Pinnacle Care of Battle Creek

Inspectors wroteBased on observations, interviews, and record review the facility failed to protect the resident's (Resident #1) right to be free from physical abuse by Resident #2. Findings Included:This citation pertains to intake number 3032111. Resident #1 (R1): Review of R1's electronic medical record (EMR) revealed R1 was a [AGE] year-old male who was admitted to the facility on [DATE]. Diagnoses included repeated falls and muscle weakness, Resident #2 (R2): Review of R2's EMR revealed R2 was a [AGE] year-old male who was admitted to the facility on [DATE]. Diagnoses included psychotic disturbance, vascular dementia, severe, with behavioral disturbance. Review of a Social Services Quarterly Evaluation dated 6/4/2026 revealed that on 5/4/2026 R2's Brief Assessment of Mental Status (BIMS) score was a 13 out of 15 which indicated R2 was of normal cognitive functioning. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure required Quality Assurance Performance Improvement (QAPI) committee members attended all QAPI meetings. Findings Included: This citation pertains to intake number 3014134. In an interview on 6/18/2026 at 7:35 AM, Medical Director (MD) E, who was the facility's Physician, stated that he had not been to a QAPI meeting at the facility in so long that he could not recall the last time he was at one. MD E stated that the facility always scheduled the meetings at times he could not attend, and he told them several times the times he was available to attend but they still did not schedule the QAPI meetings around his availability. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure they had qualified Dietary Staff in a current facility census of 62 residents.

Inspectors wroteBased on interview and record review, the facility failed to develop and maintain a Quality Assistance and Process Improvement (QAPI) program which identified and prioritized quality deficiencies, systematically analyzed the underlying causes of systemic quality deficiencies, and implemented effective corrective action or performance improvement activities to remedy those deficiencies. This deficient practice has the potential to affect the safety and quality of life of all 63 residents at the facility. Findings Included:Review of facility policy entitled Quality Assurance and Performance Improvement (QAPI), provided during survey, had a blank Date Implemented:, a blank Date Reviewed/Revised: and a blank Reviewed/Revised by: . Review of the QAPI documents provided revealed a copyright of 2025 and heading from another company. During an interview on 04/10/2026 at 09:57 a.m. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure 3 nurses of 5 reviewed had the required Cardiopulmonary Resuscitation (CPR) certifications in a current facility census of 62 residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure that 5 randomly selected licensed nurses had the knowledge, competencies and skill sets to provide care.

Inspectors wroteBased on observation and interview, the facility failed to maintain the required in-service training for nurse aides.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Activities Director had the appropriate qualifications.

Inspectors wroteThis citation pertains to intake #2630915Based on observation, interview, and record review, the facility failed to protect a resident's right to be free from resident-to-resident physical and verbal abuse for 2 (Resident #103 and Resident #104) of 4 residents reviewed for abuse, resulting in Resident #103 experiencing physical contact with facial laceration and verbal threats by Resident #104. Resident #103(R103)Review of the Face Sheet and Minimum Data Set (MDS) dated , 8/18/25 reflected R103 was a [AGE] year-old male admitted to the facility on [DATE], with diagnoses that traumatic brain injury, intermittent explosive disorder, psychologic disorder, anxiety and depression. The MDS reflected R103 had a BIM (assessment tool) score of 13 which indicated his ability to make daily decisions was cognitively intact. [...]

Inspectors wroteThis citation pertains to intake 2668291Based on observation, interview and record review the facility failed to allow one Resident (Resident #105) to return to the facility after being hospitalized immediately upon the first available bed and failed to implement required discharge policies and procedures, resulting in increased likelihood of anxiety, stress and uncertainty about placement. Review of the Face Sheet and Minimum Data Set (MDS) submitted 10/16/25, reflected R105 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses that included progressive neurologic disorder, dementia with agitation, and adjustment disorder with anxiety. The MDS reflected that R105 had a BIM (assessment tool) score of 9 which indicated his ability to make daily decisions was moderately impaired. [...]

Inspectors wroteThis citation pertains to intake 2668291. Based on interview and record review, the facility failed to notify the resident and/or resident's representative of the facility policy for bed hold and a written reason for the transfer, for one (Resident #105) of three reviewed for hospitalization. Review of the Face Sheet and Minimum Data Set (MDS) submitted 10/16/25, reflected R105 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses that included progressive neurologic disorder, dementia with agitation, and adjustment disorder with anxiety. The MDS reflected that R105 had a BIM (assessment tool) score of 9 which indicated his ability to make daily decisions was moderately impaired. [...]

Inspectors wroteThis citation pertains to intakes 1194799 and 2564904. Based on observation, interview and record review, the facility failed to protect the resident's (R1's) right to be free from sexual abuse by R2.

