Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Fenton Healthcare during CMS and state inspections, most recent first.
A resident with severe protein-calorie malnutrition, hypomagnesemia, and multiple comorbidities was admitted with hospital discharge orders to continue an oral magnesium supplement (MG Plus Protein 133 mg) that had been used to treat low magnesium levels. The physician order and MAR showed a daily dose, but over the resident’s entire stay nurses documented the drug as held or unavailable, with eMAR notes indicating it was not on hand and progress notes by an NP that mentioned the drug without noting it was not being given. Pharmacy later reported it did not carry the product and had faxed this information to the facility, and the consultant pharmacist stated the supplement was considered OTC/house stock that the facility was responsible to supply. No alternative magnesium supplement was obtained, and the resident did not receive the ordered medication before discharge.
Water Management Plan Did Not Demonstrate Accurate Chlorine Residual Monitoring. The facility failed to maintain an active and ongoing plan to reduce the risk of legionella and other opportunistic pathogens in premise plumbing. During an environmental tour, the chlorine residual at a staff bathroom sink was undetectable using a test kit that only measures 1 to 10 ppm, and staff confirmed no other kit had been used to measure residuals below 1 ppm. Record review showed the Water Management Plan documented free chlorine residuals as .1 ppm, while meeting minutes listed control limits of 0.2-4.0 ppm as acceptable, and the Administrator stated the low readings were a mistake.
Advance directive status was not properly ordered or documented for a resident with significant cardiac and pulmonary diagnoses. Although the resident signed as full code and was described as cognitively intact, the full code status was missing from the Advance Directive section, not found in the MD orders, and not posted on the face sheet or in the resident profile; the DON and SW confirmed the omission.
Respiratory care was not provided as ordered for two residents. One resident’s nebulizer was stored wet in a bag instead of being dried, and another resident’s oxygen was set above the physician order with dry humidification that had not been changed as expected. The resident on oxygen reported taking it off and on and having nosebleeds and nasal dryness, while staff confirmed the oxygen setting and humidification issues.
A resident with severe cognitive impairment had their credit card stolen and used for fraudulent purchases by a CNA, who later admitted to the theft and resigned. The resident's family discovered the missing card and reported it after noticing unauthorized charges. The facility's inventory process for personal belongings was inconsistently followed, and not all staff with access to the resident were interviewed during the investigation.
The facility failed to provide appropriate skin care interventions for three residents, leading to deficiencies in pressure ulcer care. A resident with a sacral pressure ulcer had missing treatment documentation, indicating inconsistent care. Another resident with a stage 3 ulcer also had lapses in treatment records, with staff interviews confirming that unsigned treatments were assumed not performed. A third resident had an unreported open area on the sacrum, with incomplete treatment documentation. The facility's wound care protocol was not adequately followed.
The facility was found to have multiple deficiencies in maintaining a clean and safe environment, including dirty air conditioner filters, fecal matter on bathroom fixtures, and an overflowing soiled utility room. A strong urine odor was detected near the nurse's station and in resident rooms. Staff interviews revealed inadequate cleaning protocols and oversight.
A facility failed to provide adequate ADL assistance for a resident who preferred to be clean-shaven, as his preference was not documented in his care plan. Additionally, a CNA did not follow proper hand hygiene protocols while providing a bed bath to another resident, failing to change gloves or wash hands after peri care. A resident meeting also revealed concerns about missed showers due to low staffing.
The facility failed to provide adequate supervision and complete fall investigations for several residents, leading to multiple falls and safety concerns. A resident with severe cognitive impairment experienced three falls with incomplete incident reports. Another resident with a history of falls and mobility issues had two falls, also with incomplete reports. A third resident with significant mobility impairments experienced five falls, with reports lacking essential details. Additionally, a resident was observed without a required cervical collar, indicating a failure to follow physician orders.
The facility failed to maintain sanitary conditions in the kitchen, with several pieces of equipment found with dried-on food particles and rust-like substances. Additionally, clean kitchen equipment was not properly air-dried, increasing the potential for foodborne illness among residents.
