which then traveled to the unit with approximately 25 meal trays and was fully delivered before the test tray was returned to the conference room. When the test tray was checked with a rapid-read thermometer, the pot pie measured 127.6°F and the mixed vegetables measured 104°F, demonstrating that hot foods were not maintained at the expected temperatures, resulting in decreased food consumption and potential nutritional decline for the residents involved. No additional resident-specific medical histories or conditions were documented in the report beyond the noted decreased food consumption and potential nutritional decline associated with the improperly maintained food temperatures.
Failure to Provide Advance Directive Information Before Changing Code Status
Penalty
Summary
The facility failed to give information for Advance Medical Directives to a resident’s representative, resulting in the resident’s code status being changed to full code. The resident had resided in the facility since [DATE] and had multiple diagnoses including vascular dementia. The resident was unable to be interviewed due to cognition status. The resident’s record included an Annual Report of Guardian on condition of Legally Incapacitated Individual showing a legal guardian company assigned and a Do-Not-Resuscitate order executed, with guardianship in effect from [DATE] through [DATE]. A prior AMD form dated [DATE] identified the resident as DNR and was signed by the guardian company representative. A second AMD form dated [DATE] identified the resident as full code and was not signed by a legal guardian or resident representative; it was signed by the social worker and noted the resident was unable to sign and had dementia with confusion. The resident’s representative stated they were not included in decision making and did not know the code status had been changed to full code. Review of progress notes and social service notes did not show documentation that the representative was provided information regarding formulating an AMD. The social worker stated the guardian paperwork had expired and there was no information to determine who was the legal guardian, and the nursing home administrator stated the resident had no legal guardian and was changed back to full code by default. There was no documentation that the facility petitioned for another guardian or that the representative was given information about the AMD.
Failure to Timely Transmit MDS Discharge Assessment
Penalty
Summary
The facility failed to transmit a Minimum Data Set (MDS) discharge assessment for one resident, R173, within the required timeframe. During review of the resident’s electronic health record, it was found that R173 had discharged from the facility on 8/27/25, but the MDS assessment for discharge status had not been transmitted to the CMS system and was over 120 days overdue. During interview, the MDS coordinator stated that the MDS had not yet been transmitted and acknowledged that it was late, explaining that staff changes had occurred and some transmittals had been missed. The Nursing Home Administrator stated that the expectation was for MDS assessments to be sent timely in accordance with federal regulations.
Inaccurate MDS Assessments for Restraint Use and Dialysis
Penalty
Summary
The facility failed to accurately complete MDS assessments for two residents. One resident’s MDS section P indicated use of a limb restraint less than daily, but review of the EHR found no orders, care plans, or documentation supporting any restraint use. The resident was observed in bed using a wedge bolster and later up in a recliner chair, with no visible restraints in the room. Unit staff stated there were no restraints in the facility and confirmed the resident had never had restraints. The MDS Director also reviewed the assessment and stated it was an obvious mistake because the resident had never had a restraint. A second resident’s MDS section O indicated the resident received hemodialysis, but the EHR contained no orders or documentation supporting dialysis. The resident was observed seated up in bed watching TV and stated they do not get dialysis and never had dialysis. The MDS Director reviewed this assessment and confirmed it was inaccurate, stating the resident did not receive dialysis.
Failure to Complete PASARR Level II Screening for Resident With Schizophrenia
Penalty
Summary
The facility failed to refer one resident with a serious mental disorder, paranoid schizophrenia, to the state designated authority for a Level II PASARR review after admission. Record review showed no Level II PASARR completed by the facility after the resident’s admission, even though the referring hospital’s Level I PASARR dated 8/1/25 identified schizophrenia, a history of prior mental health treatment, and routine use of the antipsychotic Invega. The resident’s record also listed diagnoses including paranoid schizophrenia, alcohol abuse, hypothyroidism, type 2 diabetes, hypertension, hyperlipidemia, rhabdomyolysis, prostatic hyperplasia, and ischemic attack. The resident told the surveyor that he did not receive behavior or psychiatric supports at the facility. The resident’s MDS showed a BIMS score of 13, indicating cognitive intactness. Social Services staff stated that staffing changes over the summer caused the department to fall behind on PASARR processes and acknowledged that the resident’s Level II PASARR was not done. The NHA stated that PASARR screenings were the responsibility of the Social Services Department and confirmed that the resident had not received psychiatric services or medication for schizophrenia since admission. The facility policy stated that if Level I screening indicates mental illness and/or intellectual/developmental disability, the person is referred for a comprehensive Level II screening, and the Level I screening criteria for this resident identified current mental illness, prior treatment for mental illness, and routine receipt of antipsychotic medication within the last 14 days.
