Fenton Healthcare

In the surveyor’s words

From the most serious findings on record at Fenton Healthcare, in the surveyor’s own words.

• Actual harm, isolatedF689Jul 21, 2026

  This 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. Findings include: Resident #4 (R4): A record review for R4's Minimum Data Set (MDS) assessment revealed a Brief Interview of Mental status (BIMs) score of 10 that indicated moderate cognitive impairment. […]

• Actual harm, isolatedF686Jun 14, 2022

  Based on observation, interview and record review, the facility failed to properly identify, assess, manage, document, prevent development, and treat skin conditions for two residents ( Resident #47 and Resident #52) of five residents reviewed for pressure injury, resulting in residents developing Stage 4 pressure injuries ( Resident #47) and developing a deep tissue injury (Resident #52) and suffering pain, hospitalization s, and surgical debridement. Findings include: Resident #52: According to admission face sheet, Resident #52 was a [AGE] year-old female, admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to Minimum Data Set (MDS) dated [DATE], Resident #52 was scored 13 on the Cognition Assessment, indicating intact Cognition. […]

• Actual harm, isolatedF686Apr 1, 2021

  Based on observations, interviews, and record reviews, the facility failed to prevent the development of a Stage IV pressure ulcer for one resident (Resident #33) of three residents reviewed for pressure ulcers and care, resulting in the development of a Stage IV pressure ulcer of the sacrum for Resident #33, which required multiple treatments to the area. Findings include: The facility 'Skin Management' Policy, dated as revised 10/2019, documented: It is the policy that the facility should identify and implement interventions to prevent the development of clinically unavoidable pressure injuries. Guests and residents with wounds and/or pressure injury and those at risk for skin compromise are identified, evaluated, and provided appropriate treatment to promote prevention and healing. […]

• No harm, potential for more than minimal, widespreadF880Dec 4, 2025

  Based 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.Findings include: On 12/02/2025 at 1:15pm during the environmental tour with the Environmental Services Director I, the Environmental Services Director I tested the chlorine residual at the staff bathroom sink on the first floor and the result was undetectable on the [NAME] K-2005 chlorine test kit. The testing kit measures chlorine residual from 1 to 10 parts per million (ppm). The test kit is primarily designed to test for chlorine in swimming pools, not drinking water. […]

• No harm, potential for more than minimal, widespreadF921Oct 3, 2024

  Based 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. […]