Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hartwell Health And Rehabilitation during CMS and state inspections, most recent first.
Expired insulin pens were found on two medication carts in the facility, with one Humalog pen lacking an open date and a Novolog pen past its discard date. Both pens were removed by the respective LPN and RN, who confirmed the expiration and placed them in a destruction bin. The RN reported the issue to the DON, who stated that expired medications should be discarded per protocol.
The facility failed to maintain clean exhaust fans in six shared bathrooms, leading to a buildup of dust and possible mold. Observations showed thick layers of dust on the fans, and staff interviews revealed inconsistencies in cleaning routines. The Maintenance Supervisor indicated daily cleaning was required, but Environmental Service Aides had varying practices, with some unaware of specific cleaning protocols.
The facility failed to manage elopement risks for two residents with wander guards, lacking proper assessments and documentation. One resident had a history of exit-seeking behavior, while another was preparing to leave the facility, indicating inadequate supervision. Additionally, a resident was found with unauthorized medication at her bedside, without proper assessment or physician's order, highlighting lapses in medication policy adherence.
A resident receiving oxygen therapy did not receive the prescribed flow rate, as observations showed incorrect settings on the oxygen concentrator. The resident, with conditions like heart failure, was at risk due to this discrepancy. Staff interviews revealed a lack of adherence to the physician's order, with the DON aware of the issue but no corrective actions documented.
A resident with COPD and AF was not instructed to rinse her mouth after using a steroid inhaler, as required by facility policy, during medication administration by an LPN. The resident had mildly impaired cognition and required minimal assistance with daily activities. The LPN confirmed the omission, and the DON acknowledged the policy requirement.
A facility failed to accurately document a resident's fall and injury, leading to a deficiency in maintaining medical records. The resident, with multiple diagnoses including a left tibia fracture, experienced a fall that was incorrectly recorded as a right ankle fracture in several documents. Interviews revealed that the facility's process for updating fall status was not followed, highlighting a lapse in adhering to professional standards.
The facility failed to maintain an eyewash station properly, resulting in water flowing from an open pipe onto the floor and staff's feet. The Maintenance Director used a bucket to catch the water, but the Administrator acknowledged the potential slip hazard.
Expired Insulin Pens Found on Medication Carts
Penalty
Summary
The facility failed to remove expired insulin pens from two of the three medication carts observed, which could potentially lead to the administration of expired medications to residents. During an observation, a Humalog insulin pen with a discard date of 10/21/2024 was found on a medication cart managed by an LPN. The pen did not have an identifiable open date, and the LPN confirmed the expiration and removed the pen, placing it in a destruction bin. Another observation revealed a Novolog insulin pen on a different medication cart, managed by an RN, with an open date of 9/23/2024 and a discard date of 10/21/2024. The RN confirmed the expiration and removed the pen, also placing it in a destruction bin. The RN stated that this issue would be reported to the Director of Nursing (DON), who later confirmed that all expired medications should be removed and discarded according to the manufacturer's instructions or facility policy.
Failure to Maintain Clean Exhaust Fans in Shared Bathrooms
Penalty
Summary
The facility failed to maintain clean exhaust fans in six shared bathrooms out of 35, which could compromise the hygiene and safety of the shared bathroom environments. Observations revealed that the exhaust fans in several shared bathrooms were covered with a thick layer of white, fuzzy substance, indicating a significant buildup of dust and possible mold. The facility's policy on housekeeping intended to maintain a clean and sanitary environment, but the guidelines were not consistently followed, as evidenced by the unclean exhaust fans. Interviews with staff revealed inconsistencies in the cleaning routines and awareness of the facility's cleaning protocols. The Maintenance Supervisor noted that exhaust fans should be cleaned daily, but the Environmental Service Aides (ESAs) had varying practices, with one dusting every two weeks and another checking twice a week without specific knowledge of the cleaning frequency. The Environmental Service Supervisor confirmed that ESAs were expected to inspect the exhaust fans daily and clean them approximately three times a week, but acknowledged that some aides, particularly newer staff, required frequent reminders about their tasks.
Deficiencies in Elopement Risk Management and Medication Administration
Penalty
Summary
The facility failed to properly assess and manage the elopement risk for two residents, R54 and R68, who were equipped with wander guards. R54, diagnosed with Alzheimer's disease and dementia, had a history of exit-seeking behavior and had left the property twice on a previous occasion. Despite this, there were no physician orders for behavior monitoring, wander guard use, or skin checks under the wander guard bracelet. The care plan indicated a moderate risk for elopement, but the necessary interventions and documentation were not adequately implemented. Similarly, R68, who was admitted with cognitive impairments and a history of delusions and behavioral symptoms, was also at risk for elopement. The resident's care plan noted the risk due to confusion and frequent requests to go home, yet there were no orders for behavior monitoring or skin checks related to the wander guard. Observations revealed that R68 was preparing to leave the facility, indicating a lack of effective supervision and intervention to prevent potential elopement. Additionally, the facility failed to assess R32 for self-administration of medication properly. R32, with a history of dementia and cerebrovascular accident, was found with an unauthorized topical analgesic rub at her bedside. The resident was unable to demonstrate the necessary understanding and skills for self-administration, and there was no physician's order for the medication. Despite staff awareness of the ointment's presence, it was not addressed until observed by a surveyor, highlighting a lapse in adherence to the facility's medication policies.
