Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Majestic Care Of Battle Creek during CMS and state inspections, most recent first.
Advance Directive forms were not accurately completed for four residents. One cognitively intact resident with multiple serious diagnoses signed a Michigan DNR Order requesting no resuscitation, but the chart contained a Full Code physician order instead. Three other residents had DNR documents with undated witness signatures, and SW and DON staff confirmed the forms were incomplete or did not match the residents’ documented wishes.
Staff failed to follow Transmission-Based Precautions for two COVID-19 positive residents on droplet precautions. One resident with severe dementia and a recent COVID-19 diagnosis had a droplet precaution sign posted, yet a social services staff member entered the room wearing only a surgical mask and did not perform hand hygiene. Another resident with COPD and moderate cognitive impairment, recently returned from the hospital with COVID-19, also had droplet precautions posted. A housekeeper entered this room wearing a gown, gloves, surgical mask, and face shield, but not the N95 mask they believed was required. The DON stated the expectation for contact with COVID-19 positive residents was use of gown, gloves, N95 mask, and face shield.
A resident admitted with a femur fracture and COPD had a BIMS score indicating cognitive intactness and was ordered buspirone 15 mg TID for anxiety, but the medical record did not contain consent for the antianxiety medication. The DON stated that consents were generally obtained on admission and later acknowledged that the resident's buspirone consent had been missed.
The facility failed to document a clinical rationale for duplicate antidepressant therapy for a resident who was receiving Amitriptyline HCl and Venlafaxine HCl ER, with no depression diagnosis listed in the chart. The facility also failed to ensure appropriate monitoring for another resident receiving Quetiapine, as the record showed only CBC and CMP results and no documented Hgb A1c monitoring despite the DON’s report that it should be checked within 6 months of starting Seroquel and every 6 months thereafter.
Medication Administration Error Rate Exceeded: An LPN incorrectly primed an insulin pen without a needle, administered insulin after the resident had already finished breakfast, and gave an incorrect Metformin dose. The resident had type 2 DM and orders for insulin aspart before meals and Metformin 500 mg daily, but the medication administration did not follow the physician's orders, resulting in an 8% med error rate.
Failure to provide timely dental services for two residents. One resident with severe dementia had a signed consent and physician orders for dental care, but family reported no dental visit in about 2 years and no dentures for about 1.5 years, and the record showed no dental services provided. Another cognitively intact resident reported occasional dental pain and no dental visit or offer of dental services; the chart had a dental order but no consent and no documentation of dental care.
A resident who was cognitively intact and their own decision maker signed a binding arbitration agreement, but later said they did not recall discussing or signing it and would not have agreed if they had understood it waived the right to court litigation. The DOMA said staff described arbitration only as a voluntary third-party process and did not explain the waiver of the right to litigation, while the NHA said the agreement was optional and believed the waiver language was simply written in the document.
Two residents experienced changes in their skin integrity, including the development and worsening of pressure ulcers, but their care plans were not updated with new interventions to address these changes. Despite documented progression of wounds and staff acknowledgment that care plans should be revised as conditions change, the interventions remained unchanged from admission.
A resident with severe malnutrition and quadriplegia had their PEG tube dislodged, and a foley catheter was inserted in its place. The facility failed to notify the provider of this change in condition, contrary to their policy requiring notification for significant changes. Interviews revealed uncertainty among staff about whether the provider was informed.
The facility failed to provide hot beverages at a palatable temperature, as reported by several residents. A resident, who was cognitively intact, expressed dissatisfaction with cold coffee, leading to a grievance that was not addressed. The facility maintained a temperature log for hot liquids, but staff were unsure of the policy's origin. A past incident of a resident being burned by hot liquids led to a corrective plan, but the facility's policy allowed for hot beverages with interventions to minimize burn risks.
The facility failed to maintain food safety and sanitation standards, with improperly dated food items, inadequate dishwashing practices, and poor equipment maintenance. Observations included undated or improperly stored food, unclean utensils, and plumbing issues, violating FDA Food Code requirements.
The facility failed to implement an effective infection prevention and control program, particularly in managing Legionella risks in the plumbing system. Observations revealed unflushed water fixtures, including a shower and utility sink, leading to discolored water. The Water Management Program lacked active control measures, and clean supplies were stored under a wastewater line, risking contamination.