Medication Left at Bedside Without Self-Administration Order
Penalty
Summary
The facility failed to follow standards of practice for medication administration for one resident, R183, who was observed on 01/27/2026 with three pills in a medication cup left on the bedside table. When asked about the pills, R183 stated the nurse leaves them there because they cannot swallow all the pills at once, and also said they were not sure what the pills were or what they were taken for. A record review showed R183 was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right side, muscle wasting and atrophy, hyperlipidemia, hypertension, gastro-esophageal reflux disease, depression, and insomnia. The MDS dated 1/6/2026 showed a BIMS score of 15/15, indicating no cognitive impairment. A review of physician orders found no order allowing R183 to self-administer medications. During interview, LPN D confirmed that R183 did not have an order to self-administer medications and stated that professional standards include observing the resident take the medication and that it is not safe or appropriate to leave medications at the bedside. The DON also stated that medications are not left at the bedside and that this is not the facility's process. The facility policy on Medication Administration states that resident medications are to be administered in an accurate, safe, timely, and sanitary manner and that the nurse should observe the resident swallow oral medications unless the resident is approved for self-administration.
Wheelchair Footrests Not in Place During Resident Transport
Penalty
Summary
The facility failed to ensure that two residents, R33 and R118, had wheelchair footrests in place during wheelchair mobility. On 1/27/2026, R33 was observed sitting in a wheelchair and being propelled by LPN V into the hallway without any footrest in place; both of R33's legs were lifted off the floor at intervals, with the left leg dropping to the floor. No footrest was found in the room or closet. When interviewed, LPN V stated the resident did not have leg rests but that therapy would be called to get some, and said the resident should have them for safety reasons. R33's record showed diagnoses including sequelae of cerebral infarction, bilateral sensorineural hearing loss, dementia, hypertension, and osteoarthritis, and the quarterly MDS indicated moderate cognitive impairment with a BIMS score of 09/15. The ADL care plan documented a functional ability deficit requiring assistance with self-care and mobility related to fatigue/weakness, impaired balance, impaired cognition, and impaired mobility. R118 was observed multiple times in a wheelchair without footrests, with feet resting directly on the floor, including while sitting in the rehab wing day room, outside the nurses' station, and while being pushed by CNA K from the room to the day room. During transport, R118's feet were sliding directly on the floor. CNA K stated that R118's wheelchair should have footrests. LPN L stated that R118 should have leg/footrests and was dependent for wheelchair mobility, and that all residents who are dependent should have footrests for wheelchair mobility. The DON stated staff are expected to ensure dependent residents have footrests/leg rests on the wheelchair prior to transport to reduce the risk for accidents, and the Rehab Manager stated dependent residents should not be pushed in a wheelchair without footrests because they would be at risk of injury or fall. R118's record showed diagnoses including pneumonia and adult failure to thrive, a BIMS score of 6/15 indicating severe cognitive impairment, and mobility documentation showing dependence for wheelchair transfers and mobility.
Failure to Provide Ordered Oxygen
Penalty
Summary
The facility failed to follow a physician order for oxygen administration for one resident who had diagnoses including pneumonia and adult failure to thrive and was ordered oxygen by nasal cannula at 2 L/min continuously for shortness of breath. On 1/28/2026, the resident was observed sitting in the rehab wing day room in a wheelchair with a portable oxygen tank while a CNA assisted with breakfast, but the resident was not wearing the oxygen cannula and was coughing. The resident was unable to answer questions regarding care. When questioned, an LPN acknowledged the resident should have been on oxygen and noted the resident had just returned from isolation for COVID-19. The LPN checked the portable oxygen tank and found it empty, then obtained a new tank and applied the oxygen cannula. The CNA stated the resident had been brought to the day room that morning and that the portable oxygen was out, but the CNA had not told the nurse because of being distracted. Record review showed the resident's care plan and Kardex did not include oxygen use, and the DON stated staff were expected to follow physician orders and check portable oxygen tanks before transporting residents.