A facility failed to maintain the dignity and privacy of a resident during a bed bath, leaving them uncovered and exposed, and did not ensure another resident had their call light within reach, leaving them waiting for assistance. These actions violated the facility's policies on resident dignity and call light accessibility.
The facility failed to update care plans for two residents, leading to unmet needs. A resident with chronic conditions was not shaved according to his preference, as his care plan lacked this information. Another resident, requiring assistance for transfers, was not helped out of bed over a weekend due to a communication lapse between therapy and nursing staff. The facility's policy mandates specific, resident-centered care plans, but these were not adequately maintained.
Failure to Provide Ordered Magnesium Supplement for Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide a prescribed magnesium supplement, MG Plus Protein 133 mg, to a resident admitted with multiple serious diagnoses, including respiratory failure, myelodysplastic syndrome, stem cell transplant, severe protein-calorie malnutrition, hypomagnesemia, heart failure, atrial fibrillation, depression, hypothyroidism, gout, and deep vein thrombosis. Hospital discharge orders indicated the resident had received both IV magnesium and MG Plus Protein tablets in the hospital for low magnesium levels and was to continue the oral MG Plus Protein at the facility. The physician order and MAR reflected a daily MG Plus Protein 133 mg tablet from admission through discharge, but the medication was repeatedly documented as held or unavailable. From 3/26 through 3/31, nursing staff documented on the MAR that the MG Plus Protein tablet was held, with eMAR notes on multiple days stating the medication was unavailable or on order. Progress notes by the NP on several dates referenced the MG Plus Protein tablet but did not document that the resident was not receiving it. The resident’s care plan identified severe protein-calorie malnutrition, hypomagnesemia/hypokalemia, and nutritional risk, with an intervention to provide supplements as ordered, yet the ordered magnesium supplement was not administered during the stay. On 4/1, a nurse contacted the pharmacy and was informed that the pharmacy did not carry MG Plus Protein and would recommend an alternative; the NP was informed, and a note indicated the facility was awaiting a new order. Later that day, staff contacted the resident’s cancer center to review the medication and were told it could be put on hold pending further guidance, with the resident and spouse made aware. The consultant pharmacist later stated that MG Plus Protein was considered an OTC/house stock item that the facility was responsible to provide and that the pharmacy had faxed the facility on 3/25 indicating the product was not available. The resident remained at the facility for nine days and did not receive the ordered MG Plus Protein supplement or an alternative medication before discharge home.
Water Management Plan Did Not Demonstrate Accurate Chlorine Residual Monitoring
Penalty
Summary
The facility failed to have an active and ongoing plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing. During an environmental tour with the Environmental Services Director I, the chlorine residual at the staff bathroom sink on the first floor was tested and found to be undetectable using the [NAME] K-2005 chlorine test kit, which measures chlorine residual from 1 to 10 ppm and is primarily designed for swimming pools rather than drinking water. When asked whether another test kit had been used to measure chlorine residual since the chlorine logs showed results below 1 ppm, the Environmental Services Director I stated no. Record review showed that the Water Management Plan included a Legionella Environmental Assessment Form with free chlorine residual results recorded as .1 ppm. The Water Management Team Meeting Minutes dated 3/3/25-6/16/25 listed the chlorine residual control limits as 0.2-4.0 ppm and marked them as acceptable. When interviewed about how chlorine residual results were recorded below 1 ppm when the test kit was not sensitive enough to measure below 1 ppm, the Administrator stated that the Environmental Services Director I made a mistake. The State Operations Manual for Water Management states that facilities must demonstrate measures to minimize the risk of Legionella and other opportunistic pathogens in building water systems, including control measures and how to monitor them.
