Majestic Care of Battle Creek

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Advance Directives were accurately completed for four (R8, R9, R39 and R52) of four reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain consent for psychotropic medication use for one (R23) of five reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to 1) document clinical rationale for duplicate psychotropic medication therapy for one (R23) of five reviewed; and 2) ensure appropriate monitoring of antipsychotic medication use for one (R41) of five reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate less than 5% when 2 of 25 medications were not administered in accordance with physician's orders for 1 (R40) of 4, resulting in a medication error rate of 8%.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide timely routine and emergency dental services for two (R4 and R6) of four reviewed for dental services.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a Binding Arbitration Agreement was explained to the resident in a form and manner they understood for one (R23) of three reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff utilized appropriate personal protective equipment (PPE) for two residents (R6 and R31) of two reviewed for Transmission-Based Precautions.

Inspectors wroteThis citation pertains to intake number 2610947. Based on observation, interview, and record review the facility failed to ensure for two out of four residents (Residents #1 and 3) care plans were revised as care needs changed. Resident #1 (R1):Per the facility face sheet R1 was admitted to the facility on [DATE]. Diagnoses included a stage III pressure ulcer of the sacrum (butt bone). Review of a Skin Condition Evaluation form dated 6/9/2025, revealed R1 had a wound to the right inner thigh documented to be unstageable, a pressure wound to the gluteal fold (the crease in the buttocks) that was documented at a stage II, another wound on the right gluteal fold that was a stage II, a pressure ulcer to the left great toe, and a pressure ulcer to the left heel. [...]

Inspectors wroteThis citation pertains to intake MI00148919. Based on observation, interview and record review, the facility failed to notify the provider of a change in condition for one (Resident #1) of two reviewed.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide hot liquids at a palatable temperature to 5 of 8 residents in a group interview and one of two residents (R30) surveyed. This deficient practice has the potential to result in decreased hydration consumption and potential for decreased satisfaction of living. On 10/28/24 at 1:00 pm during the confidential group meeting , 5 of 8 group participants reported being frustrated with the temperatures of beverages, stating coffee and tea are always cold and water for hot cocoa was always too cold resulting in the cocoa packet not getting dissolved and left clumpy. Resident #30 Review of the clinical record including the Minimum Data Set (MDS) dated [DATE] Resident # 30 (R30) was admitted to the facility on [DATE] with diagnoses that included, major depression, hemipelaigia and hemiparesis. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food in the kitchen.

Inspectors wroteThis Citation Pertains to Intake #M00145852 Based on observation, interview and record review the facility failed to provide consistent and accurate activity calendars and failed to provide meaningful, diverse and engaging activity programs for one resident (#30) of three residents reviewed and 6 of 8 residents from confidential group meeting. Resident #30 Review of the clinical record including the Minimum Data Set (MDS) dated [DATE] Resident # 30 (R30) was admitted to the facility on [DATE] with diagnoses that included, major depression, hemipelaigia and hemiparesis. Review of the MDS reflected R30 scored 15 out of 15 (cognitively intact) on the Brief Interview Mental Status (BIMS), further review of the MDS reveled R30 had clear speech and adequate hearing. [...]

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 and failed to protect clean and sanitary supplies from possible wastewater contamination. This deficient practice has the potential for the growth and transmission of Legionella in the circulating water of the building and the spread of Legionella infections, and potential contamination of clean supplies, affecting all residents.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure required transfer and discharge documentation was completed for one (Resident #20) of two residents reviewed for discharge. Resulting in the potential for ineffective or mismanaged continued care, as care plan goals were omitted from the transfer paperwork.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a written copy to one (Residents #20) of two residents of the reason for transfer/discharge to the hospital in a language that was understandable, resulting in potential for lack of understanding and knowledge. Findings Include: Resident #20 (R20) Review of the medical record reflected R20 was an initial admission to the facility on [DATE] with a readmission on [DATE]. Diagnoses of Parkinsons Disease, Diabetes Mellitus, Dementia, Cardiac Arrhythmias, Anxiety, Chronic Pain and weakness. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/12/2024, revealed R20 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively intact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R20 requires minimal assistance with personal care. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide a written copy to one (Resident #20) of two residents reviewed for bed hold notification in a language that was understandable, resulting in potential for lack of understanding and knowledge for and what the bed hold policy entailed.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Preadmission Screening (PAS)/ Annual Resident Review (ARR) form for Mental Illness (MI)/ Intellectual Disability (ID)/ Related Conditions Identification (DCH-3877) document was timely completed and sent to the local state agency for an evaluation for a Level II determination for one residents (R18) of one residents reviewed for PASARRs.

Inspectors wroteBased on interview and record review the facility failed to ensure baseline care plans were developed within 48 hours of admission for one of 13 residents (Resident #41) resulting in the potential for unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to revise timely, individualized care plans for one (Resident #25) of 13 residents reviewed for care planning, resulting in the potential for inadequate/inappropriate care and this resident not maintaining or achieving their highest practical physical well-being. Resident #25 (R25) Review of the medical record reflected R25 was an initial admission to the facility on [DATE] with a readmission on [DATE]. Diagnoses of Diabetes Mellitus with foot ulcer, restless leg syndrome, non-pressure related ulcers of the right foot with necrosis, Peripheral Vascular Disease and Chronic Kidney Disease. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/30/2024, revealed R25 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively intact) out of 15. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to have an emergency tracheostomy readily available for 1 (R9) of 1 resident reviewed for tracheostomy care, resulting in the potential for a delay in needed action in the event of an emergency tracheostomy dislodgement.