Inspectors wroteOn 05/05/25 at 01:03 P.M., Domestic hot water temperatures were monitored utilizing a ThermoWorks Super-Fast Thermapen model CR2032 digital thermometer. The following domestic hot water temperatures were recorded: Resident room [ROOM NUMBER]: 128.9 degrees Fahrenheit* Resident room [ROOM NUMBER]: 136.7 degrees Fahrenheit* Resident room [ROOM NUMBER]: 152.6 degrees Fahrenheit* Resident room [ROOM NUMBER]: 145.6 degrees Fahrenheit* Resident room [ROOM NUMBER]: 106.9 degrees Fahrenheit Resident room [ROOM NUMBER]: 105.0 degrees Fahrenheit Resident room [ROOM NUMBER]: 111.7 degrees Fahrenheit On 05/05/25 at 01:45 P.M., An interview was conducted with Environmental Services Director (ESD) E regarding domestic hot water temperature monitoring and documentation log sheets. (ESD) E stated: We routinely monitor hot water temperatures. (ESD) E also stated: [...]

Inspectors wroteBased on observation, interview and record review the facility 1) failed to implement and update Physician orders, 2) accurately assess and document a pressure ulcer, 3) failed to ensure pressure ulcer prevention interventions were implemented, 4) failed to adequately assess and treat pain prior to wound care and 5) failed to prevent the development of pressure ulcers for 2 (Resident #11, Resident #20) out of 3 reviewed for pressure ulcers resulting in worsening of a pressure ulcer, unrelieved pain during wound care, and an increased risk of further skin breakdown.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to: (1) effectively clean and maintain food service equipment, and (2) effectively date mark all potentially hazardous ready-to-eat food products effecting 61 residents who consume food, resulting in the increased likelihood for cross-contamination, bacterial harborage, and resident foodborne illness.

Inspectors wroteBased on interview and record review the facility failed to maintain an effective Quality Assurance and Performance Improvement program that identified areas of focus and improvement in a current facility census of 61 residents. Findings Included: During the survey a concern was identified at an Immediate Jeopardy level regarding hot water temperatures in which the facility was unaware off. Also, it was identified during the survey a concern of accommodation of resident needs regarding call light accessibility. Review of resident council meeting minutes, dated 3/5/2025, revealed a concern was brought up regarding not having hot water in the resident rooms. The facility's response was to check the hot water temperatures, and to also check them weekly. Review of QAPI minutes revealed no further discussion of weekly hot water temperatures, nor were any documented logs noted. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 61 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, decreased air quality, and potential cross-connections between the potable (drinking) and non-potable (non-drinking) water supplies.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure six out of 15 residents (Resident # 4, 7, 23, 26, 46 & 134) had call lights that were accessible. Findings Included: Resident #4 (R4): During an interview on 5/05/2025 at 10:42 AM, Resident #4 (R4) was observed in bed. The call light was observed to be hanging out of reach of R4. R4 was alert and able to answer questions. R4 stated that he does not have a call light, but there was one hanging on the wall. It was then observed that a call light was wrapped around the call light outlet box that was on the wall. The call light was not within reach of R4, and R4 stated he was not able to reach the call light, and also stated he never used that call light. [...]

Inspectors wroteResident #67 (R67) Review of the medical record revealed R67 was admitted to the facility on [DATE] with diagnoses that included diabetes, quadriplegia, anxiety, and atrial fibrillation. The Discharge Minimum Data Set (MDS) with an Assessment Reference Date of 4/6/25 revealed R67 was independent with cognitive skills for daily decision making and had an unplanned discharge to the hospital with a return not anticipated. Review of hospital records from prior to admission revealed a wound assessment dated [DATE] which revealed an abdominal wound to the left lower quadrant. The wound measured 3.5 centimeters (cm) long x 15 cm wide x 1 cm deep. The wound had moderate serous: thin, water, clear drainage. Wound management was listed as Negative Pressure Wound Therapy (NPWT/wound vacuum assisted closure [vac]). [...]

Inspectors wroteOn 5/7/25 at 12:24 PM, during a confidential Resident Council meeting, when asked if the residents get the help and care they need without waiting a long time and if staff respond to their call lights timely, responses included: One resident laughed and replied not on nights Usually takes at least a half an hour. Staff turn off call lights and don't take care of the need. It depends on who is working, with certain people I have to wait 45 minutes When asked if there is enough staff, 10 of 10 residents responded no and provided the following responses: We are always short that is why we have to wait so long for call lights. Nights is worse. [...]

Inspectors wroteResident #9 (R9): Review of the medical record reflected R9 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included dementia, major depressive disorder, insomnia, Alzheimer's and psychotic disorder with delusions. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/31/25, reflected R9's cognition and mood were not assessed. R9's medical record did not reflect evidence that monthly Pharmacy Medication Regimen Reviews had been conducted for July 2024, August 2024, September 2024, October 2024 and March 2025. On 05/07/25 at 12:59 PM, an email request was sent to Nursing Home Administrator (NHA) A and Director of Nursing (DON) B for monthly Pharmacy Medication Regimen Reviews, Pharmacy recommendations and follow-up actions for R9 since 5/1/24. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications were properly labeled and stored per professional standards of practice for two residents (R35 and R36) and a medication cart in a current facility census of 61 residents. Findings Included: During an observation of a medication administration on 5/06/2025 at 8:10 AM, Registered Nurse (RN) EE was observed to obtain an iron pill from a bottle to administer to a resident. RN EE was asked why was the observed handwritten date on the bottle there, RN EE stated she did not know other than the nurse were to write the date of the bottle being opened, but stated it meant nothing. A review of the bottle of iron revealed the bottle did not have a manufacture's expiration date on the bottle. [...]

