Hartford Nursing & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Hartford Nursing & Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689May 1, 2023

  This citation pertains to intake MI00135760. Based on interview and record review, the facility failed to adequately supervise Resident #101 (R101) when on 4/6/23 at 10:16 PM R101 left the facility through the front door without the knowledge of the facility staff. The facility staff was unaware of R101's disappearance until 4/7/23 at 7:50 AM, approximately 10 hours later. R101 was found by local police on 6 Mile Road and Telegraph Road, approximately five miles away from the facility. Local police took R101 to the local hospital on 4/7/23 at 3:08 AM. This deficient practice resulted in the likelihood of all independent ambulatory residents to have serious injury, serious harm, serious impairment, or death when R101 left the facility unsupervised and without staff knowledge. […]

• Actual harm, isolatedF689Mar 31, 2025

  This citation pertains to intake #MI00151498. Based on observation, interview and record review, the facility failed to utilize a two-person assist while turning and reposition a resident while performing care for one resident (R903) of three residents reviewed for accidents, resulting in a fall with injury. R903 sustained a right hip fracture that required surgical repair. Findings include: Review of an allegation received through the State Agency revealed the following: (R903) has a history of stroke and is paralyzed from the waist down. (R903) has been in a nursing/rehab facility for the past two years . On or about 3/21/25, (R903) brief was being changed by an employee, and (R903) fell out of the bed. […]

• No harm, potential for more than minimal, widespreadF812Jan 29, 2026

  Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen.Findings Include:On 1/27/2026 at 9:59 AM, observation of the walk-in cooler found an increased accumulation of black spotted debris on the top surfaces of the hard plastic shelving used to store food product. When asked how often the storage shelves get cleaned, Dietary Manager (DM) F stated they get power washed, but it's been so cold we have not been able to take them outside.On 1/27/2026 at 10:19 AM, an interview with DM F found that the clean utensil bin is cleaned weekly. […]

• No harm, potential for more than minimal, widespreadF880Jan 29, 2026

  Based on observation, interview, and record review, the facility failed to have an active and ongoing plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP), resulting in the potential for increased risk of respiratory infection among all residents in the facility.Findings include:On 1/27/26 at 10:25 AM observation of the kitchen serving room revealed a possible stagnant water line coming from the hand sink area down the wall near the steam tables. An interview with the Maintenance Director (MD) H found that he was unaware of the water line. […]

• No harm, potential for more than minimal, widespreadF921Jan 29, 2026

  Based on observation and interview the facility failed to maintain general cleanliness and repair of the premises. This resulted in an increased potential for contamination and a possible decrease in the satisfaction of living, affecting all residents.Findings include: On 1/27/26 starting at 1:17 PM, an environmental tour was conducted in the homebound unit with the following observations:The faucet in resident room [ROOM NUMBER] was observed with only a pencil thin stream of hot water when in use. The faucet was loose to mount and was able to be moved around. The shower room found eight razors stacked on the sink basin. […]