Inspection Reports for
Hampton Manor of Trenton
5999 Fort St, Trenton, MI 48183, United States, MI, 48183
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
13 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
150% worse than Michigan average
Michigan average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Routine
Deficiencies: 9
Date: Mar 5, 2025
Visit Reason
Routine inspection of Arbor Manor Care Center to assess compliance with regulatory requirements related to resident care, medication administration, infection control, food service, and medical record maintenance.
Findings
The facility was found deficient in multiple areas including failure to provide a homelike environment due to frequent loud overhead paging, failure to provide timely written notices for transfer/discharge and bed hold policy, inadequate administration and monitoring of enteral nutrition, incomplete monitoring of psychotropic medications, improper medication storage, unsanitary food service equipment, incomplete medical records for pressure ulcers, and failure to follow infection prevention protocols including PPE use and hand hygiene.
Deficiencies (9)
F 0584: The facility failed to provide a homelike environment for up to 84 residents due to numerous loud overhead paging announcements throughout the day.
F 0623: The facility failed to provide a written notice of transfer/discharge for one resident (R92) of two reviewed.
F 0625: The facility failed to provide a written notice of bed hold policy upon transfer for one resident (R92) of two reviewed.
F 0692: The facility failed to ensure enteral nutrition was administered as ordered and weights were monitored for two residents (R33 and R41) of four reviewed.
F 0758: The facility failed to ensure monitoring of psychotropic medications was completed as ordered for one resident (R74) of five reviewed.
F 0761: The facility failed to ensure proper storage of medication in one of three medication carts and one medication room of three reviewed.
F 0812: The facility failed to effectively clean and maintain food service equipment, increasing the likelihood for cross-contamination and bacterial harborage affecting 84 residents.
F 0842: The facility failed to maintain complete and accurate medical records for one resident (R90) of 18 reviewed, lacking wound measurements and staging documentation for pressure ulcers.
F 0880: The facility failed to ensure appropriate use of Personal Protective Equipment (PPE) and hand hygiene for Transmission-Based Precautions for one resident (R4) of two reviewed.
Report Facts
Residents affected: 84
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Medication syringes: 20
Residents affected: 84
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN R | Licensed Practical Nurse | Identified expired medications and improper labeling in medication cart |
| RN S | Registered Nurse | Reported expired Heparin syringes and planned disposal |
| LPN F | Licensed Practical Nurse | Reported and observed enteral feeding administration issues for Resident #41 |
| RD E | Registered Dietitian | Reported on enteral nutrition and weight monitoring for Residents #33 and #41 |
| DON B | Director of Nursing | Reported on multiple findings including medication monitoring, PPE use, and documentation |
| UM P | Unit Manager | Assessed pressure ulcers and medical record documentation for Resident #90 |
| CNA J | Certified Nurse Aide | Observed not wearing PPE when entering Resident #4's room |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 8, 2025
Visit Reason
The inspection was conducted due to a complaint intake (MI00149135) regarding the facility's failure to ensure proper and safe transfer of a resident using an assistive device, which resulted in harm.
Complaint Details
This citation pertains to intake number MI00149135. The complaint was substantiated as the facility failed to safely transfer Resident #1, resulting in a fall and fracture.
Findings
The facility failed to ensure safe transfer of Resident #1 using a sit to stand assistive device, resulting in a fall and fracture to the resident's right femur. Staff did not use a gait belt as required, and the sit to stand lift battery died during transfer, causing the resident to be lowered to the floor.
Deficiencies (1)
F 0689: The facility failed to ensure a nursing home area was free from accident hazards and provided adequate supervision to prevent accidents. This resulted in actual harm to Resident #1 due to improper transfer with an assistive device causing a fall and fracture.
Report Facts
Residents Affected: 1
Assist x3: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA C | Nurse Aid | Involved in transferring Resident #1 and failed to use gait belt; left room to find battery. |
| NA D | Nurse Aid | Involved in transferring Resident #1 and failed to use gait belt; assisted in lowering resident to floor. |
| LPN E | Licensed Practical Nurse | Called to Resident #1's room after fall; noted staff had not used gait belt and scolded them. |
| CNA F | Certified Nurse Aid | Provided information about battery indicator window on lifts. |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 120
Deficiencies: 1
Date: Jan 7, 2025
Visit Reason
The inspection was conducted in response to an anonymous complaint alleging that medications were not administered on time at the facility.