Inspectors wroteBased on interview and record review the facility failed to consistently offer bedtime snacks to nine of ten residents who attended the confidential Resident Council Meeting.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively maintain the resident call system effecting 61 residents, resulting in the increased likelihood for delayed emergency response and/or negative resident outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (R38) was treated with dignity and respect out of one reviewed.

Inspectors wroteBased on interview and record review, the facility failed to obtain and document required informed consent from the resident's guardian prior to administering a psychotropic medication for two (Resident #33, #41) of five reviewed for unnecessary medications.

Inspectors wroteBased interview and record review, the facility failed to ensure the accuracy of code status information for one (R36) of one reviewed for advance directives.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure personal belongings were available for use for one (Resident #38) of one reviewed for personal belongings, resulting in misplaced personal items.

Inspectors wroteBased on interview and record review, the facility failed to limit the duration of a PRN (as needed) psychotropic medication to 14 days and/or ensure the physician documented rationale to extend the duration of use for one (Resident #33) out of five reviewed for unnecessary medications.

Inspectors wroteBased on interview and record review, the facility failed to provide the resident/representative with a written notice of transfer/discharge and send a copy to the ombudsman for one (R67) of one reviewed.

Inspectors wroteBased on observation, interview, and record review the facility failed to accurately complete a comprehensive assessment for one (Resident #20) of 15 residents reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to perform a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) for one (R11) of 15 reviewed.

Inspectors wroteResident #9 (R9): Review of the medical record reflected R9 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included dementia, major depressive disorder, insomnia, Alzheimer's and psychotic disorder with delusions. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/31/25, reflected R9's cognition and mood were not assessed. On 05/06/25 at 1:12 PM, R9 was observed seated in a wheelchair, in their room, watching TV. Section C (Cognitive Patterns) of the Quarterly MDS, with an ARD of 3/31/25, reflected questions C0100 through C1000 were marked with responses of dashes and Not assessed. Section D (Mood) of the same MDS was marked with responses that included Not assessed and Not assessed/no information. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive Care Plan for one (R11) of 15 reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to conduct a quarterly care conference for one (resident 33) of three residents reviewed for careplanning.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide consistent and meaningful activities, ensure adequate staffing and staff engagement, and maintain accountability for the implementation of scheduled activities for one (Resident #33) out of one reviewed for activities.

Inspectors wroteBased on observation, interview, and record review the facility failed to properly adhere to the physician's order for double protein portions for one resident (Resident #20) out of one reviewed for nutrition. Resident #20 A review of the medical record indicates that Resident #20 was admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses include heart failure and both acute and chronic respiratory failure with hypoxia. On 05/05/25 at 11:54 AM, Resident #20 was observed seated in the dining room, where their lunch consisted of two chicken tenders, potatoes, and coleslaw. Upon further observation, it was noted that the portion size of Resident #20's meal was consistent with that of the other residents in the dining room. The medical record shows that Resident #20's weight was recorded on the following dates: 2/28/25, 3/1/25, 3/14/25, 4/18/25, and 5/2/25. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a medication error rate of less than 5% for three observed medication errors out of 25 opportunities, resulting in a medication error rate of 12%. Findings Included: During an observation of a medication administration on 5/06/2025 at 8:10 AM, Registered Nurse (RN) EE was observed to obtain an iron pill from a bottle to administer to a resident. RN EE was asked why was the observed handwritten date on the bottle there, RN EE stated she did not know other than the nurse were to write the date of the bottle being opened, but stated it meant nothing. A review of the bottle of iron revealed the bottle did not have a manufacture's expiration date on the bottle. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure oxygen tubing was changed every seven days for one out of two residents (Resident #61). Findings Included: In an observation on 5/05/2025 at 12:25 PM, an oxygen concentrator (tank that delivers oxygen) was observed to be on. Tubing was observed to go from the tank to Resident #61's (R61) nose and was administering oxygen to the R61. The tubing was observed to have a tapped label on it which had a date of 4/20/2025. In another observation on 5/07/2025 at 3:07 PM, R61 was observed to have the same oxygen tubing in place as observed on 5/5/2024 and was still labeled 4/20/2025. In an interview on 5/07/2025 at 3:45 PM, Infection Control Preventionist (ICP), who was also a Registered Nurse (RN) J stated that she did not monitor and track the use of oxygen tubing via the infection control program. [...]

Inspectors wroteBased on interview and record review, the facility failed to document education provided regarding the benefits and potential side effects of the pneumococcal immunization for two (R2 and R22) of five reviewed.