Failure to Obtain Legal Guardian for Legally Incapacitated Resident
Penalty
Summary
The facility failed to provide medically-related social services to help a legally incapacitated resident achieve the highest possible quality of life because it did not obtain a legal guardian for the resident after the prior guardian company’s paperwork expired and the company went out of business in 2024. The resident had lived in the facility since [DATE] and had multiple diagnoses, including vascular dementia. The Annual Report of Guardian on condition of a Legally Incapacitated Individual showed the resident had a guardian company until [DATE], but there was no further information to determine whether the resident had a current legal guardian. The resident’s representative stated they were not being included in decision making and were not the resident’s legal guardian, and said they were trying to obtain guardianship through the court system without assistance from the facility. The resident’s advance medical directive was dated [DATE], identified the resident as full code, and was signed by the social worker because the resident was unable to sign due to dementia with confusion. The resident’s progress notes and social service notes did not document a legal guardian, and there was no documentation that the facility made attempts to obtain one. The social worker and nursing home administrator both stated the resident had no legal guardian and could not provide documentation of efforts to acquire one.
Incorrect Diet Texture Provided to a Resident with Dysphagia
Penalty
Summary
The facility failed to ensure that a resident with a physician-ordered regular diet with pureed texture and thin liquids received food in the ordered form. On 1/27/2026, R203 was observed in the room with a lunch tray whose meal ticket listed a regular diet with pureed texture, but the tray contained chicken pot pie, a bread roll, peas and carrots, and applesauce, and the food was not pureed. The resident began to remove the plastic wrap from the bread roll to eat it before the surveyor notified an LPN of the concern. Record review showed R203 was admitted with a diagnosis of dysphagia, had a BIMS score of 7 indicating severe cognitive impairment, and required supervision or touching assistance with eating. The physician order dated 1/24/2026 specified a regular diet with pureed texture and thin liquids, and the care plan documented the ordered pureed diet and tray set-up for meals. The SLP stated the resident had ongoing chewing and swallowing difficulty and that it would be concerning if the resident received a regular textured diet. The RD and NHA both stated it would be concerning for the resident to receive the incorrect diet, with the RD noting the resident would be at risk for aspiration.
Failure to Document Flu and Pneumonia Vaccination Consent or Refusal
Penalty
Summary
Develop and implement policies and procedures for flu and pneumonia vaccinations was cited after surveyors found that one resident, R33, did not have documentation of current influenza or pneumococcal immunizations, refusals signed by the guardian, or documentation that the vaccines were contraindicated. R33 was admitted with diagnoses of transient cerebral ischemic attack, dementia, and Alzheimer's disease. The Infection Preventionist reported that the resident lacked documentation of influenza or pneumococcal immunizations or refusals by the guardian, and the DON stated that R33's guardian should have been contacted to obtain consent or declination. Review of the facility's immunization policies showed that residents are to be offered influenza vaccination annually with refusal and education documented, and that pneumococcal vaccination requires informed consent, including discussion with the resident's authorized representative when appropriate.
Failure to Document COVID-19 Vaccine Consent or Declination
Penalty
Summary
The facility failed to ensure that one resident, R33, was provided COVID-19 vaccination education and that the resident’s vaccination status was properly documented. R33 was admitted with diagnoses of transient cerebral ischemic attack, dementia, and Alzheimer’s disease. During interview, the Infection Preventionist reported that R33 did not have documentation of a current COVID-19 immunization or a signed refusal by the guardian. Review of the electronic health record showed no documentation that the COVID-19 vaccine was declined by the guardian or that it was contraindicated. The DON stated that R33’s guardian should have been contacted to obtain consent or declination. The facility policy required a signed consent form for COVID-19 vaccine administration from the resident or designated health care representative, or a signed declination if consent was not given.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to accidents occurring. The deficiency centers on the lack of appropriate measures to identify and eliminate hazards, as well as insufficient oversight to safeguard residents from potential harm.