Advance Directive Status Not Ordered or Posted
Penalty
Summary
The facility failed to ensure that one resident’s advance directive status was ordered, signed by the physician, and posted in the resident’s clinical record according to facility policy. Resident #80 was observed in bed wearing a life vest and had diagnoses including NSTEMI myocardial infarction, ischemic cardiomyopathy, right bundle branch block, paroxysmal atrial fibrillation, COPD, pleural effusion, and heart failure. The record showed no code status in the Advance Directive section, even though a Code Status Form had been signed by the resident. The resident’s chart also did not reflect the signed full code status in the Advance Directive section for staff to know her wishes. The record review and interviews showed that the resident was documented as cognitively intact and had signed as full code, but the full code status was not written in the clinical record, not posted on the face sheet, not found in the physician’s orders, and not reflected in the resident’s profile. The Social Worker confirmed the resident was her own responsible party and competent when she signed the advance directive, but the status was not ordered. The DON acknowledged that the full code order was not in the record and stated it should have been entered, while also confirming that the code status was not found in the resident’s clinical file.
Respiratory Care Not Provided as Ordered
Penalty
Summary
Safe and appropriate respiratory care was not provided for two residents when oxygen humidification was not maintained, physician oxygen orders were not followed, and nebulizer equipment was not stored according to facility policy. Resident #51 had diagnoses including COPD and pneumonia and was observed with a nebulizer and mask on the bedside table, stored in a see-through bag with liquid still in the medication chamber and not dried before storage. The resident stated the nebulizer was used when he was sick. The resident had an order for ipratropium-albuterol solution via nebulizer every 4 hours as needed for shortness of breath or wheezing. Resident #69 had diagnoses including heart failure and pneumonia and was assessed as having moderately impaired cognition and needing assistance with several activities of daily living. The resident was observed with oxygen tubing over her ears and the nasal cannula on her chin while the concentrator was set at 3 L/min, although the physician order was for 2 L/min. The humidification container was dry, dated 11/15/25, and had not been changed with the tubing change dated 12/1/25. The resident reported taking oxygen off and on and having nosebleeds and dryness. Staff interviews confirmed the humidification had not been changed and that the oxygen should have been at 2 L/min, while the facility policy stated nebulizer equipment should be rinsed and air-dried or discarded after treatment.
Failure to Protect Resident from Misappropriation of Property by Staff
Penalty
Summary
A facility failed to protect a resident from misappropriation of property by a staff member. The incident involved a resident with severe cognitive impairment, a history of stroke, depression, diabetes, and congestive heart failure, who required assistance with activities of daily living. The resident's family member discovered fraudulent charges on the resident's credit card and reported the card missing. The family member handled all of the resident's finances and noticed the card was missing from the resident's wallet, which was found in the resident's room. The resident was unaware of the missing card or the fraudulent charges due to cognitive impairment. The facility's investigation revealed that a Certified Nursing Assistant (CNA) was identified as the suspect after inconsistencies were found in their statements. The CNA admitted to taking the card and resigned after being suspended pending investigation. The CNA had worked at the facility for six years with no prior performance issues. The facility did not interview all staff who had access to the resident during the relevant period, including housekeeping staff, as the administrator felt it was unnecessary after identifying the suspect. A review of the resident's admission inventory documentation showed that the wallet and credit card were not listed, and there was inconsistency in the process of documenting and securing residents' personal belongings. Staff interviews indicated that the inventory process was not consistently followed, with some staff stating they did not participate in or sign the inventory forms. The resident's family also reported that other items, such as hearing aids, were not properly inventoried upon admission.