The facility failed to provide consistent and engaging activity programs, with discrepancies in activity calendars leading to resident confusion and boredom. A resident, who was cognitively intact, reported the absence of an Activity Director and frequent cancellations of activities. During a group meeting, several residents expressed similar frustrations. The Nursing Home Administrator confirmed the lack of activity staff, with CNAs filling in without proper training, leading to further inconsistencies.
A facility failed to complete required transfer and discharge documentation for a resident with multiple diagnoses, including Parkinson's and Dementia. The resident, who was cognitively intact, was hospitalized twice for UTIs and metabolic encephalopathy, but the necessary discharge/transfer notices were missing from the medical records. When requested, the facility provided an incomplete form that was not part of the original records, leading to potential mismanagement of continued care.
A facility failed to provide a resident with a written copy of the reason for transfer or discharge to the hospital in a language that was understandable, leading to potential lack of understanding. The resident, who was cognitively intact and required minimal assistance, was hospitalized twice for medical issues, but no discharge/transfer notice was found in her medical record. When requested, the facility provided an incomplete form that the resident had never seen.
A facility failed to provide a written bed hold notification in a language understandable to a resident, who was cognitively intact and had multiple diagnoses. The resident reported hospitalizations for a UTI and a fall, but there was no documentation of hospital discharge or transfer notices in the medical record. A bed hold/transfer/discharge form was provided upon request, but it lacked a date or signature and was not part of the medical record before the request. The resident stated she had never seen the form and was not given any forms during her hospitalizations.
A facility failed to timely complete and submit the PASARR form for a resident with mental illness and intellectual disabilities. The resident, who had a history of quadriplegia, schizoaffective disorder, and dementia, showed worsening behavioral symptoms. Despite scoring cognitively intact on the BIMS, no reevaluation was conducted, and the previous PASARR determination excluded a Level II assessment. Staff acknowledged the need for reassessment due to potential changes in the resident's condition.
A resident was admitted with complex medical needs, including dyskinesia and dysphasia, but the facility failed to develop baseline care plans within 48 hours. Nutritional and medication management plans were delayed, potentially leading to unmet care needs. Interviews revealed no documentation of timely care plan development.
A resident with diabetes and foot ulcers did not receive timely updates to their care plan, resulting in inadequate wound care. Despite orders for a wound vac, the facility failed to implement the treatment, citing non-compliance, which the resident disputed. The care plan lacked new interventions since the previous year, and staff did not document education provided to the resident.
A facility failed to have an emergency tracheostomy readily available for a resident with chronic respiratory failure and a tracheostomy. During care, an LPN could not immediately find the necessary equipment, which lacked an obturator. The facility's policy requires essential equipment to be easily accessible for emergencies.
A facility failed to assess a resident's ability to safely self-administer medications. The resident, with multiple diagnoses including Parkinson's and Dementia, was left alone with medications by an LPN and had a tube of normal saline at bedside for self-use. Despite being cognitively intact, a previous assessment indicated the resident could not self-administer medications, and she had requested assistance with medication administration.
A facility failed to coordinate and document hospice services for a resident, leading to inadequate care. The resident, with multiple health issues, was on hospice but lacked a clear care plan and schedule for hospice visits. Staff interviews revealed confusion and lack of awareness about hospice responsibilities, and necessary documentation was missing from the hospice binder and medical records.
The facility failed to provide grooming and bathing according to resident preferences for three residents. One resident had her hair cut due to staff neglecting to brush it, another resident's hair was not washed as per her care plan, and a third resident reported infrequent hair brushing.
The facility failed to ensure safe smoking practices for three residents, leading to a citation for accident hazards and inadequate supervision. One resident was observed rolling cigarettes in his room, another kept smoking materials in his possession without proper assessment, and a third had a strong smell of cigarette smoke in his room despite the facility's non-smoking policy. Staff interviews revealed inconsistencies in policy enforcement.