Inspectors wroteBased on interview, observation and record review, facility failed to ensure one (resident#20) of one resident was assessed to safely self-administer medications. Resident #20 (R20) Review of the medical record reflected R20 was an initial admission to the facility on [DATE] with a readmission on [DATE]. Diagnoses of Parkinsons Disease, Diabetes Mellitus, Dementia, Cardiac Arrhythmias, Anxiety, Chronic Pain and weakness. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/12/2024, revealed R20 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively intact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R20 requires minimal assistance with personal care. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper communication/documentation of Hospice services provided to one (Resident #45) of one residents reviewed for Hospice services, resulting in a lack of coordination of comprehensive services and care provided Resident #45 (R45) Review of the medical record reflected R45 was an initial admission to the facility on [DATE] with a readmission on [DATE] and then signed up for hospice services on 08/26/24. Diagnoses of Chronic Kidney Disease, Bacteremia, Osteomyelitis, Methicillin Susceptible Staphylococcus, Diabetes Mellitus, Pressure Ulcer of Sacral Region. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/16/2024, revealed R45 had a Brief Interview of Mental Status (BIMS) of 14 (cognitively intact) out of 15. [...]

Inspectors wroteThis citation pertains to MI00143615. Based on observation, interview and record review, the facility failed to ensure bathing and grooming was provided according to resident preferences for three (Resident #1, #2 and #6) of eight reviewed for hygiene and grooming.

Inspectors wroteThis citation pertains to MI00143615. Based on observation, interview and record review, the facility failed to ensure safe smoking practices for three (Resident #8, #9 and #14) of three reviewed for smoking.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient staff to meet residents needs in seven of eight reported during a confidential Resident Council meeting, and in four of 14 sampled residents (Resident #8, #14, #18 & #252), in a census of 46 residents, resulting in the potential for unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: (1) effectively date and label cooked food put in the refrigerator, (2) effectively testing and maintaining the three-sink log with correct temperatures and sanitizing times and date effecting 46 residents, resulting in the increased potential for resident foodborne illness. During an observation and interview on 10/15/23 at 09:18 AM with the initial tour of the kitchen, a bowl of a brown substance was located in the refrigerator without a label and no date on the clear wrap over the bowl. Bowl was removed and disposed of by [NAME] L. During this same observation and interview, the three-sink dish washing log was already filled out with all three temperature checks for the whole day under date of 10/15/23. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote resident dignity while dining for two of 46 residents reviewed for dining (Resident #8 & #51) resulting in decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to complete a level I Preadmission Screening/Annual Resident Review (PASARR) for one (Resident #22) of one residents reviewed for PASARR, resulting in the potential for lack of appropriate mental health treatment and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement comprehensive care plans for 2 (Resident #6 and #14) of 14 residents reviewed resulting in the potential for unmet care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to revise resident care plans in three of 14 residents reviewed for care plans (Resident #12, #13, & #28), resulting in the potential for unment needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide for one out of three Residents sampled (Resident #12), resulting in the potential for decline in skin integrity without ability to perform own activities of daily living (ADL's). Resident #12 (R12). Review of the medical record revealed Resident #12 (R12) was initially admitted to the facility on [DATE] and then re-admitted on [DATE] with diagnoses that included Chronic respiratory failure, heart failure, chronic obstructive pulmonary disease, obesity, diabetes, blind in both eyes and oxygen dependent. According to Resident #12 (R12)'s Minimum Data Set (MDS) dated [DATE], revealed R12 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS- a cognitive screening tool) and had no behaviors. R12 requires maximum assistance with all activities of daily living. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received assistance with care according to their care plans for 1 residents(R6) of 3 residents reviewed for activities of daily living (ADL's), resulting in the increased likelihood for inadequate hygiene and grooming and feelings of embarrassment.

Inspectors wroteBased on observation, interview and record review, the facility failed to arrange ophthalmology services in one of one reviewed for vision services (Resident #14) resulting in decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to implement pharmacy recommendations in one of five residents reviewed for medication regimen (Resident #33), resulting in the potential for an oral infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to properly store and secure Schedule II controlled drugs in one of one medication room reviewed for medication storage, resulting in the increased likelihood medication errors and/or diversion. During an interview on 10/15/23 at 4:09 PM, Licensed Practical Nurse (LPN) U reported the facility had four medication carts and one medication room. During an observation on 10/16/23 at 1:44 PM, the Hall A treatment cart was located in the hall , unlocked with no staff in the area until 2:10 p.m. During an observation and interview on 10/17/23 at 9:36 AM, Registered Nurse(RN) T unlocked the medication room and reported nurses and the DON had keys to the medication room. An unlock box was observed in the unlocked refrigerator with a 30 mg bottle of liquid Xanax(controlled medication) for R 36. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents/resident's guardians understood the purpose of binding arbitration agreements (an out-of-court alternate form of dispute resolution) for 2 residents, (R37 and R252) of 4 residents reviewed for arbitration, resulting in the residents and/or their representatives to not be informed of their rights.

Inspectors wroteBased on observation, interview and record review the facility failed to in perform hand hygiene per Centers for Disease Control Prevention recommendations and administer eye drops using best practices, in 3 of a census of 46 residents reviewed for infection control practices (Resident #14, #18, & #32), resulting in the potential for the spread of infections.

Inspectors wroteBased on interview and observation, the facility failed to ensure that the nurse staffing data was posted daily and filled out completely resulting in the potential for all 46 residents as well as visitors to be uninformed of the facility's daily staffing information.