Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
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 Hartford Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
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.
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.
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 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.
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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.
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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 | — | 2 | 0 |
| Westwood Nursing Center | 0.9 mi | — | 19 | 0 |
| Oakpointe Senior Care And Rehab Center | 1.3 mi | — | 0 | 0 |
| Sheffield Manor Nursing & Rehabilitation Center | 1.4 mi | — | 14 | 0 |
| The Villa At Great Lakes Crossing | 1.9 mi | — | 8 | 0 |
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