Fenton Healthcare

Inspectors wroteThis Citation pertains to intake Number 3069106. Based on interview and record review, the facility failed to ensure that safe positioning and supervision was maintained during provision of care for one resident (Resident #4) of three residents reviewed for supervision and safety with falls. This deficient practice resulted in Resident #4's fall from the bed causing the resident pain and sustaining facial contusions with a 4.5 cm hematoma on the forehead and a laceration requiring a hospital evaluation, monitoring and skin repair.

Inspectors wroteTis citation pertains to Intake Number 2972860. Based on interview and record review, the facility failed to provide a medication, as ordered, for one resident (Resident #4) of three residents reviewed for medication administration. Findings Include:Resident #4:A record review of the Face sheet and progress notes for Resident #4 indicated admission to the facility on 3/25/2026 with diagnoses: Respiratory failure, myelodysplastic syndrome, stem cell transplant, severe protein-calorie malnutrition, hypomagnesemia, heart failure, atrial fibrillation, depression, hypothyroidism, gout, and deep vein thrombosis. Resident #4 discharged to home on 4/4/2026. A review of the physician orders for Resident #4 identified the following: [...]

Inspectors wroteBased 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, resulting in the potential for increased risk of respiratory infection among all residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the advance directive status was ordered, signed by the physician, and posted in the resident's clinical record per facility policy for one resident [Resident #80 (R80)] of 5 residents reviewed for advance directives.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that oxygen humidification was provided, physician's orders for oxygen were followed and nebulizer equipment was stored according to facility policy for two residents (#51 and #69) of three residents reviewed for respiratory care.

Inspectors wroteThis Citation Pertains to Intake Number MI00148563. Based on interview and record review, the facility failed to protect the resident's right to be free from misappropriation of property by facility staff for one resident (Resident #701) of three residents reviewed.

Inspectors wroteREFER TO INTAKE NUMBER: MI00147356 Based on observation, interview, and record review, the facility failed to provide the appropriate skin care interventions to prevent the development of pressure ulcers and promote healing consistent with professional standards for three residents (R301, R302, and R304) of four sampled residents reviewed for pressure ulcers resulting in delay in treatment and healing and potential for worsening of wound, infection and further complications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a clean and safe environment for 11 residents' rooms, 2 main hallways, and 1 residential sitting area, resulting in the likelihood for resident injury (bug and spider bites and hand splinters), anger and frustration from family members and residents, and cross contamination with illnesses with increased use of antibiotics. Findings Include: During an environmental walk through done on 10/2/24 starting at 8:16 a.m., accompanied by Director of Maintenance, Housekeeping and Laundry D; the following concerns were observed: First Floor: -At 8:16 a.m., room [ROOM NUMBER], the oxygen tubing with nasal cannula was observed on the floor (not in a bag) next to his bed. The resident had no idea where his oxygen was. -room [ROOM NUMBER], the bathroom toilet had BM on the back of the seat and the floor was found dirty. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents received assistance with showering and shaving for one resident (Resident #20) and failed to use appropriate hand hygiene during ADL (activities of daily living) care for Resident #265, of five residents reviewed for ADL care and 3 of 5 confidential group of residents voicing concern of not receiving bathing activity, resulting in the potential for embarrassment, frustration, needs not meet, infection and lack of feelings of self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility 1) Failed to ensure a safe environment with adequate supervision and implement interventions to prevent a fall for three residents (Resident #2, Resident #53 and Resident #54) and failed to do a complete fall investigation for those three residents and 2) Failed to ensure that Resident #212 had their C-collar (Cervical collar or brace used to support the neck and spinal cord, often used for neck pain, spinal fractures, surgery recovery or trauma) on while out of bed as ordered by the physician of 7 residents reviewed for falls and accident hazards, resulting in potential for pain and decline in medical condition and the likelihood of repeated fall with serious injury to occur due to incomplete investigations for R2, R53 and R54 and the potential for pain or worsening/decline in medical condition for Resident #212.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain the kitchen and food preparation equipment in a sanitary condition and ensure clean and ready-for-use kitchen equipment was air dried properly, resulting in an increased potential for food borne illness, potentially affecting 60 residents of a census of 62 residents who consume oral nutrition from the facility kitchen. Findings Include: Review of the U.S. Public Health Service 2009 Food Code, as adopted by the Michigan Food Law, effective October 1, 2012, directs those physical facilities shall be cleaned as often as necessary to keep them clean, food equipment was to be dried in a manner that leaves no water left inside prior to storage, and ready-to-eat foods shall be clearly marked at the time the original container is open if held for more than 24 hours. [...]

Inspectors wroteBased on observation, interview and record review, the facility 1) Failed to ensure the dignity and privacy of one resident (Resident #265) while doing a bed bath, and 2) Failed to ensure that one resident (Resident #212) had their call light within reach, resulting in the likelihood for shame, embarrassment, anger towards staff, feeling of isolation and fear of not having a readily available call light. Findings Include: Resident #265: Review of the Face Sheet, physician orders dated 9/21/24 through 10/1/24, and care plans dated 9/21/24 through 9/26/24, revealed Resident #265 was 73 years-old, admitted to the facility on [DATE], alert and able to make healthcare decisions, and dependent on staff for assistance with Activities of Daily Living (ADL). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to up-date person-centered comprehensive care plans to ensure that a shaving preference was identified for one resident (Resident #20) and a transfer status was updated for one resident (Resident #212) of 17 residents reviewed for care plans, resulting in the potential for Residents' needs not being met, frustration, Resident #20 not shaved to their preference and Resident #212 not assisted with getting out of bed during the weekend.