Complaint Details
The complaint was anonymous and alleged that medications were not administered on time. The allegation was substantiated based on review of medication records and staff interviews.
Findings
The investigation substantiated the allegation that medications were not administered on time. Medication Administration Records showed blank entries and instances where medications were administered up to three hours earlier than scheduled, inconsistent with facility policy.
Deficiencies (1)
Medications were not administered on time, with some administered up to three hours early and medication records left blank.
Report Facts
Residents present: 56
Total capacity: 120
Dates with blank medication entries: 5
Dates medications administered early: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Rogers | Licensing Staff | Conducted investigation and authored report |
| Andrea L. Moore | Manager, Long-Term-Care State Licensing Section | Approved the report |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Oct 23, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to implement, revise, and evaluate the care plan for a resident with multiple falls, resulting in injury and hospitalization.
Complaint Details
The investigation was complaint-driven, focusing on Resident #4's repeated falls and the facility's failure to implement effective interventions. The family was upset about the falls and initiated discharge planning. The complaint was substantiated with findings of inadequate care plan updates and supervision.
Findings
The facility failed to update or revise the care plan and interventions for Resident #4 after multiple falls between July and October 2024, leading to continued falls and a hospitalization for a femur fracture. Documentation and supervision were inadequate, and family involvement was limited.
Deficiencies (2)
F 0657: The facility failed to develop, revise, and evaluate the care plan within 7 days of the comprehensive assessment for Resident #4, resulting in unnecessary falls and hospitalization with major injury.
F 0689: The facility failed to ensure the nursing home area was free from accident hazards and did not provide adequate supervision to prevent falls for Resident #4, resulting in continued falls and hospitalization for major injury.
Report Facts
Number of falls: 8
Assessment Reference Date: Jul 9, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DON B | Director of Nursing | Named in interviews regarding fall interventions and care plan updates for Resident #4. |
| SW L | Social Worker | Provided information about fall reviews, family involvement, and supervision for Resident #4. |
| Unit Manager J | Unit Manager | Responsible for updating care plans and providing documentation related to Resident #4's care. |
| LPN O | Licensed Practical Nurse | Interviewed about Resident #4's supervision and care. |
| NP Q | Nurse Practitioner | Assessed Resident #4 and ordered stat X-rays after complaints of pain. |
Inspection Report
Complaint Investigation
Capacity: 120
Deficiencies: 3
Date: Apr 9, 2024
Visit Reason
The inspection was conducted in response to a complaint alleging that Resident A lacked care and did not receive medications as ordered by the licensed healthcare professional.
Complaint Details
The complaint alleged Resident A had dementia, suffered a fall resulting in a femur fracture and pressure ulcers, and that staff failed to provide adequate care and medication. The complaint was substantiated with violations established.
Findings
The investigation substantiated violations including inadequate care for Resident A, failure to administer medications per orders, and failure to communicate changes in service plans with the authorized representative. The facility's service plans and medication administration records lacked specific instructions and documentation.
Deficiencies (3)
Resident A's service plan lacked specific instructions for wound care and frequency of staff checks, resulting in inadequate care.
Medication administration records lacked documentation and specific instructions for wound care medication and as needed pain medications.
Failure to communicate changes in Resident A's service plan with the authorized representative.
Report Facts
Facility capacity: 120
Complaint receipt date: Mar 22, 2024
Investigation initiation date: Mar 22, 2024
Report due date: May 21, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Rogers | Licensing Staff | Conducted the inspection and authored the report |
| Shahid Imran | Authorized Representative/Administrator | Named in relation to the facility and exit conference |
Inspection Report
Routine
Deficiencies: 8
Date: Mar 28, 2024
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements including resident transfer notifications, medication management, assessment accuracy, vaccination policies, food service sanitation, and facility maintenance.