Advance Directive Forms Were Inaccurately Completed
Penalty
Summary
Advance Directive documents were not accurately completed for four residents whose records were reviewed. The deficiency involved Michigan Do-Not-Resuscitation Order forms and DNR documents that did not match the residents’ documented wishes or were missing required witness dates. The records reviewed showed that the facility relied on nursing staff and social work staff to review these forms for accuracy, but the documents remained incomplete or inconsistent in the chart. For one resident with chronic respiratory failure, COPD, morbid obesity, tracheostomy, oxygen dependence, heart failure, hypertension, bipolar disorder, schizophrenia, and other diagnoses, the resident was cognitively intact and had signed a Michigan Do-Not-Resuscitation Order stating that no resuscitation should be attempted if heart and breathing stopped. However, the physician order in the record was Full Code, which did not reflect the resident’s stated wishes. The DON reviewed the form and confirmed the resident had signed it requesting no resuscitation, but could not explain why the physician order did not match. For three other residents, the Michigan Do-Not-Resuscitation Order or DNR documents were missing dates on the two witness signatures. One resident was cognitively intact and had severe protein-calorie malnutrition, cachexia, CHF, COPD, dysphagia, pulmonary fibrosis, and other diagnoses; another had bipolar schizoaffective disorder and dementia with severe cognitive impairment; and the third had traumatic subdural hemorrhage, Alzheimer’s disease, cerebral infarction, depression, and other diagnoses with severe cognitive impairment. Social work and nursing staff confirmed the witness signatures were undated on these documents and stated they could not explain why the forms had not been completed accurately.
Failure to Use Appropriate PPE for Residents on Droplet Precautions
Penalty
Summary
The deficiency involves staff failure to follow the facility’s infection prevention and control program and Transmission-Based Precautions for residents on droplet precautions for COVID-19. One resident with severe vascular dementia and a recent positive COVID-19 test had a droplet precaution sign posted on the room door. Despite this, the Social Services Director entered the resident’s room wearing only a surgical mask and did not perform hand hygiene upon entry. In a subsequent interview, the Social Services Director acknowledged awareness of the droplet precautions and stated they should have slowed down and read the precaution signage on the door. Another resident with COPD, moderate cognitive impairment, and a recent positive COVID-19 test following a hospital stay also had a droplet precaution sign posted on the room door. The sign instructed that everyone must clean their hands before entering and leaving the room and ensure eyes, nose, and mouth were fully covered before entry. A housekeeper was observed in this resident’s room wearing a gown, gloves, surgical mask, and face shield. When questioned, the housekeeper stated they believed they were supposed to wear an N95 mask for this COVID-19 positive resident, acknowledged they were not wearing an N95 mask, and could not explain why. The DON later reported that the expectation for contact with COVID-19 positive residents was to wear a gown, gloves, N95 mask, and face shield.
Failure to Obtain Consent for Antianxiety Medication
Penalty
Summary
The facility failed to obtain consent for psychotropic medication use for one resident. R23 was admitted with diagnoses including fracture of the lower end of the right femur and COPD, and the admission MDS dated 12/22/25 showed a BIMS score of 13 out of 15, indicating the resident was cognitively intact, and that the resident was receiving antianxiety medication. The medical record reflected a physician's order dated 12/16/25 for buspirone 15 mg three times daily for anxiety, and the resident was observed seated in a wheelchair in their room on 01/16/2026. The record did not contain a consent for buspirone. In interview, the DON stated that consents were generally obtained upon admission, that antianxiety medications were a classification for which consent would be obtained, and later acknowledged that R23's buspirone consent had been missed.
Duplicate psychotropic therapy and antipsychotic monitoring deficiencies
Penalty
Summary
The facility failed to document a clinical rationale for duplicate psychotropic medication therapy for one resident. R23 was admitted with diagnoses including fracture of the lower end of the right femur and COPD, and the admission MDS showed the resident was cognitively intact and receiving antidepressant medication. The medical record showed orders for Amitriptyline HCl 75 mg at bedtime for depression and Venlafaxine HCl ER 150 mg daily for depression, but the diagnosis list did not include depression. During interview, the DON stated the facility continued the resident’s medications from the hospital and acknowledged that the diagnoses were listed in a nurse practitioner progress note as part of the medication orders, but documentation supporting the duplicate antidepressant therapy was not found in the record. The facility also failed to ensure appropriate monitoring of antipsychotic medication use for another resident. R41 was admitted with diagnoses including hyperglycemia, dementia with anxiety, depression, anxiety disorder, dysthymic disorder, obsessive compulsive disorder, and altered mental status, and the MDS reflected severe cognitive impairment and antipsychotic use. The resident had an order for Quetiapine Fumarate 12.5 mg at bedtime, but the most recent laboratory tests in the record were a CBC and CMP from July 2025. The DON stated the facility’s pharmacist indicated a hemoglobin A1c should be monitored within six months of starting Seroquel and every six months after, but the record reviewed did not show that monitoring.