Inspectors wroteObservation of Transmission-Based Precautions: On 9/12/23 at 4:22 PM, an observation was made in room [ROOM NUMBER]. The room was for single occupancy and had transmission-based precautions sign on the door that indicated the Resident was on contact precautions. Personal protection equipment (PPE) was available on the door. Upon entrance, an observation was made of the Resident laying in bed. An interview was conducted with the Resident. After the completion of the interview, an observation was made of the bathroom across from the Resident and was not readily accessible due to a chair and overbed table in the vicinity of the door to the bathroom. PPE was removed at the doorway to the hall and deposited in the receptacle for discarded PPE. [...]

Inspectors wroteNarcotic Storage: On 9/14/23 at 12:18 PM, medication storage and labeling was reviewed with Nurse C of the medication room with the Omnicell that holds prescriptions medication that can be accessed by a computer to obtain necessary medications for Residents. The medication room was located behind the nurses' station and was locked. An observation was made of two vials of Ativan 2 mg (milligrams)/ml (milliliters) in a removable locked plastic box in an unlocked medication refrigerator. The locked plastic box was not secured inside the refrigerator. Nurse C was asked about the narcotic count and reconciliation of the Ativan. The Nurse reported that the Ativan was part of the Omnicell and that pharmacy takes care of that. The Nurse indicated the key to the box with the Ativan was in the Omnicell with a computer to access the contents and sign out the medication with a key from the Omnicell. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide documentation of adequate notice of non-coverage for Medicare Part A benefits for two residents (Resident #174 and Resident #175) of 3 residents reviewed for notice of non-coverage of Medicare Part A benefits, resulting in the residents' inability to exercise the right to file an appeal in a timely manner. FACILITY Beneficiary Notification: Resident #174: A record review of the Face Sheet and Minimum Data Set (MDS) assessment indicated Resident #174 was admitted to the facility on [DATE] with diagnoses left femur fracture repair, weakness, heart failure, atrial fibrillation, hypertension, arthritis, GERD, anxiety and depression. A review of the progress notes revealed Resident #174 was discharged home on 1/16/2023. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to implement a comprehensive care plan for one resident (Resident #70) of 19 residents reviewed for care plans, resulting in Resident #70 lacking a urinary catheter securement device. Findings Include: Resident #70: Urinary Catheter or UTI A record review of the Face Sheet and Minimum Data Set (MDS) assessment indicated Resident #70 was admitted to the facility on [DATE] with diagnoses: recent history of pulmonary embolism, diabetes atrial fibrillation, heart failure, hypertension, deep vein thrombosis left lower extremity, weakness, morbid obesity, chronic kidney disease. On 8/8/2023 diagnosis of chronic ulcer let thigh and left lower leg and on 8/32023 a diagnosis of urinary retention was added. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to correctly identify an intravenous (IV) catheter to ensure appropriate care and maintenance of the catheter for one resident (Resident #15) of 3 residents reviewed for IV catheter use, resulting in the potential for Resident #15 to not receive the necessary care and services needed to prevent a decline in condition.

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent the development of a Stage II (blister) heel pressure ulcer for one resident (Resident #49) of 3 residents reviewed for pressure ulcers, resulting in a Stage II heel pressure ulcer, pain, discomfort, agitation, and wound treatments.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Enteral nutrition (tube feeding/nutrition through a feeding tube into the stomach or intestines) formula was provided as ordered for one resident (Resident #56) of 2 residents reviewed for enteral nutrition, resulting in the potential for Resident #56 to not receive the appropriate amount of Enteral formula. Findings Include: Resident #56: Tube Feeding A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #56 was admitted to the facility on [DATE] and discharged and readmitted several times with the most recent readmission on [DATE] with diagnoses: Encephalopathy, anxiety, depression, urinary retention, gastrostomy tube for enteral nutrition, dementia, history of a stroke, GERD, hypertension, aphasia (absence of speech) and dysphagia (difficulty talking). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that one resident's (Resident #11) preferred tracheostomy care supplies was available for the resident to perform their own tracheostomy cleaning and that the water for humidification was dated and replaced on the Airvo machine (oxygen delivery system with water for humidification used for the administration of oxygen through the tracheostomy tube) for Resident #11 of one resident reviewed for tracheostomy care, resulting in frustration for the resident and the potential for infection and respiratory illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure that laboratory testing levels for Tobramycin (an antibiotic used to treat infection) were drawn as recommended by Pharmacy services and that laboratory testing results were obtained timely for one resident (Resident #54) of three residents reviewed for antibiotic use, resulting in an IV (intravenous) antibiotic medication, Tobramycin, not administered, a delay in treatment of infection, and the potential for worsening infection and decline in overall health.