Hartwell Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Hartwell Health and Rehabilitation, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Feb 8, 2026

  Based on observations, staff interviews, and review of facility policy titled, Food Preparation and Distribution, the facility failed to ensure dietary staff properly washed hands in the dish room to prevent cross contamination. The facility census was 85 and all residents were receiving an oral diet. The deficient practice had the potential to affect all facility residents.Findings include:Review of the facility policy titled Food Preparation and Distribution revealed Cross contamination - hand washing should occur before putting on gloves and after removing gloves. […]

• No harm, potential for more than minimal, patternF761Oct 24, 2024

  Based on observations, record review, staff interviews, and review of the facility's policy titled Medication Beyond-Use and Expiration Dates, the facility failed to remove expired insulin pens from two of three medication carts observed. This failure had the potential for residents to be administered expired medications. Findings include: Review of the undated facility's policy titled Medication Beyond-Use and Expiration Dates, under the section titled Guidelines revealed, An expiration date indicates the last date at which the manufacturer guarantees a drug's full potency and safety Medication should not be stored, transported, or administered after beyond-use or expiration date. […]

• No harm, potential for more than minimal, isolatedF607Feb 8, 2026

  Based on record review, staff interviews, and review of the facility policy titled, Abuse Prohibition-Screening, Hiring, And Training Practices, the facility failed to complete and receive satisfactory background check screenings for one of 11 nursing staff reviewed. The deficient practice had the potential for staff with criminal backgrounds to care for vulnerable residents.Findings include:Review of the facility policy titled Abuse Prohibition-Screening, Hiring, And Training Practices reviewed date 12/04/2021 revealed it is the intent of this center to establish standards of practice for screening, hiring and training of associates. […]

• No harm, potential for more than minimal, isolatedF677Feb 8, 2026

  Based on observations, resident and staff interviews, record review, and review of the facility policy titled, Foot Care, the facility failed to adequately provide Activities of Daily Living (ADL) care pertaining to foot treatment for one of 36 sampled residents (R) (R11). The deficient practice had the potential to place R11 at risk for unmet needs and a diminished quality of life.Findings include:Review of the facility policy titled Foot Care review dated 12/27/2024 revealed under Intent: To provide foot care in accordance with professional standards of practice as part of routine care to assist in identifying skin concerns, maintain mobility and sustain good foot health.Review of the electronic medical record (EMR) for R11 revealed she was admitted to the facility with diagnoses… […]

• No harm, potential for more than minimal, isolatedF684Feb 8, 2026

  Based on staff and resident interviews and record review, the facility failed to follow physician orders and to contact the physician for a change in condition for one of 16 residents (R) (R13) sampled with physician orders for daily weights. The deficient practice had the potential to place R13 at risk for medical complications, unmet needs, and a diminished quality of life.Findings include:Review of R13's electronic medical record (EMR) revealed R13 was admitted to the facility with pertinent diagnoses including but was not limited to acute and chronic respiratory failure with hypoxia, hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, stage 3 chronic kidney disease, chronic diastolic (congestive) heart failure, paroxysmal… […]