Inspectors wroteBased on interview and record review, the facility failed to ensure the daily nurse staffing posting was dated with the year and included the actual hours worked by category of licensed and unlicensed nursing staff (i.e., Registered Nurse (RN), Licensed Practical Nurse (LPN), Certified Nurse Aide (CNA)) directly responsible for resident care per shift.

Inspectors wroteBased on interview and record review, the facility failed to administer a COVID-19 vaccine per consent for one (R33) of five reviewed.

Inspectors wroteThis citation pertains to MI00149061 and MI00151480 Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from abuse for three of nine residents reviewed, resulting in resident-to-resident physical abuse, bruising for R11, bruising and bleeding for R12, and a head laceration requiring sutures and hospital admission for R17.

Inspectors wroteThis citation pertains to MI00150826. Based on observation, interview, and record review, the facility failed to provide activities of daily living (ADL) assistance for two residents (Resident 14 and Resident 21) of three residents reviewed.

Inspectors wroteThis citation pertains to MI00151617 and MI00150826 Based on observation, interview, and record review, the facility failed to obtain orders for catheter care and failed to properly maintain urinary catheters for two (Resident 10 and Resident 14) of three reviewed.

Inspectors wroteThis citation refers to intake MI00148755. Based on observation and interview, the facility failed to maintain an effective Pest Control Program effecting 64 residents, resulting in complaints regarding rodents, the presence of rodent activity in multiple areas of the facility, and the potential to cause cross-contamination and resident discomfort.

Inspectors wroteThis citation pertains to intake MI00147038. Based on observation, interview and record review, the facility failed to report an allegation of resident to resident physical abuse to the State Agency for two (Resident #4 and #5) of five reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure management and monitoring of diabetes for one (Resident #1) of four reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide appropriate monitoring and treatment for a resident experiencing symptoms of repeat Urinary Tract Infection (UTI), for 1 resident (R18) of 2 residents reviewed for UTI, resulting in a lack of monitoring, a delay in the treatment of a UTI, hospitalization, and sepsis (a life threatening complication of infection.)

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to: (1) date mark all potentially hazardous ready-to-eat food products, (2) maintain the mechanical dish machine, and (3) maintain ventilation hood lighting effecting 53 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, resident foodborne illness, and decreased illumination.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure for all 46 residents, who resided in the facility, effective administration oversite of the facility's plan of correction for the survey dated 3/19/2024, and bringing the facility into compliance for 10 identified deficient practices. Findings Included: Review of the facility's plan of correction (POC) for survey dated 3/19/2024 revealed that the POC was not completed by 4/22/2024, the facility's alleged POC date, nor by 5/9/2024 upon exit of the revisit survey for the following tags, F561, 565, 582, 625, 656, 657, 684, 740, 761, and 812. Further review of the facility's POC revealed: F561, the facility did not perform audits to monitor and ensure continued compliance for resident self-determination, and did not provide education for all staff. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure, through the facility's Quality Assurance and Performance Improvement (QAPI) program, monitoring of corrective action for 10 deficiencies that were identified on the previous survey, dated 3/19/2024, were in compliance by 4/22/2024 the facility's alleged compliance date. Findings Included: Review of the facility's plan of correction (POC) for survey dated 3/19/2024 revealed that the POC was not completed by 4/22/2024, the facility's alleged POC date, nor by 5/9/2024 upon exit of the revisit survey for the following tags, F561, 565, 582, 625, 656, 657, 684, 740, 761, and 812. Further review of the facility's POC revealed: F561, the facility did not perform audits to monitor and ensure continued compliance for resident self-determination, and did not provide education for all staff. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for one of eight residents reviewed for medications (Resident #18), affecting a census of 53 residents, resulting in inappropriate antibiotic use and increased risk of adverse events associated with antibiotic use.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide an effective Pest Control Program effecting 53 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, insect/rodent infestations, and resident discomfort.

Inspectors wroteBased on interview and record review, the facility failed to address and resolve grievances reported in Resident Council Meetings as stated during a confidential Resident Council meeting resulting in unresolved concerns and unmet needs of residents.

Inspectors wroteBased on interview and record review the facility failed to complete accurate Minimum Data Set (MDS) assessments for two residents (#7 and #38) of 15 residents reviewed for MDS accuracy, resulting in inaccurate MDS assessments, and the potential for inaccurate care plans and unmet care needs. Findings Included: Resident #7 (R7): Review of the medical record reflected Resident #7 (R7) admitted to the facility 2/1/24, with diagnoses that included diabetes, angina pectoris (chest pain caused by reduced blood flow to the heart) and hypertension (high blood pressure). The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/14/24, reflected R7 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). R7 no longer resided in the facility at the time of the survey. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to: (1) effectively secure an active physical plant renovation site, (2) maintain flooring and wall surfaces, (3) maintain roofing and plumbing systems, and (4) secure electrical heating devices (crock pot) for 1 (#47) of 14 sampled residents effecting 53 residents, resulting in the increased likelihood for accidental resident falls and/or serious bodily injury.