Medication Administration Error Rate Exceeded
Penalty
Summary
The facility failed to ensure a medication error rate of less than 5% when 2 of 25 medications were not administered in accordance with physician's orders for one resident, resulting in an 8% medication error rate. The resident was admitted with a diagnosis of type 2 diabetes and had physician's orders for insulin aspart 10 units subcutaneously three times daily before meals and Metformin HCl 500 mg by mouth one time a day. During an observation, an LPN removed the resident's insulin aspart FlexPen from the medication cart, dialed the pen to 5 units, and pushed the injection button while reporting that she primed the insulin pen with 5 units as she always does. The LPN did not have a needle on the insulin pen during priming. When the LPN entered the resident's room, the resident had already finished breakfast and no longer had a breakfast tray present. The LPN then administered 10 units of insulin aspart and metformin 1000 mg. The insulin pen was primed incorrectly and the insulin was given after breakfast instead of before, and the Metformin dose administered was incorrect. A later observation of the medication cart confirmed the resident only had Metformin 1000 mg available, and the DON stated a needle should be applied to the insulin pen before priming.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to provide timely routine and emergency dental services for two residents. One resident was admitted with vascular dementia, severe psychotic disturbance, major depressive disorder, and a history of cerebral infarction, and had severely impaired cognition on MDS. The resident’s family member reported that the resident had not been seen for dental services in approximately 2 years and had not had dentures in about a year and a half. The record showed physician orders allowing dental services and a signed consent for dental services with 360 Care, but no documentation was found showing that dental services had actually been provided. The Social Service Director stated that, based on the admission date and valid consent, the resident should have already been seen by dental services, but could not provide any record of dental care. Another resident, admitted with osteomyelitis of the left ankle and foot, hypertension, type 2 diabetes, muscle weakness, lack of coordination, a chronic left foot ulcer, depression, diabetic foot ulcer, and absence of left toes, was cognitively intact on the most recent MDS. During interview, the resident stated having occasional dental pain and reported not having seen a dentist at the facility or been offered dental services. The medical record contained a physician order permitting dental services, but no consent for dental services and no documentation that dental services had been provided since admission. The Social Worker stated residents are offered dental services upon admission and sign a consent for ancillary services, but could not locate a consent in the record. A later document was identified as a request for service noting mouth pain, but it was not a consent, and dental services had still not been provided for the resident’s dental pain.
Arbitration Agreement Not Explained in Understandable Terms
Penalty
Summary
The facility failed to ensure a Binding Arbitration Agreement was explained to a resident in a form and manner they understood. The resident, R23, was admitted with diagnoses including anxiety and depression, and the MDS with an ARD of 12/22/25 showed a BIMS score of 13 out of 15, indicating the resident was cognitively intact and their own decision maker. R23 signed the Arbitration Agreement on 12/19/25, and the DOMA signed as the authorized facility representative. On 01/16/2026, R23 stated they did not recall discussing or signing an Arbitration Agreement. When the agreement was explained to them as giving up the right to litigation in a court proceeding and using arbitration instead, R23 said they would not have signed it. The DOMA stated the agreement was part of the main admission agreement, that staff explained it as a voluntary process involving a third party if the resident was unhappy and could not reach agreement with the facility, and that they did not explain anything about giving up the right to litigation in a court proceeding. The NHA stated the agreement was optional and believed the waiver of court proceedings was written in the agreement, adding that they would not expect a nursing home employee to understand all of it.
Failure to Revise Care Plans as Residents' Conditions Changed
Penalty
Summary
The facility failed to ensure that care plans were revised as residents' care needs changed for two out of four residents reviewed. One resident was admitted with a stage III sacral pressure ulcer and subsequently developed additional pressure wounds, including unstageable and stage II ulcers on the right inner thigh and gluteal folds, as well as pressure ulcers on the left great toe and heel. Despite documented worsening of the sacral pressure ulcer over several weeks, with increasing wound size and depth, the care plan interventions remained unchanged from those implemented at admission. No new interventions were added to address the progression of the wound, and the care plan was not updated to reflect the resident's changing condition. Another resident, who did not have pressure ulcers upon admission, sustained a fall resulting in an abrasion on the back, which later developed into a stage III pressure ulcer. Although a care plan was in place identifying risk for skin breakdown, the interventions were not updated to reflect the actual development of a stage III pressure ulcer. The care plan was not revised with new interventions until a significant delay after the wound had progressed. Staff interviews confirmed that care plans should have been updated with new interventions as the residents' conditions changed, but this was not done in these cases.
