Hartley Nursing and Rehab

In the surveyor’s words

From the most serious findings on record at Hartley Nursing and Rehab, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF656Jan 23, 2026

  Based on observation, interview and record review, it was determined that the facility failed to develop and implement comprehensive care plans for the use of 1) oxygen (O2) therapy and 2) cardiac medications. This was evident for 4 (Residents #45, #62, #53 and #2) of 23 residents reviewed for care planning during the recertification survey. The findings include: A care plan is a guide that addresses the unique needs of each Resident. It is used to plan, assess, and evaluate the effectiveness of the Resident's care. The care plan consists of focus, goal and interventions. 1a. On 1/14/2026 at 10:30 AM, during the initial tour of the facility, Resident #45's O2 concentrator was found turned off with tubing on the floor, under the bed. […]

• No harm, potential for more than minimal, patternF695Jan 23, 2026

  Based on observation, interview, and record review, it was determined that the facility failed to provide necessary respiratory care services by failing to label oxygen administration equipment. This was evident for 4 (Resident #57, #53, #62 and #45) of 4 residents reviewed for respiratory care during the recertification survey. The findings include: Oxygen (O2) therapy is a treatment that provides a person with extra O2 to breathe in. It is also called supplemental O2. A nasal cannula is a thin, flexible tube that delivers O2 through the nose. A humidifier in O2 therapy is a device that adds moisture to dry, concentrated O2 to prevent drying and irritation of a patient's nasal passages, throat, and lungs. […]

• No harm, potential for more than minimal, patternF727Jan 23, 2026

  Based on a review of staffing sheets and interview, it was determined that the facility failed to ensure a registered nurse (RN) was on duty of at least 8 consecutive hours, 7 days a week. This was evident for 2 of 23 days reviewed during the recertification survey and has the potential to affect all residents. The findings include: On 1/20/2026 at 10:14 AM, a review of the staffing sheets revealed that no RN worked during the 7-3 and 3- 11 shifts on Sunday, January 4, 2026, or the 3-11 shift on Saturday, January 10, 2026. On 1/21/2026 at 12:22 PM, in an interview with the Director of Nursing (DON), she confirmed that although she was the on-call RN on January 4, she was unable to fulfill her duties due to personal reasons. […]

• No harm, potential for more than minimal, patternF812Jan 23, 2026

  Based on observations and staff interviews, it was determined that the facility failed to store and prepare food in a manner that maintained professional standards of food service safety. This practice had the potential to affect all residents eating food prepared in the facility's kitchen. The findings include:During the initial tour of the kitchen conducted on 01/14/2026 at 9:40 AM, the Surveyor and Food Service Director observed multiple food items stored in the dry storage area that were opened and undated or had illegible labeling. […]

• No harm, potential for more than minimal, isolatedF580Jan 23, 2026

  Based on record review and interviews, it was determined that the facility failed to notify the Physician and Resident Representative (RP) of the residents' change in condition. This was evident for 2 (Resident #5 and Resident #57) of 4 residents reviewed for hospitalizations during the recertification survey. The findings include: 1. On 1/22/26, review of Resident #5's clinical record revealed that the resident was transferred to the hospital on 1/6/26 following a change in condition and returned to the facility on 1/14/26. […]