Findings
The facility failed to provide timely written transfer and bed hold notices to residents, ensure accuracy of Minimum Data Set assessments, maintain proper controlled medication handling and documentation, offer pneumococcal vaccinations per CDC guidelines, and maintain clean and safe food service equipment and physical plant conditions.
Deficiencies (8)
F0623: The facility failed to provide a written notice of transfer for one resident, resulting in potential uninformed residents or representatives.
F0625: The facility failed to notify one resident in writing of the bed hold policy upon hospital transfer, risking uninformed residents or representatives.
F0641: The facility failed to ensure accurate Minimum Data Set assessments for four residents, including incorrect coding of physical restraints and hospice services.
F0755: The facility failed to follow pharmacy policy for controlled medication handling, timely recording, and proper destruction, risking medication diversion.
F0756: The facility failed to ensure a licensed pharmacist performed monthly drug regimen reviews and address medication irregularities for one resident.
F0812: The facility failed to effectively clean and maintain food service equipment, including excessive sanitizer concentration, soiled microwave and ventilation hood, and malfunctioning transportation carts.
F0883: The facility failed to offer pneumococcal immunizations per CDC recommendations for two residents, missing updated vaccine types and documentation.
F0921: The facility failed to maintain a safe, clean, and comfortable environment, including damaged drywall, stained ceiling tiles, soiled equipment, non-functional lights, and inadequate maintenance documentation.
Report Facts
Residents reviewed for hospitalizations: 2
Residents reviewed for MDS accuracy: 18
Medication carts with deficient controlled medication counts: 3
Residents reviewed for medication irregularities: 5
Residents affected by food service sanitation issues: 83
Residents affected by physical plant maintenance issues: 83
Employees mentioned
| Name | Title | Context |
|---|---|---|
| B | Director of Nursing | Interviewed regarding transfer notices, bed hold policy, medication administration, and vaccination policies |
| J | Registered Nurse | Interviewed about transfer/discharge notices and bed hold policy forms |
| I | Admissions Director | Interviewed about bed hold policy and documentation |
| C | MDS Nurse | Interviewed about MDS assessment coding and hospice services |
| D | Director of Social Services | Interviewed about MDS question misunderstanding and PASRR evaluations |
| K | Licensed Practical Nurse | Observed and interviewed regarding medication destruction and controlled substance documentation |
| M | Licensed Practical Nurse | Observed and interviewed regarding controlled medication signing and administration |
| N | Licensed Practical Nurse | Interviewed about controlled medication count documentation |
| E | Director of Food Services | Interviewed about food service sanitation and equipment maintenance |
| H | Director of Maintenance | Interviewed about physical plant maintenance and work order system |
| G | Director of Housekeeping and Laundry Services | Interviewed about cleaning and sanitation of facility areas |
| O | Unit Manager | Interviewed about pneumococcal vaccination policy |
Inspection Report
Renewal
Capacity: 120
Deficiencies: 0
Date: Oct 17, 2023
Visit Reason
The inspection was conducted as a renewal inspection to determine compliance with applicable licensing statutes and rules for license renewal.
Findings
The facility was found to be in compliance with all applicable rules and statutes. Renewal of the license is recommended.
Report Facts
Number of staff interviewed and/or observed: 5
Number of residents interviewed and/or observed: 12
Number of others interviewed: 2
Inspection Report
Deficiencies: 0
Date: Aug 22, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for Arbor Manor Care Center following a regulatory survey completed on August 22, 2023.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Deficiencies: 15
Date: Apr 4, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including resident care, safety, infection control, medication management, staffing, and facility maintenance.
Findings
The facility was found deficient in multiple areas including failure to maintain call light accessibility, failure to report elopement, incomplete care plans, inadequate pressure ulcer care, insufficient staffing, improper medication labeling and storage, poor infection control practices, lack of hospice care coordination, and unsanitary food service and facility conditions.
Deficiencies (15)
F 0558: Facility failed to maintain a call light within reach for Resident #53, impairing resident access to request assistance.
F 0609: Facility failed to timely report an elopement of Resident #39 to the State Agency, resulting in unreported elopement.