Failure to Provide Required Two-Person Assist Results in Resident Fall and Hip Fracture
Penalty
Summary
A deficiency occurred when a resident with a history of stroke, paralysis from the waist down, and multiple comorbidities, including chronic foot ulcer and neuropathy, was not provided the required two-person assistance during bed mobility. The resident's care plan and Kardex both specified that extensive to maximum assistance with two staff members was necessary for repositioning and turning in bed due to the resident's high fall risk and functional deficits. Despite these documented requirements, a single Certified Nurse Aide (CNA) attempted to change the resident's brief and reposition them alone. During the care event, the CNA rolled the resident onto their side and, after moving to the other side of the bed, the resident lost balance and fell to the floor. The CNA admitted to taking their hands off the resident and not being aware of the two-person assist requirement, stating they had previously cared for the resident alone without incident. The CNA also revealed a lack of knowledge about the Kardex and its role in communicating care needs, relying instead on verbal shift reports for information. As a result of the fall, the resident sustained an acute intertrochanteric fracture of the right femur, which required surgical repair. The resident experienced significant pain, was unable to participate in activities, and expressed emotional distress over the loss of independence and missed activities. The incident was corroborated by interviews, medical records, and hospital documentation, all confirming that the resident was left without adequate supervision and assistance, directly leading to the accident and injury.
Failure to Clean and Sanitize Resident Equipment
Penalty
Summary
The facility failed to ensure that resident equipment was cleaned and sanitized properly for 14 residents on the third floor. During an observation on the morning of November 22, 2024, a shower chair was found in the hallway with visible dried feces. Additionally, a sit-to-stand machine, used for positioning residents, was noted to be soiled with dirt and food particles. These findings indicate a lack of adherence to proper cleaning protocols for resident equipment. When questioned, an LPN stated that the midnight shift was responsible for cleaning the equipment and that it should be cleaned after each use to prevent cross-contamination. The Nursing Home Administrator confirmed that the facility was responsible for cleaning the equipment and reiterated that it should be cleaned after each use and during the midnight shift. A review of the facility's policy on cleaning and disinfecting multi-use resident equipment highlighted the importance of cleaning and disinfection to prevent the transmission of infectious pathogens, emphasizing that noncritical items should be cleaned when visibly soiled and on a regular schedule.
Failure to Maintain Cleanliness of Resident's Recliner
Penalty
Summary
The facility failed to maintain the cleanliness of a geriatric recliner used by a resident, compromising the resident's right to a safe, clean, comfortable, and homelike environment. On two separate occasions, the resident was observed sitting in a recliner that was visibly dirty, with dried food, dust, candy wrappers, and stains present. The recliner had dried brownish drip stains on the left side and a dried white substance on the top. Despite the facility's policy on cleaning and disinfecting multi-use resident equipment, the recliner remained unclean over a period of days. The resident involved had a medical history that included chronic obstructive pulmonary disease, hemiplegia and hemiparesis following cerebral infarction, glaucoma, and hallucinations. The resident required dependent assistance for activities of daily living. The Assistant Director of Nursing (ADON) acknowledged that the cleaning of chairs was supposed to be done by aides on the midnight shift and as needed, but the assignment sheets reviewed did not reflect this task. This oversight in maintaining cleanliness contributed to the deficiency noted by the surveyors.
Failure to Complete and Transmit MDS Assessments Timely
Penalty
Summary
The facility failed to ensure that a Minimum Data Set (MDS) assessment for a resident, identified as R54, was completed and transmitted to the Centers for Medicare and Medicaid Services (CMS) within the required timeframe. Specifically, the Admission MDS assessment for R54 had an assessment reference date (ARD) of July 1, 2024, and was completed on July 10, 2024. However, it was not locked and accepted until July 23, 2024, which was beyond the 14-day requirement after completion. Additionally, R54 was discharged from the facility on July 19, 2024, but the discharge MDS assessment was neither completed nor submitted, resulting in the assessment being overdue by 112 days as of the review date. During an interview, the MDS Coordinator, identified as Nurse D, acknowledged that the discharge assessment for R54 was not completed and expressed uncertainty about why it was missed. The review of the Resident Assessment Instrument (RAI) guidelines, as documented in October 2024, highlighted the responsibilities of nursing homes to complete assessments in accordance with 42 CFR 483.20. These requirements apply to all residents in Medicare and/or Medicaid certified long-term care facilities, regardless of various factors such as age, diagnosis, or payment source. The failure to complete and transmit the MDS assessments as required led to inaccurate tracking of resident assessments, including admission, quarterly, and discharge assessments.