Deficiencies in Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide appropriate skin care interventions for three residents, leading to deficiencies in pressure ulcer care. Resident 301, who had a diagnosis of Type 2 Diabetes Mellitus and a pressure ulcer of the sacral region, was found to have missing signatures on their Treatment Administration Record (TAR) for several dates in July, August, and September 2024. This lack of documentation indicated that prescribed treatments, such as cleansing and applying creams to the sacral area, were not consistently administered. The resident's wound was noted to be deteriorating, and they were eventually sent to a hospital for further evaluation. Resident 302, admitted with Parkinsonism and a stage 3 pressure ulcer, also experienced lapses in treatment documentation. The TAR for October 2024 showed unsigned treatment boxes on specific dates, and there were no corresponding notes in the nurses' records to explain these omissions. Interviews with nursing staff revealed that if a treatment is not signed off, it is assumed not to have been performed, highlighting a gap in adherence to treatment protocols. Resident 304 was observed with an open area on the sacrum, which was not initially identified in the facility's list of residents with pressure sores. The treatment for this resident was also not consistently documented, with an unsigned treatment box noted in October 2024. Interviews with the wound nurse and the Director of Nursing confirmed that treatments must be signed off to indicate completion, yet this protocol was not followed. The facility's wound care protocol emphasized the need for preventative measures and documentation, which were not adequately implemented for these residents.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean and safe environment for its residents, as evidenced by multiple observations during an environmental walkthrough. On the first floor, issues included oxygen tubing left on the floor, a bathroom with fecal matter on the toilet seat, and dirty air conditioner filters. Additionally, the shower room had dead bugs and spider webs, and the dining room tables had exposed wood, posing safety and infection control concerns. The laundry room was found with heavy lint buildup on dryer screens and dust on exhaust fan blades, with clean linens being folded directly beneath the dusty fan. On the second floor, several areas had black marks and scuffs on the walls, and a strong urine odor was detected near the nurse's station and in resident rooms. The air conditioners in multiple rooms were found with dust and mold-like substances, and window tracks were dirty with dead bugs. The soiled utility room was overflowing with bags of soiled linen, contributing to the urine odor in the hallway. Interviews with staff revealed a lack of proper cleaning protocols and oversight. The Director of Maintenance/Housekeeping/Laundry admitted to not having a checklist for walkthroughs, and the Laundry Aide mentioned cleaning filters only as needed. The Director of Nursing acknowledged the need for improvement, and the facility's infection control walkthroughs failed to identify any unclean areas, despite the numerous issues observed during the survey.
Deficiencies in ADL Assistance and Hand Hygiene
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for Resident #20, who was admitted with multiple diagnoses including chronic obstructive pulmonary disease, dementia, and muscle weakness. Observations revealed that the resident had facial hair that he did not prefer, indicating a lack of assistance with shaving. Interviews with staff, including a CNA and the Director of Nursing (DON), confirmed that the resident's preference for being clean-shaven was not documented in his care plan or Kardex, leading to a failure in meeting his personal hygiene needs. Additionally, the facility did not adhere to proper hand hygiene protocols during ADL care for Resident #265. The resident, who was dependent on staff for ADL assistance due to conditions such as encephalopathy and respiratory failure, was observed receiving a bed bath from CNA F. During the process, the CNA failed to change gloves or wash hands after performing peri care and handling soiled linens, which is a violation of the facility's hand hygiene policy. Furthermore, a confidential resident meeting revealed that three out of five residents expressed concerns about missing showers due to low staffing. This indicates a broader issue within the facility regarding the provision of bathing activities, potentially affecting multiple residents and contributing to unmet personal care needs.
Inadequate Supervision and Incomplete Fall Investigations
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision for several residents, leading to multiple falls and incomplete investigations. Resident #2, who has severe cognitive impairment and requires maximum assistance with activities of daily living, experienced three falls. The incident reports for these falls were incomplete, lacking staff witness statements and essential investigation details. The resident was observed in unsafe positions, indicating inadequate supervision and intervention to prevent falls. Resident #53, who has a history of repeated falls and requires assistance with transfers, also experienced two falls. The incident reports for these falls were incomplete, missing staff witness statements and necessary investigation details. The resident was noted to be forgetful and in need of constant reminders to use mobility aids, yet the facility failed to provide adequate supervision and intervention to prevent falls. Resident #54, who has significant mobility impairments and requires full assistance with transfers, experienced five falls. The incident reports for these falls were incomplete, lacking assessments of pain levels, mental status, and staff witness statements. The facility failed to ensure the resident's environment was safe and did not provide adequate supervision to prevent falls. Additionally, Resident #212 was observed without a required cervical collar while out of bed, indicating a failure to follow physician orders and ensure the resident's safety.
