The Oaks at Battle Creek

Inspectors wroteThis citation pertains to Intakes: 2790134Based on observation, interview, and record review the facility failed to provide an environment free from physical and verbal abuse for two Residents (#29, #95) of two residents reviewed for abuseFindings Included:Resident #29 (R29)Review of the medical record revealed R29 was admitted to the facility 01/02/2025 with diagnoses that included kidney disease, type 2 diabetes, morbid obesity, hyperlipidemia (high fat concentration in blood), depression, anxiety, chronic pain, tachycardia, and heart disease. Review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/06/2026, revealed R29 had a Brief Interview for Mental Status (BIMS) of 15 (cognitively intact) out of 15. [...]

Inspectors wroteBased on interview, and record review the facility failed to complete an accurate level I and level II screening for one (Resident #9) of two residents reviewed for Preadmission Screening/Annual Resident Review (PASARR). Findings Included: Resident #9 (R9)Review of the medical record revealed R9 was admitted to the facility 10/28/2025 heart disease, bipolar disorder, hyperlipidemia (high fat level in blood), gastro-esophageal reflux disease, dementia, low back pain, depression, asthma, anxiety disorder, obstructive sleep apnea, cerebral vascular accident, dysphagia (difficulty swallowing), type 2 diabetes, urinary retention, and hypertension. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/05/2026, revealed R9 had a Brief Interview for Mental Status (BIMS) of that could not be completed because R9 is rarely/never understood. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to: 1.) ensure the safety and 2.) ensure a prescribed intervention related to fall prevention was in place for 1 of 2 residents (R78) reviewed for falls, resulting in R78's fall during transfer with staff.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that food was served and held at a palpable temperature. Resulting in the potential to affect all residents (total facility census of 70) that consume food from the kitchen. Findings Included: Resident #173 (R173) Review of the medical record revealed R173 was admitted to the facility 02/14/2025 with diagnoses that included prosthetic left hip joint, fracture of left femoral neck, type 2 diabetes, hypertension, hyperlipidemia (high fat content in blood), depression, anemia (low red blood cells), osteoarthritis (type of arthritis occurs when tissue at end of bones wears down), unilateral inguinal hernia, and pain in left hip. The Minimum Data Set, with an Assessment Reference Date (ARD) of 02/20/2025, demonstrated a Brief Interview for Mental Status (BIMS) of 9 (moderate cognitive impairment) out of 15. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment effecting 70 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and plumbing water leaks.

Inspectors wroteBased on observation, interview, and record review, the facility failed to practice effective infection prevention standards related to hand hygiene, 1) adhere to infection control practices, during medication administration with three of four nurses; and 2) facility failed to maintain infection control practices, in one of two wounds, Resident #59 (R59). Findings Included: Resident #59 (R59) Review of the medical record reflected R59 was an initial admission to the facility on [DATE]. Diagnoses of Congested Heart Disease, Chronic Kidney Disease, Peripheral Vascular Disease, Chronic Obstructive Pulmonary Disease and Diabetes. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/12/2024, revealed R59 had a Brief Interview of Mental Status (BIMS) of 13 (cognitively intact) out of 15. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to advocate for one out of two residents (#29) reviewed for dignity resulting in the resident feeling unheard, decreased self-worth, frustration, decreased quality of life and suffered mental anguish.

Inspectors wroteBased on interview and record review the facility failed to ensure that the Notice of Medicare Non-Coverage (NOMNC) was provided for two Residents (#2 and #179) and a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) was provided for three Residents (#2, #178, and #179) out of three reviewed for Beneficiary Notification. Findings Included: Resident #2 (R2) Review of the medical record revealed R2 was admitted to the facility 10/02/2024 with diagnoses that included chronic kidney disease, hyponatremia (low sodium level) type 2 diabetes, atrial fibrillation, chronic obstructive pulmonary disease (COPD), anemia (low red blood cells), hyperlipidemia (high fat content in blood), depression, chronic pain, and gastro-esophageal reflux disease. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident medical records were secured and held confidential for 1 resident (R8) of 17 residents sampled, resulting in exposed resident medical information.

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a person centered care plan for targeted behaviors for the use of psychotropic medications for one Resident (Resident 20) of 17 residents reviewed for care plans.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that meaningful activities were provided for one resident (R26) out of two resident who are dependent on staff for transferring and mobility and the likelihood for depression, feelings of melancholy using the reasonable person concept. This deficient practice resulted in the potential for boredom, lack of stimulation and loneliness. Findings Include: Resident #26 (R26) Review of the medical record reflected R26 was an initial admission to the facility on [DATE]. Diagnoses of a Stroke, Hypertension, Coronary Artery Disease, Hemiplegia on right side, Malnutrition, Depression and Anxiety. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/21/2024, revealed R26 had a Brief Interview of Mental Status (BIMS) of 14 (cognitively intact) out of 15. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents prescribed anti-psychotic medication had an adequate indication for use, clinical rational to support continued use, as well as identify and monitor resident specific specific behaviors and approaches and non-pharmacological approaches for one resident (Resident #20) of five residents reviewed for unnecessary medications.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment effecting 68 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper communication/documentation of Hospice services provided to one Resident (# 48) of one resident reviewed for Hospice services, resulting in the lack of coordination of comprehensive services and care provided. Review of the clinical record including the Minimum Data Set (MDS) dated [DATE] reflected Resident 48 (R48) was a [AGE] year old female admitted to the facility on [DATE] with diagnosis that included dementia. R48 scored 4 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS), further review of the clinical record reflected R48 was receiving hospice care as of 9/12/23. On 04/17/24 at 12:46 PM, Licensed Practical Nurse (LPN) P reported the Nursing staff were not informed about hospice schedules and do not have any type of schedule or calendar to refer to. [...]

Inspectors wroteThis citation pertains to intake MI000139094. Based on interview and record review the facility failed to ensure resident rights in accordance to preferences were followed for one out of three residents (Resident #1), resulting in restrictions of a visitor, and the potential for further resident preferences to not be followed. Findings Included: Per the facility face sheet Resident #1 (R1) was admitted to the facility on [DATE]. R1 no longer resided at the facility at the time of the onsite investigation. In an interview on 9/18/2023 at 9:32 AM, R1's wife stated that when R1 was being admitted to the facility she told a staff member (could not recall who) that she wanted to stay the night with R1. R1's wife said she was told no she could not stay the night with R1. [...]