A list of the most recent deficiencies for Majestic Care of Battle Creek. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-10-17 | 2023-11-21 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-10-17 | 2023-11-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-17 | 2023-11-21 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-10-17 | 2023-11-21 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-10-17 | 2023-11-21 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-17 | 2023-11-21 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-10-17 | 2023-11-21 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-10-17 | 2023-11-21 | N |
| Post nurse staffing information every day. | Health | 2023-10-17 | 2023-11-21 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-10-17 | 2023-11-21 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-10-17 | 2023-11-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-17 | 2023-11-21 | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2023-10-17 | 2023-11-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-17 | 2023-11-21 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-10-23 | 2023-11-05 | N |
| Have exits that are accessible at all times. | Fire Safety | 2023-10-23 | 2023-11-05 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-10-23 | 2023-11-05 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-10-23 | 2023-11-05 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-05-23 | 2023-06-30 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-05-23 | 2023-06-10 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-05-23 | 2023-06-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-23 | 2023-06-10 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-23 | 2023-06-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-05-23 | 2023-06-10 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-03-06 | 2023-03-22 | Y |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-08-31 | 2022-12-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-31 | 2022-12-07 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-08-31 | 2022-12-07 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-08-31 | 2022-12-07 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-31 | 2022-12-07 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-31 | 2022-12-07 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-08-31 | 2022-12-07 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-08-31 | 2022-12-07 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-08-31 | 2022-12-07 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-08-31 | 2022-12-07 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-08-30 | 2022-12-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-30 | 2022-12-07 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-08-31 | 2022-10-10 | N |
| Provide activities to meet all resident's needs. | Health | 2022-08-31 | 2022-10-10 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-08-31 | 2022-10-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-31 | 2022-10-10 | N |
| Dispose of garbage and refuse properly. | Health | 2022-08-31 | 2022-10-10 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-08-31 | 2022-10-10 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2022-08-31 | 2022-10-10 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-08-31 | 2022-10-10 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-08-31 | 2022-10-10 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-08-31 | 2022-10-10 | N |
| Report COVID19 data to residents and families. | Health | 2022-08-31 | 2022-10-10 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-08-31 | 2022-10-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-31 | 2022-10-10 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-08-30 | 2022-10-10 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-08-30 | 2022-10-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-08-30 | 2022-10-10 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-08-30 | 2022-10-10 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-08-30 | 2022-10-10 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-06-02 | 2022-06-25 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-03-24 | 2022-06-25 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-24 | 2022-06-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-24 | 2022-06-25 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-03-24 | 2022-06-25 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-03-24 | 2022-06-25 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-03-24 | 2022-06-25 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2022-03-24 | 2022-04-25 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-03-24 | 2022-04-25 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-03-24 | 2022-04-25 | Y |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-03-24 | 2022-04-25 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-03-24 | 2022-04-25 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-03-24 | 2022-04-25 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-03-24 | 2022-04-25 | Y |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2022-03-24 | 2022-04-25 | Y |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2022-03-24 | 2022-04-25 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-09-16 | 2021-10-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-16 | 2021-10-08 | Y |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2021-09-16 | 2021-10-08 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-09-16 | 2021-10-08 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2021-09-16 | 2021-10-06 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2020-11-05 | 2020-12-02 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2020-11-05 | 2020-12-02 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-11-05 | 2020-12-02 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2020-11-05 | 2020-12-02 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-11-05 | 2020-12-02 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2020-11-05 | 2020-12-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-11-05 | 2020-12-02 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2020-11-05 | 2020-12-02 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2020-11-05 | 2020-12-02 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2020-11-05 | 2020-12-02 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2020-11-05 | 2020-12-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-11-05 | 2020-12-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-11-02 | 2020-12-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-11-02 | 2020-12-02 | N |