Oxygen Therapy Administration Deficiency
Penalty
Summary
The facility failed to administer oxygen therapy to a resident, R33, in accordance with the physician's order, which specified a flow rate of 2 liters per minute (LPM) via nasal cannula as needed. Observations revealed that the oxygen concentrator flow rate was set at 2.5 LPM and 1.75 LPM on different occasions, deviating from the prescribed rate. The resident, who was admitted with conditions including paroxysmal atrial fibrillation and heart failure, was at risk of respiratory complications due to this discrepancy. The facility's policy on oxygen therapy intended to ensure optimal oxygenation was not adhered to, as evidenced by the incorrect flow rates. Interviews with staff, including an LPN and the DON, confirmed that the oxygen flow rates were not consistently set as ordered. The LPN admitted to not checking the flow rate during her shift, while the DON acknowledged awareness of the issue, noting that it was a common problem and had been discussed in meetings. The DON also mentioned that the corporate RRT had previously identified the issue and recommended contacting the physician to adjust the order and conducting self-audits to ensure compliance. Despite these recommendations, there was no documentation of staff education or audits being conducted prior to the survey.
Failure to Instruct Resident on Proper Inhaler Use
Penalty
Summary
The facility failed to properly administer an oral steroid inhaler to a resident, identified as R6, during medication administration. The facility's policy on Oral Inhalation and Nebulizer Administration requires that after using a steroid inhaler, the patient should thoroughly rinse their mouth with water and spit it out to minimize the risk of oral pharyngeal candidiasis (thrush). However, during an observation on October 23, 2024, it was noted that the Licensed Practical Nurse (LPN) administering the medication did not instruct or educate R6 to rinse her mouth after using the inhaler. R6, who was admitted with chronic obstructive pulmonary disease (COPD), atrial fibrillation (AF), and peripheral vascular disease (PVD), had a physician's order for fluticasone furoate/vilanterol trifenatate inhaler to be administered twice daily. The resident had mildly impaired cognition with a Brief Interview for Mental Status (BIMS) score of eight and required minimal assistance with activities of daily living due to lower body weakness. During an interview, the LPN confirmed the omission, and the Director of Nursing acknowledged that inhalers should be administered according to physician's orders and facility policy.
Inaccurate Documentation of Resident Fall and Injury
Penalty
Summary
The facility failed to maintain accurately documented resident records in accordance with accepted professional standards and practices regarding falls for one resident, identified as R32. The deficiency was identified through observation, record review, resident and staff interviews, and a review of the facility's policies on Fall Management and Documentation in the Medical Record. The facility's policy requires that each resident's risk for falls be evaluated by the interdisciplinary team, with a plan of care developed and implemented based on this evaluation. However, the facility did not adhere to these standards, as evidenced by the inaccurate documentation of R32's fall and subsequent injury. R32 was admitted to the facility with multiple diagnoses, including a displaced fracture of the medial malleolus of the left tibia, unsteadiness on feet, and unspecified dementia. The resident's quarterly Minimum Data Set indicated a fall with major injury since admission. Despite this, the facility's incident report fall list documented a fall on 8/2/2024 with no apparent injury, contradicting the nurse's notes that indicated a probable fracture of the medial malleolus. The facility incorrectly recorded the fracture as being on the right ankle in multiple documents, including the Event Follow-Up and Therapy Referral, despite the diagnosis clearly indicating a left ankle fracture. Interviews with the Director of Nursing and the Administrator revealed that the facility's process for updating the status of falls was not followed. The Director of Nursing acknowledged that the charting should have been updated to reflect a fall with major injury and that it was the responsibility of the first nurse noting the fall to change the status. The Administrator emphasized the clinical team's responsibility to ensure accurate and comprehensive documentation. The failure to accurately document the resident's fall and injury status represents a deficiency in maintaining medical records according to professional standards.
Eyewash Station Maintenance Deficiency
Penalty
Summary
The facility failed to maintain an eyewash station in a safe and functional manner, as observed during a survey. Specifically, water flowed from an open pipe below the eyewash station onto the floor and onto the feet of staff using the sink. This issue was identified during a tour of the laundry department, where water was seen flowing from under the eyewash station onto the feet of the surveyor and a Laundry Aide. The Laundry Aide confirmed that the pipe under the eyewash station was always open, causing water to flow onto the floor whenever the station was used. The Maintenance Director acknowledged that the open pipe had been present since before his tenure at the facility, which began five years ago. He stated that he checked the eyewash station monthly and used a bucket to catch the water to prevent it from flowing onto the floor. However, he believed that as long as the eyewash station was operational, it was sufficient, despite the potential hazard. The Administrator expressed that her expectation was for the water to drain properly and not spill onto the floor, as the current situation posed a slip and fall hazard.
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 39 citations issued within 25 miles in the last 12 months — 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 Hartwell
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hart Care Center | 1.2 mi | — | 0 | 0 |
| Brown Health And Rehabilitation | 11.1 mi | — | 7 | 0 |
| Iva Post-acute | 15.8 mi | — | 5 | 0 |
| Comer Health And Rehabilitation | 17.1 mi | — | 4 | 0 |
| Pruitthealth - Spring Valley | 17.2 mi | — | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Hartwell Health And Rehabilitation.
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 August 2026) and official state health department websites.