Failure to Notify Provider of PEG Tube Dislodgment
Penalty
Summary
The facility failed to notify the provider of a change in condition for a resident who was admitted with severe protein-calorie malnutrition, degenerative disease of the nervous system, and quadriplegia. The resident was dependent on a PEG tube for nutrition, hydration, and medication. On December 8, 2024, the resident's PEG tube was found dislodged, and a nurse inserted a foley catheter in its place. However, the medical record did not reflect that a provider was notified of the dislodgment or that any orders were given on how to proceed with care. Interviews with facility staff revealed that the Director of Nursing was informed of the dislodged PEG tube, but there was no confirmation that a provider was notified. The facility's policy required that a provider be notified of significant changes in a resident's condition, such as the need to alter treatment. The failure to notify the provider was contrary to the facility's Change in Condition/Physician Notification policy and Enteral Feeding policy, which emphasized the importance of notifying a practitioner when a feeding tube change arises unexpectedly.
Deficiency in Providing Palatable Hot Beverages
Penalty
Summary
The facility failed to provide hot liquids at a palatable temperature to several residents, as observed during a group interview and individual resident survey. Five out of eight residents in a group interview expressed frustration with the temperature of beverages, noting that coffee and tea were consistently cold, and hot cocoa was not hot enough to dissolve properly. One resident, who was cognitively intact and had clear speech and adequate hearing, reported dissatisfaction with the cold coffee, which led to the resident's spouse bringing in coffee from outside. This resident had filed a grievance about the coffee temperature, but no changes were made by the facility. During a kitchen tour, it was found that the facility maintained a temperature log for hot liquids between 120F and 140F, but the Dietary Manager was unsure of the policy's origin. The Nursing Home Administrator and Director of Nursing were also unfamiliar with the hot liquid policy. A review of the facility's documentation revealed a past incident where a resident was burned by hot liquids, leading to a corrective plan that included evaluating residents for hot liquid risks. However, the facility's policy stated that residents should not be restricted from hot beverages, and interventions should be implemented to minimize burn risks, such as maintaining a serving temperature of not more than 180 degrees Fahrenheit and using protective measures.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a kitchen inspection. Several items in the refrigeration unit were improperly dated or lacked date markings, including hot dogs, sliced smoked ham, and strawberry sauce. This is a violation of the 2017 FDA Food Code, which requires ready-to-eat, time/temperature control for safety food to be clearly marked with a date by which they should be consumed or discarded. Additionally, a bottle of lemon juice was found unrefrigerated despite manufacturer instructions to refrigerate after opening, and several utensils and storage containers were found with food debris and were improperly cleaned. Further observations revealed that the facility's dishwashing practices were inadequate. A dietary aide was seen handling both dirty and clean dishes without washing hands or changing gloves, which is a breach of the FDA Food Code's handwashing requirements. The dish machine area was also found to have an accumulation of debris, and the physical condition of the area was deteriorating, with pitting and open holes observed near the floor. The inspection also identified issues with the facility's plumbing and equipment maintenance. The ice machine's air gap was improperly installed, creating a potential backflow risk, and the mop sink faucet was left on with a Y valve attached, which could compromise the vacuum breaker's integrity. The hot water valve was missing its handle, preventing it from being turned off. These findings indicate a failure to maintain the plumbing system in good repair, as required by the FDA Food Code.
Inadequate Water Management and Infection Control
Penalty
Summary
The facility failed to maintain an active and ongoing infection prevention and control program, specifically in managing the risk of Legionella and other opportunistic pathogens in the plumbing system. During a facility tour, it was observed that several water fixtures, including a shower fixture in a small shower room and a utility sink in the central supply room, were not being regularly flushed. The Maintenance Director (MD) admitted to not flushing certain fixtures, such as the old tub spigot in the small shower room and the utility sink, which resulted in brown and discolored water when briefly turned on. Additionally, the eyewash station in the central supply room was not regularly flushed due to the absence of a wastewater line, causing water to spill onto the floor. The facility's Water Management Program, approved in December 2023, outlined the need for an interdisciplinary water management team and specific measures to control Legionella growth, such as monitoring water stagnation and disinfection levels. However, interviews and record reviews revealed that no active and ongoing control measures or control limits were documented or in place. Furthermore, clean and sanitary nursing items were stored under a large wastewater line in the basement central supply room, posing a risk of contamination. The Maintenance Director confirmed that there were no current sampling procedures in place, and monthly meetings were held with the maintenance group but lacked in-house coordination.