F 0656: Facility failed to develop and implement comprehensive care plans for 10 of 16 reviewed residents, risking unmet care needs.
F 0657: Facility failed to develop a complete care plan within 7 days of assessment and failed to coordinate hospice care for Resident #24.
F 0686: Facility failed to provide appropriate pressure ulcer care and prevention for Resident #47 and Resident #5, including lack of turning/repositioning and incomplete wound assessments.
F 0689: Facility failed to prevent elopement of Resident #39 due to inadequate supervision and delayed intervention.
F 0690: Facility failed to provide continence care and intermittent catheterization per professional standards for Residents #13, #20, and #33, increasing risk of urinary tract infections and continued incontinence.
F 0692: Facility failed to implement nutritional interventions for Residents #33 and #39, resulting in avoidable weight loss.
F 0725: Facility failed to provide sufficient nursing staff to meet resident needs, resulting in long wait times and decreased quality of care.
F 0761: Facility failed to ensure nursing staff and aides had appropriate competencies and skills to provide care.
F 0812: Facility failed to ensure medications were accurately labeled and stored, including mislabeling of eye drops and expired medications.
F 0849: Facility failed to effectively clean and maintain food service equipment and physical plant, increasing risk of contamination and bacterial harborage.
F 0880: Facility failed to maintain infection control during wound care for Resident #13 and failed to properly label and store oxygen tubing for Resident #27.
F 0881: Facility failed to monitor antibiotic use for Residents #27 and #33, resulting in incomplete antibiotic courses and increased risk of resistant organisms.
F 0921: Facility failed to maintain a safe, clean, and comfortable environment, including damaged surfaces, soiled ventilation grills, stained flooring, and broken equipment.
Report Facts
Weight loss: 9.22
Weight loss: 15.89
Missed antibiotic doses: 2
Missed antibiotic doses: 2
Residents reviewed: 16
Residents reviewed: 5
Residents reviewed: 63
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN Y | Licensed Practical Nurse | Noted medication labeling errors and storage issues. |
| DON B | Director of Nursing | Provided multiple interviews regarding care deficiencies and facility policies. |
| ADON V | Assistant Director of Nursing | Interviewed regarding antibiotic use, wound care, and resident care. |
| CNA S | Certified Nursing Assistant | Reported elopement incident and resident care observations. |
| LPN DD | Licensed Practical Nurse | Reported elopement incident and resident supervision. |
| RD G | Registered Dietician | Interviewed regarding nutritional interventions and resident intake. |
| Scheduler FF | Scheduler | Provided staffing information. |
| LPN/UM O | Licensed Practical Nurse/Unit Manager | Provided wound care and staffing information. |
| CNA J | Certified Nursing Assistant | Interviewed regarding hospice care and shower schedules. |
| CNA H | Certified Nursing Assistant | Interviewed regarding hospice care and shower schedules. |
| LPN M | Licensed Practical Nurse | Observed providing wound care and hospice care. |
| Maintenance Director C | Maintenance Director | Interviewed regarding facility maintenance and cleaning. |
| Maintenance Technician D | Maintenance Technician | Interviewed regarding facility maintenance and cleaning. |
Inspection Report
Original Licensing
Capacity: 120
Deficiencies: 0
Date: Mar 6, 2023
Visit Reason
The inspection was conducted as an original licensing study to determine compliance with applicable licensing statutes and administrative rules for Hampton Manor of Trenton.
Findings
The study determined substantial compliance with home for the aged Public Health Code and administrative rules. The facility was approved for a temporary 6-month license with a maximum capacity of 120 beds, including programs for aged and Alzheimer's disease or related condition care.
Report Facts
Capacity: 120
Residential units: 77
Double occupancy units: 43
Memory care units: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Krausmann | Licensing Staff | Conducted the licensing study and signed the report. |
| Shahid Imran | Authorized Representative | Facility owner/authorized representative involved in the licensing process. |
| Razanne Pedawi | Executive Assistant | Met with licensing staff during on-site inspection. |
| Carol Cancio | Executive Assistant | Met with licensing staff during on-site inspection. |
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