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient staff to meet resident needs as reported in a confidential Resident Council meeting resulting in the potential for unmet care needs.

Inspectors wroteBased on interview and record review the facility failed to ensure the attending physician documented in the medical record that identified medication review irregularities were reviewed, the action taken, and the rationale for no changes to the medications for four (R2, R25, R38 and R44 ) of six reviewed for unnecessary medications

Inspectors wroteThis citation has 2 Deficient Practice Statements (DPS), #1 and #2. DPS #1 Based on observation, interview, and record review, the facility failed to ensure eye drops were removed from use according to manufactures instructions, in one of two medication carts reviewed, resulting in risk of decreased efficacy.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively maintain the facility resident call system effecting 29 residents, resulting in the increased likelihood for delayed emergency response and/or negative resident outcomes.

Inspectors wroteBased on observation and interview, the facility failed to maintain the physical plant, including floor wall junctures and lighting, resulting in unsanitary and unsafe conditions for any residents residing in or traversing through the North Hall and open areas of the South Hall.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain dignity for one resident (R11) of two residents reviewed for dignity, resulting in the likelihood of feelings of embarrassment and humiliation based on the reasonable person concept.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident choices were honored for two of two residents (Residents #4 and #206) reviewed for choices and as reported by four of seven residents during a confidential Resident Council meeting resulting in frustration and distress.

Inspectors wroteBased on interview and record review, the facility failed to 1) issue a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) to one (Resident #56) of three reviewed for Beneficiary Notification; and 2) ensure the SNF ABN included the estimated cost of items and services for which the resident may be charged for two (Resident #14 and #47) of three reviewed for Beneficiary Notification.

Inspectors wroteBased on interview and record review, the facility failed to provide medical information to the hospital for one (Resident #7) of one resident reviewed for hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and/or the resident's representative, in writing, of the reason for transfer/discharge to the hospital for one (Resident #7) of one reviewed for hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and/or the resident's representative of the facility's policy for bed hold for one (Resident #7) of one reviewed for hospital transfer.

Inspectors wroteBased on interview and record review the facility failed to complete a Significant Change in Status Assessment (SCSA) for one resident (#29) of 14 residents reviewed for Minimum Data Set (MDS), resulting in the potential for inaccurate care plans and unmet needs. Findings Included: Resident #29 (R29) Review of the medical record demonstrated R29 was admitted to the facility 10/08/2018 with diagnoses that included hemiplegia (paralysis) and hemiparesis (muscle weakness or partial paralysis) affecting left dominate side, type 2 diabetes, malnutrition, apraxia (difficulty with skill movement), weakness, chronic right hip pain, edema, depression, constipation, hearing loss, hypertension, and cerebral infarction (stroke). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement care plans for two of 14 residents (Residents #4, and #29) reviewed for Care Plan implementation for behavioral health and hospice services. Findings Include: Resident #4 (R4) Review of the medical record revealed Resident #4 (R4) was initially admitted to the facility on [DATE] with diagnoses that included heart disease with heart failure, supra-pubic catheter, neurogenic bladder (overactive). According to Resident #4 (R4)'s Minimum Data Set (MDS) dated [DATE], revealed R4 scored 10 out of 15 (Moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS- a cognitive screening tool) and had no behaviors. R4 required substantial/maximum assistance with toileting, showering/bathing, getting dressed and personal hygiene. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure care plan interventions were evaluated for effectiveness and updated in a timely manner, with new interventions, to prevent further decline in condition for one (Resident #4) of 14 sampled residents reviewed for care plan timing and revision. Findings Include: Resident #4 (R4) Review of the medical record revealed Resident #4 (R4) was initially admitted to the facility on [DATE] with diagnoses that included heart disease with heart failure, supra-pubic catheter, neurogenic bladder (overactive). According to Resident #4 (R4)'s Minimum Data Set (MDS) dated [DATE], revealed R4 scored 10 out of 15 (Moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS- a cognitive screening tool) and had no behaviors. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to actively pursue discharge planning for one resident (#206) of one resident reviewed for discharge planning resulting in frustration with the facility discharge process. Findings Included: Resident #206 (R206) Review of the medical record demonstrated R206 was admitted to the facility 02/20/2024 with diagnoses that included central cord syndrome at the cervical spinal cord (causing impairment of upper limb motor function), abnormalities in gait and mobility, muscle spasm of back, rheumatoid arthritis, low back pain, overactive bladder, quadriplegia, hyperlipidemia (high fat content in blood), anxiety, constipation, insomnia, heart disease, hypertension, pain in upper left arm, and need for assistance with personal care. [...]