Inconsistent Activity Programs and Calendars
Penalty
Summary
The facility failed to provide consistent and accurate activity calendars and meaningful, diverse, and engaging activity programs for residents. One resident, who was cognitively intact and had clear speech and adequate hearing, reported being bored due to the lack of activities and the absence of an Activity Director or Activity Aid for a month. The resident noted discrepancies between the activity calendar posted in their room and the one in the hallway, leading to confusion about scheduled activities, which were often canceled. The resident had filed multiple grievances regarding missed activities and lack of notification about changes, with no documented resolutions. During a confidential group meeting, six out of eight participants expressed similar frustrations about the lack of activities and inconsistencies in the activity calendars. The Nursing Home Administrator confirmed the absence of activity staff, with CNAs filling in without proper training. One CNA admitted to not understanding the activity calendars and substituting activities with coloring due to a lack of guidance. The CNA also reported that activities were not conducted as scheduled, with no communication to residents about changes. The facility's failure to maintain a consistent and engaging activity program was evident, with no explanation provided for the discrepancies in the activity calendars.
Failure to Complete Required Transfer and Discharge Documentation
Penalty
Summary
The facility failed to ensure that the required transfer and discharge documentation was completed for a resident, identified as Resident #20, who was reviewed for discharge. The resident had been admitted to the facility with multiple diagnoses, including Parkinson's Disease, Diabetes Mellitus, Dementia, Cardiac Arrhythmias, Anxiety, Chronic Pain, and weakness. The resident was cognitively intact, as indicated by a Brief Interview of Mental Status (BIMS) score of 15 out of 15, and required minimal assistance with personal care. Despite these conditions, the facility did not provide the necessary hospital discharge or transfer notices for two hospitalizations related to urinary tract infections and metabolic encephalopathy. During interviews, the resident stated that she had not received any forms when she was hospitalized in March and April 2024. A review of the medical records revealed that the facility staff documented the resident's conditions, but the required discharge/transfer notices were missing. When requested, the facility provided a bed hold/transfer/discharge form with demographic information, but it lacked a date or signature and was not part of the medical record prior to the request. This oversight resulted in the omission of care plan goals from the transfer paperwork, potentially leading to ineffective or mismanaged continued care.
Failure to Provide Transfer/Discharge Notice in Understandable Language
Penalty
Summary
The facility failed to provide a written copy of the reason for transfer or discharge to the hospital in a language that was understandable to the resident, resulting in a potential lack of understanding and knowledge. This deficiency was identified for one resident, who was initially admitted to the facility with multiple diagnoses including Parkinson's Disease, Diabetes Mellitus, Dementia, Cardiac Arrhythmias, Anxiety, Chronic Pain, and weakness. The resident was cognitively intact, as indicated by a Brief Interview of Mental Status (BIMS) score of 15 out of 15, and required minimal assistance with personal care. The resident was hospitalized on two occasions, once for a urinary tract infection (UTI) and hypoxia, and another time for metabolic encephalopathy related to a UTI. In both instances, the facility did not provide a hospital discharge/transfer notice in the resident's medical record. When requested, the facility provided a bed hold/transfer/discharge form with demographic information but without a date or signature, and it was not part of the medical record prior to the request. The resident confirmed during an interview that she had never seen the form before and was not given any forms during her hospitalizations.
Failure to Provide Bed Hold Notification in Understandable Language
Penalty
Summary
The facility failed to provide a written bed hold notification in a language understandable to Resident #20, who was reviewed for bed hold notification. Resident #20 was initially admitted to the facility and later readmitted with multiple diagnoses, including Parkinson's Disease, Diabetes Mellitus, Dementia, and others. The resident was cognitively intact, as indicated by a BIMS score of 15 out of 15, and required minimal assistance with personal care. During interviews, the resident reported hospitalizations due to a urinary tract infection and a fall, but there was no documentation of hospital discharge or transfer notices in the medical record for these hospitalizations. Upon request, the facility provided a bed hold/transfer/discharge form with the resident's demographic information, but it lacked a date or signature and was not part of the medical record before the request. The resident stated she had never seen the form and was not given any forms during her hospitalizations in March and April 2024. This lack of documentation and communication resulted in the potential for the resident to lack understanding and knowledge of the bed hold policy.