Unsanitary Kitchen Conditions and Improper Equipment Drying
Penalty
Summary
The facility failed to maintain the kitchen and food preparation equipment in a sanitary condition, as observed during a kitchen tour. Several pieces of equipment, including a large can opener, plate warmer, steam table, prep table, and oven, were found with dried-on food particles and rust-like substances. Additionally, the Robot Coupe food processor was found with a wet area and a dark brown substance on it, and the liquid coffee maker had a dried-on black thick substance on the nozzle. The cooler also had dried-on drips on its sides and front. Furthermore, clean and ready-for-use kitchen equipment was not properly air-dried, as evidenced by five stacked plate covers found wet inside one another. Two black plate covers in the plate warmer had dried-on food particles. The microwave had dried-on food inside, and the floor on the side of the oven was dusty and dirty. The facility's kitchen cleaning duties were reviewed, revealing specific cleaning schedules for the coffee pot, steam table, and stove, but these were not adhered to, as indicated by the unsanitary conditions observed.
Failure to Ensure Resident Dignity and Call Light Accessibility
Penalty
Summary
The facility failed to ensure the dignity and privacy of a resident during a bed bath. Resident #265, who was dependent on staff for assistance with Activities of Daily Living (ADL) and had multiple medical conditions including encephalopathy, heart failure, and end-stage renal disease, was observed receiving a bed bath without any cover or blanket, exposing him to potential embarrassment. The Certified Nursing Assistant (CNA) performing the bath did not change gloves or wash hands throughout the process, further compromising the resident's dignity. This was in violation of the facility's policy on Resident Dignity & Personal Privacy, which mandates the use of a top sheet or bath blanket during bedside care. Additionally, the facility failed to ensure that another resident, Resident #212, had their call light within reach. This resident, who required substantial assistance for various activities and had a history of spinal fusion and chronic pain, was observed sitting on the side of the bed with pants not fully pulled up, visible from the hallway due to an unpulled curtain. The resident reported waiting for staff assistance to get into a wheelchair, and the call light was found on the floor, out of reach. This was contrary to the facility's policy, which requires call lights to be within easy reach of residents.
Failure to Update Care Plans for Resident Preferences and Transfer Status
Penalty
Summary
The facility failed to update person-centered comprehensive care plans for two residents, leading to unmet needs and potential frustration. Resident #20, who has chronic obstructive pulmonary disease, dementia, and other conditions, was observed with facial hair despite expressing a preference for being clean-shaven. The care plan did not document this preference, and the Director of Nursing (DON) acknowledged that the resident's shaving preference should have been included in the care plan. Resident #212, with diagnoses including spinal fusion and chronic pain, was not assisted out of bed over a weekend due to a lack of communication between therapy and nursing staff. The resident, who required substantial assistance for transfers, reported not getting out of bed because staff were unaware of his transfer status. The therapy evaluation had been completed, but the updated transfer status was not communicated to nursing staff until the following Monday. The facility's care planning policy requires that care plans be specific, resident-centered, and based on comprehensive assessments. However, the failure to update care plans for these residents resulted in their needs not being met, as evidenced by Resident #20's unshaven state and Resident #212's inability to get out of bed over the weekend.
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What surveyors actually found near you
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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 Fenton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wellbridge Of Fenton | 1 mi | ★★★★★ | 9 | 0 |
| Caretel Inns Of Linden | 3.6 mi | ★★★★★ | 40 | 0 |
| Mission Point Nursing & Physical Rehabilitation Ce | 4 mi | ★★★★★ | 23 | 0 |
| Wellbridge Of Grand Blanc | 6.8 mi | ★★★★★ | 14 | 0 |
| Argentine Care Center | 6.8 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.