Inspectors wroteDuring observation, interview, and record review the facility failed to ensure dependent residents receive showers according to their personal preferences for three residents (#206, #47, #4)) of four residents reviewed for hygiene and grooming, resulting in missed bath/showers. Findings Included: Resident #206 (R206) Review of the medical record demonstrated R206 was admitted to the facility 02/20/2024 with diagnoses that included central cord syndrome at the cervical spinal cord (causing impairment of upper limb motor function), abnormalities in gait and mobility, muscle spasm of back, rheumatoid arthritis, low back pain, overactive bladder, quadriplegia, hyperlipidemia (high fat content in blood), anxiety, constipation, insomnia, heart disease, hypertension, pain in upper left arm, and need for assistance with personal care. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide assessment/intervention for bowel constipation for one resident (#206) of 14 residents reviewed for quality of care. Findings Included: Review of the medical record demonstrated R206 was admitted to the facility 02/20/2024 with diagnoses that included central cord syndrome at the cervical spinal cord (causing impairment of upper limb motor function), abnormalities in gait and mobility, muscle spasm of back, rheumatoid arthritis, low back pain, overactive bladder, quadriplegia, hyperlipidemia (high fat content in blood), anxiety, constipation, insomnia, heart disease, hypertension, pain in upper left arm, and need for assistance with personal care. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure appropriate treatment and services for contracture management for two residents (#32, #206) of two residents reviewed resulting in the potential for worsening contractures and pain. Findings Included: Resident #32 (R32) Review of the medical record demonstrated R32 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction (stroke), hypertension, depression, anxiety, hyperlipidemia (high fat content in blood), Pseudobulbar affect (inappropriate involuntary laughing and crying due to a nervous system disorder), tachycardia, muscle spasm, cognitive impairment, psychosis (loss of external reality), conduct disorder, chronic pain, personality and behavior disorder, dysphasia (difficulty understanding spoken language), and muscle weakness. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure one (Resident #4) out of four residents received the necessary behavioral health care and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being. Findings Included: Resident #4 (R4) Review of the medical record revealed Resident #4 (R4) was initially admitted to the facility on [DATE] with diagnoses that included heart disease with heart failure, supra-pubic catheter, neurogenic bladder (overactive). According to Resident #4 (R4)'s Minimum Data Set (MDS) dated [DATE], revealed R4 scored 10 out of 15 (Moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS- a cognitive screening tool) and had no behaviors. R4 required substantial/maximum assistance with toileting, showering/bathing, getting dressed and personal hygiene. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free from unnecessary medications in three (Resident #12 and #18) of 8 reviewed for medications , resulting in increased risk of adverse drug reactions and R18's hospital admission related to sepsis due to urinary tract infection(UTI).

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from unnecessary medications in one of three reviewed for psychotropic medications (Resident #44), resulting in increased risk of adverse drug reactions.

Inspectors wroteBased on interview and record review, the facility failed to offer pneumococcal immunization in two of five residents reviewed for immunizations (Resident #12 & #18), resulting in an increased risk of acquiring, transmitting, or experiencing complications from pneumococcal disease.

Inspectors wroteBased on interview and record review, the facility failed to maintain staff documentation of COVID-19 screening, education, offering and current COVID-19 vaccination status of one of one staff reviewed, resulting in increased risk for COVID-19 infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to promote and facilitate resident needs through support of resident choice in bathing, a toileting program, equipment needs, and services, in one of three residents reviewed for rehabilitation services (Resident #5), resulting in lack of progress in meeting resident goals for discharge.

Inspectors wroteThis citation pertains to MI00142383. Based on observation, interview and record review, the facility failed to ensure the protection of other residents by thoroughly investigating allegations of abuse for one (Resident #2) of three reviewed for abuse, resulting in the potential for abuse to occur with other residents.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment effecting 53 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, decreased interior food service equipment illumination, and plumbing water leaks.

Inspectors wroteThis citation pertains to intake MI00130932 Based on observation, interview and record review the facility failed to develop and implement comprehensive care plans for 6 (Resident #'s 14, 18, 21, 27, 48 and 50) of 15 reviewed for comprehensive care planning, resulting in the potential for unmet care needs and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise care plans for 4 (Residents #1, #14, #40, #21) of 15 reviewed for care plans resulting in the potential for inadequate/inappropriate care plan interventions and unmet resident needs.

Inspectors wroteThis citation pertains to intake M100130932 Based on observation, interview and record review, the facility failed to ensure two residents of eight residents (R21and R40) receive the necessary care and services for activities of daily living resulting in potential unmet care needs. Findings Include: Resident #21(R21) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R21 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included dementia, coronary heart disease, heart failure, peripheral vascular disease, seizure disorder, schizophrenia, and mantic depression. The MDS reflected R21had a BIM (assessment tool) score which indicated her ability to make daily decisions was severely impaired, and she required one person physical assist with bed mobility, transfers, locomotion on unit, dressing, eating, toileting, hygiene, and bathing. [...]

Inspectors wroteThis citation pertains to intake: MI00130932 Based on observation, interview and record review, the facility failed to provide meaningful activities for three Resident (R18, R21and R40) of seven residents reviewed for meaningful activities. This deficient practice resulted in the potential for boredom and decreased quality of life.