Failure to Timely Complete PASARR for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure the timely completion and submission of the Preadmission Screening and Annual Resident Review (PASARR) form for a resident with mental illness and intellectual disabilities. The resident, identified as R18, was observed in a wheelchair and had a history of quadriplegia, schizoaffective disorder, bipolar type, major depressive disorder, anxiety disorder, and dementia. Despite scoring 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating cognitive intactness, the resident exhibited worsening behavioral and mood symptoms, as documented in a Behavior Management Review. The Level I PASARR completed in 2023 documented the resident's mental illness and dementia diagnosis, which led to the exclusion of a Level II PASARR. However, there was no reevaluation conducted despite significant changes in the resident's condition, such as a potential decrease or clearing of dementia, which could allow the resident to benefit from mental health services. The Social Worker and Assistant Director of Nursing acknowledged the lack of reassessment and the need to evaluate the resident's current condition, as the previous determination may no longer be applicable.
Failure to Develop Timely Baseline Care Plans
Penalty
Summary
The facility failed to ensure that baseline care plans were developed within 48 hours of admission for a resident, resulting in the potential for unmet care needs. The resident was admitted with multiple diagnoses, including dyskinesia, dysphasia, and other chronic conditions. Despite these complex medical needs, a nutritional care plan was not implemented until six days after admission, and a care plan addressing psychotropic, antianxiety, and antidepressant medications was not developed until 13 days after admission. This delay in care planning could have led to unmet nutritional and medication management needs. The resident's medication orders included several psychotropic and antidepressant medications, which were administered starting from the day of admission. However, the lack of a timely care plan meant that the facility did not adequately address the potential risks associated with these medications. Interviews with the Director of Nursing revealed that there was no documentation or evidence that baseline care plans were developed or provided to the resident's guardian within the required timeframe, highlighting a significant oversight in the facility's admission process.
Failure to Revise Care Plan for Resident with Wound Care Needs
Penalty
Summary
The facility failed to revise and update the care plan for a resident with multiple health issues, including diabetes mellitus with foot ulcer, peripheral vascular disease, and chronic kidney disease. The resident, who was cognitively intact, required stand-by assistance to independent personal care. Despite being under the care of a wound clinic, vascular surgeon, and primary care provider, the facility did not implement a wound vac order placed by a specialty clinic. The resident expressed concerns about the improper application of the wound vac dressing by the facility nurses, which led to the resident being sent to a wound clinic instead. Interviews with the resident and facility staff revealed discrepancies in the documentation and implementation of the wound vac orders. The resident stated that he never refused the wound vac or dressing changes, contradicting the facility's claims of non-compliance. The registered nurse responsible for the resident's wound care could not find records of the wound vac dressing changes and admitted to not documenting daily education provided to the resident. The director of nursing also confirmed that no new interventions were documented in the care plan to address the resident's wound care needs. The nurse practitioner expressed concern over the facility's failure to follow her orders for the wound vac, which she believed was necessary for the resident's healing. Despite the resident's desire to improve and return home, the facility staff cited various reasons for not implementing the treatment, such as the resident's alleged non-compliance. The care plan had not been updated with new interventions since March of the previous year, indicating a lack of timely and individualized care planning for the resident's impaired skin integrity.
Emergency Tracheostomy Equipment Not Readily Available
Penalty
Summary
The facility failed to have an emergency tracheostomy readily available for a resident, identified as R9, who required tracheostomy care. During an observation, R9 was seen resting in bed with a tracheostomy that appeared intact and clean. The resident's electronic medical record indicated a history of chronic respiratory failure with hypercapnia and a tracheostomy status since 2023. However, during a tracheostomy care session, the LPN was unable to immediately locate the emergency tracheostomy equipment, which included a sterile outer and inner cannula but lacked an obturator. The deficiency was further highlighted during an interview with the LPN, the Director of Nursing, and a Clinical Consultant, where it was confirmed that the emergency tracheostomy should be within quick reach on the wall. The facility's policy on tracheostomy care, revised earlier in the year, mandates that essential equipment such as a suction machine, suction catheters, correctly sized cannulas, and an ambu bag should be easily accessible for immediate emergency care. The absence of a complete emergency tracheostomy kit posed a potential risk for delay in emergency response.
