Deficiency Records for Majestic Care of Battle Creek
Updated as of September 01, 2022
This is not the most recent data for Majestic Care of Battle Creek. For the most recent information, click here.
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? |
|---|---|---|---|---|
| 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 |
| Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting. | 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 |
| Ensure each resident receives an accurate assessment. | Health | 2021-02-18 | 2021-03-09 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-02-18 | 2021-03-09 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-12-09 | 2020-12-24 | N |
| Report COVID19 data to residents and families. | Health | 2020-12-09 | 2020-12-24 | N |
| 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 |
| 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 |
| 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 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 |
| Provide and implement an infection prevention and control program. | 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 | Y |
| 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 | Y |
| 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 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2020-11-05 | 2020-12-02 | Y |
| 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 | Y |
| 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 |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2020-09-18 | 2020-10-30 | Y |
| Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting. | Health | 2020-09-18 | 2020-10-30 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-09-18 | 2020-10-30 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-09-18 | 2020-10-30 | 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 | 2020-09-18 | 2020-10-30 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2020-08-13 | 2020-09-24 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-08-13 | 2020-09-24 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-08-13 | 2020-09-24 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-08-13 | 2020-09-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-08-13 | 2020-09-24 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-05-29 | 2020-06-17 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2020-01-16 | 2020-02-19 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-01-16 | 2020-02-19 | Y |
| Respond appropriately to all alleged violations. | Health | 2020-01-16 | 2020-02-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-01-16 | 2020-02-19 | 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 | 2020-01-16 | 2020-02-19 | Y |
| 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 | 2019-02-14 | 2019-03-14 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-02-14 | 2019-03-14 | N |
| 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 | 2019-02-14 | 2019-03-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-02-14 | 2019-03-14 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-02-14 | 2019-03-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-02-14 | 2019-03-14 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-02-14 | 2019-03-14 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-03-15 | 2018-04-17 | 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 | 2018-03-15 | 2018-04-17 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-03-15 | 2018-04-17 | 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 | 2018-03-15 | 2018-04-17 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-03-15 | 2018-04-17 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2018-03-15 | 2018-04-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-03-15 | 2018-04-17 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-03-15 | 2018-04-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-03-15 | 2018-04-17 | N |