Inspectors wroteThis citation has 2 Deficient Practice Statements: (A) & (B) (A) Based on observation, interview, and record review, the facility failed to complete routine post fall assessments and ensure timely completion of a stat x-ray order for 1 (Resident #20) of 15 residents reviewed for quality of care, resulting in delayed identification and treatment of a fracture, and increased pain.

Inspectors wroteThis Citation Pertains To Intakes: MI00128361, MI00130337, MI00130932, MI00129672, Based on observation, interview, and record review the facility failed to ensure sufficient nursing staff for 8 of 9 resident council members, resulting in the potential for all 54 residents who resided at the facility to not attain or maintain their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure three Licensed Practical Nurses (LPN C, N, II) had specific competencies and skills necessary to meet resident needs, failed ensure two Certified Nursing Assistants (CNA GG and JJ) of two CNA's reviewed for nursing competencies had their required annual competency evaluation in skills and techniques necessary to care for residents, resulting in the potential for nursing staff to lack the necessary qualifications and training to adequately care for the needs of the residents, and failed to ensure one Hospitality Aide (E) ie. non-certified/ trained staff provide services within their scope of practice.

Inspectors wroteBased on interview, observation and record review, the facility failed to ensure staff were educated in behavioral care training for two of three residents (R40 and R49) reviewed for behavioral care resulting in the potential all 24 residents residing in the Dementia unit to receive adequate behavioral care. Findings Include; Resident #49 (R49) Review of the medical record reflected R49 was originally admitted to the facility 06/15/2022 with a diagnosis of Alzheimer's Disease. Record review on 07/29/2022 reflected behavior notes on R49 who continues 15-minute checks because other residents were wondering in his room. In an interview on 12/21/22 at 11:02 AM, Social Worker (SW) D stated the facility does not have a behavioral program. SW D was provided documentation showing 15-minute checks being performed on R49. SW D was asked why R49 was placed on 15-minute checks. [...]

Inspectors wroteResident #22 According to the clinical record, including the Minimum Data Set (MDS) dated [DATE] revealed Resident 22 was admitted to the facility on [DATE], (R22) scored 00 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of R22's monthly pharmacy reviews and recommendations reflected the January 27, 2021 pharmacy recommendation read Evaluated the patient immunological history in the chart and noticed this patient may be a candidate for pneumococcal vaccination. There was no written response from the Physician, and no signed consent or refusal from R22's legal guardian. [...]

Inspectors wroteThis citation includes two Deficiet Practice Statements A and B. DPS A Based on observation, interview, and record review the facility failed to review Infection Control Policies and Program annually resulting in the potential of not following the most current Infection Control Standards of Practice and resulting in the potential for the spread of infection for all 53 Residents that reside at the facility. Findings Included: During record review of the provided facility policies regarding Infection Control no documents listed a date that the policies were implemented and no date that the policies had been reviewed annually. In an interview on 12/21/22 08:43 a.m. Nursing Home Administrator A explained that the facility Infection Control Policies are reviewed annually in a QA (Quality Assurance) Committee meeting. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to offer pneumococcal and influenza immunization for three Residents (Residents #22, #356, and #357) out of 6 reviewed and failed to provide written declination of those immunizations refused for two Residents (Residents #6 and #29) out of six Residents resulting in the potential for increased risk of acquiring, transmitting, or experiencing complications of pneumococcal or influenza disease and the potential for miscommunication and misunderstanding of Residents immunization preferences. Findings Included: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to offer COVID-19 Immunization, obtain complete declination for COVID-19 Immunization, provide COVID-19 Immunization education for five resident representatives or residents (residents #6,#29, #35, #356, and #357) out of five residents reviewed for COVID-19 Immunization resulting in the potential for miscommunication and misunderstanding of Resident COVI-19 Immunization preferences.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 53 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, decreased illumination, and plumbing leaks.

Inspectors wroteBased on observations, interviews, record reviews, and 6 of 9 from the confidential group meeting, the facility failed to provide effective pest control services effecting 53 residents, resulting in the increased likelihood for insect and rodent infestations.