Failure to Provide Timely ADL Care
Penalty
Summary
The facility failed to provide timely assistance with activities of daily living (ADL) care, specifically nail and beard care, for a resident identified as R28. Observations on two consecutive days revealed that R28 had long fingernails with debris and an unkempt beard. R28, who has a pertinent diagnosis of hemiplegia and hemiparesis following a stroke, expressed a need for a shave and nail trimming. The resident's Minimum Data Set (MDS) indicated intact cognition and a requirement for substantial assistance with personal hygiene. Despite receiving a bed bath/shower the previous evening, R28's grooming needs were not addressed. The care plan for R28, dated earlier in the month, indicated a need for limited assistance with personal hygiene. However, there were no documented refusals of ADL care in the electronic health record, and the resident was observed to agree to grooming when offered by an LPN. The facility's policy on routine resident care mandates assistance with grooming and personal hygiene, including nail care and shaving, as part of daily care. The Director of Nursing confirmed that ADLs should be performed as needed, yet the observations and interviews indicated a lapse in adhering to these expectations.
Failure to Include Resident in Restorative Program
Penalty
Summary
The facility failed to include a resident with limited range of motion (ROM) in the restorative program, as required to maintain or improve their mobility. The resident, who had an acquired absence of both legs below the knee, was not receiving therapy or exercises after the completion of their initial therapy sessions. Despite having intact cognition and requiring substantial assistance for transfers, the resident's electronic health record (EHR) did not contain a therapy to restorative form for physical therapy discharge, nor were there any orders, care plans, or Kardex entries for a restorative ROM program. Interviews with staff revealed that the resident should have been on restorative nursing services based on the documentation in the EHR. However, the Licensed Practical Nurse (LPN) responsible for restorative services stated that no referral was received from physical therapy. The Director of Nursing (DON) confirmed that the expectation was for restorative services to be assessed per therapy recommendations. The facility's policy on restorative nursing emphasized the importance of an interdisciplinary process, including referrals from skilled therapy services, which was not followed in this case.
Improper Storage of CPAP Equipment
Penalty
Summary
The facility failed to ensure that respiratory care equipment was stored in a sanitary manner for a resident who required the use of a CPAP machine for obstructive sleep apnea. The resident, who was alert and oriented, was observed with the CPAP mouthpiece and tubing loosely wrapped around the machine, with the mouthpiece resting uncovered on the nightstand. The resident reported that previous facilities provided a cover for the mouthpiece to prevent it from getting dirty, but this was not the case at the current facility. The resident also mentioned that the mouthpiece had fallen on the floor, and they would pick it up and place it back on the table, with cleaning sometimes occurring in the morning but not before use at night. The clinical record indicated that the resident was readmitted with a diagnosis of obstructive sleep apnea and required extensive assistance with activities of daily living. The physician's orders specified that the CPAP tubing and mask should be cleaned with soap and water once a week, but the medication treatment record only documented cleaning on one occasion. The facility's policy required the mask to be stored in a clean bag when not in use, but the Unit Manager was unaware that the resident did not have the proper covering. This lack of proper storage and cleaning practices resulted in the potential for respiratory infections.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to provide routine dental services to a resident, identified as R63, who had been in the facility for about two months. R63, who was cognitively intact and required assistance with activities of daily living, expressed difficulty chewing due to having only two remaining teeth and requested to have them pulled to obtain dentures. Despite a physician's order for a dental evaluation and a care plan noting dental concerns, the resident did not receive the necessary dental care. The resident's medical record indicated a need for dental services, but the facility did not coordinate or provide these services, resulting in unmet oral health needs and discomfort. Interviews with the Director of Nursing (DON) and Social Service Director (SSD) revealed a lack of awareness regarding the resident's need for dental care. The DON acknowledged the existence of a physician's order for a dental evaluation but considered it a standard order, not necessarily indicating immediate need. The SSD admitted that dental services were not offered during the initial assessment and claimed the resident did not want to see a dentist, although there was no documentation to support this claim. The facility's policy required providing routine and emergency dental services, but this was not adhered to in the case of R63.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,212 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — 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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Detroit
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Orchards At Northwest | 0.7 mi | ★★★★★ | 22 | 0 |
| Westwood Nursing Center | 0.9 mi | ★★★★★ | 21 | 0 |
| Oakpointe Senior Care And Rehab Center | 1.3 mi | ★★★★★ | 0 | 0 |
| Sheffield Manor Nursing & Rehabilitation Center | 1.4 mi | ★★★★★ | 15 | 0 |
| The Villa At Great Lakes Crossing | 1.9 mi | ★★★★★ | 8 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Hartford Nursing & Rehabilitation Center.
100% money-back within 48 hours.
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.