Failure to Assess Resident's Ability to Self-Administer Medications
Penalty
Summary
The facility failed to ensure that a resident was properly assessed for the ability to safely self-administer medications. The resident, who was initially admitted to the facility with a readmission on 01/24/24, has diagnoses including Parkinson's Disease, Diabetes Mellitus, Dementia, Cardiac Arrhythmias, Anxiety, Chronic Pain, and weakness. The most recent Minimum Data Set (MDS) indicated the resident was cognitively intact with a Brief Interview of Mental Status (BIMS) score of 15 out of 15 and required minimal assistance with personal care. During an observation, a Licensed Practical Nurse (LPN) left the resident alone with a med cup containing 14 pills while retrieving applesauce, leaving the medications out of visual sight. Additionally, the resident was observed with a tube of normal saline at bedside, which she used as an oral rinse multiple times a day. A record review revealed an assessment from 12/16/21 stating the resident could not self-administer medications, and the resident had requested that her medications be administered to her, not self-administered.
Lack of Coordination and Documentation of Hospice Services
Penalty
Summary
The facility failed to ensure proper communication and documentation of hospice services for a resident, resulting in a lack of coordination of comprehensive care. The resident, who was cognitively intact and required maximum assistance with personal care, was admitted to the facility with multiple diagnoses including chronic kidney disease, bacteremia, osteomyelitis, and pressure ulcers. The resident was signed up for hospice services, but there was no calendar or schedule for hospice visits, and the CNA care plan was missing from both the hospice binder and the medical record. Interviews with facility staff revealed a lack of awareness and coordination regarding the hospice care plan and the responsibilities of hospice CNAs versus facility CNAs. The CNA and RN interviewed were not familiar with the hospice care plan, and the social worker did not engage with the clinical aspects of the care plan. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) acknowledged the absence of necessary documentation and coordination in the hospice binder, indicating a systemic issue in managing hospice care within the facility.
Failure to Provide Grooming and Bathing According to Resident Preferences
Penalty
Summary
The facility failed to ensure bathing and grooming were provided according to resident preferences for three residents. Resident #1, who had moderate cognitive impairment and physical impairments, reported that her hair had not been brushed for about a month by male staff members, resulting in her hair becoming tangled and eventually being cut by a staff member. The Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that male staff had received training on braiding hair but admitted that male staff felt less competent than female staff in performing hair care tasks. Resident #1 expressed that she did not want her hair cut, but it was done anyway due to the knots. Resident #2, who had severe cognitive impairment, was observed lying in bed and reported receiving bed baths but was unsure how often her hair was washed. Her medical record indicated a preference for bed baths on specific days, with hair washing included, but documentation showed that her hair was not washed on several occasions without any refusals noted. Licensed Practical Nurse (LPN) C stated that nurses should follow up and document any refusals, which was confirmed by NHA A and DON B. Resident #6, who was cognitively intact, reported that staff sometimes did not brush her hair for weeks, although she wished for daily hair brushing. She managed to avoid severe tangling by keeping her hair in a braid.
Failure to Ensure Safe Smoking Practices
Penalty
Summary
The facility failed to ensure safe smoking practices for three residents, leading to a citation for accident hazards and inadequate supervision. Resident #8 was observed rolling cigarettes in his room and admitted to keeping his lighter in his pocket, contrary to the care plan intervention that required smoking materials to be kept with facility staff. Resident #9, who had moderate cognitive impairment, reported keeping his cigarettes and lighter in his possession, with no assessment for the storage of his smoking materials and no care plan intervention for their storage. Resident #14, who was cognitively intact, was found to have a strong smell of cigarette smoke in his room on two occasions, despite the facility's non-smoking policy and the requirement for smoking materials to be kept at the front desk. The facility was unable to locate a smoking assessment for Resident #14, and the resident admitted to putting extinguished cigarette butts in the trash in his room to avoid littering the parking lot. Interviews with staff revealed inconsistencies in the enforcement of the facility's non-smoking policy. An LPN reported that no residents were allowed to keep cigarettes or lighters in their rooms, while the Nursing Home Administrator acknowledged that residents were not always compliant with the policy. The lack of proper storage and supervision of smoking materials, as well as the absence of smoking assessments for some residents, contributed to the facility's failure to provide a safe environment free from accident hazards.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 285 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Battle Creek
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Oaks At Battle Creek | 0.2 mi | ★★★★★ | 0 | 0 |
| Pinnacle Care Of Battle Creek | 1.9 mi | ★★★★★ | 15 | 0 |
| The Laurels Of Bedford | 2.4 mi | ★★★★★ | 14 | 0 |
| Calhoun County Medical Care Facility | 3.7 mi | ★★★★★ | 5 | 0 |
| Evergreen Manor Senior Care Center | 4.3 mi | ★★★★★ | 19 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.