Inspectors wroteResident #40 According to the clinical record including the Minimum Data Set (MDS) dated [DATE] resident 40 (R40) was a [AGE] year old female, admitted to the facility with diagnosis that include severe intellectual disabilities, early onset Alzheimer's, Bi-polar disorder, anxiety, Down syndrome unspecified. R40 scored 00 (severe cognitive impairment) on the Brief Interview for Mental Status. Of note, further record review revealed R40 had a court appointed guardian, no contact with family, and had no visitors. R40 was observed on 12/11/22 at approximately 12:00 pm, sitting alone at a table in the dining room, her hair had not been combed, she wore mismatched clothing and had a disheveled appearance. Unidentified staff delivered R40 her lunch and walked away to assist other residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide advanced written notice prior to a room change for one resident (#20) reviewed for room changes which resulted in reported frustration with the potential for increased anxiety, misunderstanding of the reason for the room change, and the lack of opportunity for resident questions.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that grievances were promptly documented, investigated, tracked and resolved for 9 of 9 members of the Resident Council resulting in unresolved complaints, anger and frustration. Findings Include: On 12/13/22 at 10:00 am, during the Resident Council meeting, 9 of 9 participants reported their complaints are frequently not addressed, responded to timely and/or go resolved without explanation. Members of the Resident Council reported they felt unheard, ignored and angry. Review of Resident Council Meeting Minutes dated 6/8/22 reflected concerns related to meal trays taking to long, dietary staff not reading tickets (resulting in food preference not being followed) , rooms not clean, lack of Nursing staff along with nursing staff being rude. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure updated and accurate advance directive information was in place for three residents (Resident #7, #21, #27) of five reviewed for advance directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time), resulting in the potential for a resident's preferences for medical care to not be followed by the facility, or other healthcare providers. Findings Include: Review of the MICHIGAN DO-NOT-RESUSCITATE PROCEDURE ACT, Act 193 of 1996 (Revised 3-25-14), revealed that, An order executed under this section shall be on a form described in section 4. The order shall be dated and executed voluntarily and signed by each of the following persons: [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free of physical and verbal involving 2 residents (#40 and 25), of 6 residents that were reviewed for abuse, resulting in Resident 40 being verbally and physically abused.

Inspectors wroteBased on interview and record review the facility failed to report an allegation of abuse for two of 6 residents reviewed for abuse (#25 and 40). Resulting in allegations of abuse not being reported to the State Agency and the potential for additional allegations of abuse to go unreported. Resident #25 According to the clinical record, including the Minimum Data Set (MDS) dated [DATE] reflected Resident 25 (R25) was an [AGE] year old female admitted to the facility with diagnosis of dementia and bi-polar disorder. The MDS revealed R25 had long and short term memory impairment with severely impaired decision making skills. Resident #40 Review of Nursing progress notes dated 11/30/2022 reflected Certified Nursing Assistant (CNA) CC walked by R40's room at 12:30 am and observed R25 was slapping R40 and calling R40 names. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for three (Resident #21, #27, #50) of 15 reviewed, resulting in inaccurate MDS assessments and the potential for unmet care needs.

Inspectors wroteThis citation pertains to M100130932. Based on observation, interview, and record review, the facility failed to assess pressure injury risk, and failed to accurately and routinely assess and document pressure injury presentation in one of five residents (Resident #1) reviewed for pressure injuries resulting in the potential for delayed healing, wound deterioration, and the formation of additional pressure injuries.

Inspectors wroteBased on interview and record review, the facility failed to ensure the completion of routine post dialysis monitoring, assessments, and documentation for one resident (Resident #14) of one reviewed for dialysis, resulting in the potential for unidentified change in condition and complications post dialysis treatment.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that a Registered Nurse was on duty for 8 consecutive hours a day for seven days a week, resulting in the likelihood of inadequate coordination of emergency or routine care with negative clinical outcomes affecting all 53 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure that two Certified Nurse Aides (CNA GG and JJ) whose in-service training files were reviewed, had the required 12 hours of in-service training, resulting in the potential for unmet educational needs and missed opportunity for improved quality of care and services provided to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent when five medication errors were observed from a total of twenty-nine opportunities for two residents (Resident # 30 and # 8) of five reviewed for medication administration, resulting in a medication error rate of 17.24% and the potential for reduced efficacy of medications and increased risk of adverse reactions/side effects.

Inspectors wroteBased on observation and interview the facility failed to ensure nutritional supplements and over the counter medications were not expired and discarded. Resulting in the potential for altered potency and efficacy for the 53 residents receiving nutritional supplements and over the counter medications out of the medication room. During an observation and interview on [DATE] at 08:30 AM with LPN N regarding the number of medications. LPN N stated we have 2 med rooms, one on north and one on south. Med room- north-(Dementia unit) 3 bottles of Zinc 50mg expired on 08/22. On [DATE] at 08:45 A.M., A common area environmental tour was continued with Environmental Service Director F. The following item was noted: North Unit: Medical Supply Room: Two full cases of Glucerna Rich Chocolate nutritional supplement were observed with an expiration date that read [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a Certified Activities Director was employed at the facility, resulting in potential for all 53 residents to not be provided with meaningful activities. In an interview on 12/14/22 at 07:59 AM Activity Director certification. AD P stated she was not a certified as an activity director, but stated the facility set her up for an online program. however, the AD P had not started the program yet. Admin A sent an email that revealed that AD P was to start her training on 12/14/22 at 08:50 AM. On 12/14/22 at 09:58 AM and email was emailed was received from Admin A that AD P had not been signed up, until 12/14/22 Writer received second email from training site dated 12/14/22 at 09:58 AM reflecting AD P had been signed up for this online program at this date and time. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper communication/documentation of the services that Hospice had provided to two of two residents (R48 and R21) reviewed for Hospice services, resulting in a lack of coordination of care between the facility and Hospice.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Survey Book was consistently readily available, and that the book was maintained to include the facility plan of correction for identified deficiencies. Resulting in the potential for residents and visitors to be uninformed.