A list of the most recent deficiencies for Pinnacle 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 safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-05-17 | 2023-06-19 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-05-17 | 2023-06-19 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-05-17 | 2023-06-19 | 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 | 2023-05-17 | 2023-06-19 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2023-05-17 | 2023-06-19 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-17 | 2023-06-19 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-05-17 | 2023-06-19 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-12-15 | 2023-03-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-15 | 2023-02-16 | N |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2022-12-22 | 2023-01-31 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-12-22 | 2023-01-31 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2022-12-22 | 2023-01-31 | 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 | 2022-12-22 | 2023-01-31 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-12-22 | 2023-01-31 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-12-22 | 2023-01-31 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-12-22 | 2023-01-31 | 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 | 2022-12-22 | 2023-01-31 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-12-22 | 2023-01-31 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-12-22 | 2023-01-31 | N |
| 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 | 2022-12-22 | 2023-01-31 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-12-22 | 2023-01-31 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-12-22 | 2023-01-31 | 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 | 2022-12-22 | 2023-01-31 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-12-22 | 2023-01-31 | 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 | 2022-12-22 | 2023-01-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-22 | 2023-01-31 | N |
| Employ staff that are licensed, certified, or registered in accordance with state laws. | Health | 2022-12-22 | 2023-01-31 | 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 | 2022-12-22 | 2023-01-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-12-22 | 2023-01-31 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-12-22 | 2023-01-31 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-12-22 | 2023-01-31 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-12-22 | 2023-01-31 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-22 | 2023-01-31 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-12-22 | 2023-01-31 | Y |
| Provide activities to meet all resident's needs. | Health | 2022-12-22 | 2023-01-31 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-22 | 2023-01-31 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-12-22 | 2023-01-31 | 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 | 2022-12-22 | 2023-01-31 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-12-22 | 2023-01-31 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-12-22 | 2023-01-31 | Y |
| 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 | 2022-12-15 | 2023-01-31 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-12-15 | 2023-01-31 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-12-15 | 2023-01-31 | N |
| Have properly sized and located compartments to protect residents from smoke. | Fire Safety | 2022-12-15 | 2023-01-31 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-12-15 | 2023-01-31 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-12-15 | 2023-01-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-16 | 2022-04-06 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-03-16 | 2022-04-06 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2021-09-30 | 2022-02-10 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-09-30 | 2022-02-10 | N |
| Respond appropriately to all alleged violations. | Health | 2021-09-30 | 2022-02-10 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-08-25 | 2022-02-10 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-08-25 | 2022-02-10 | Y |
| 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 | 2021-09-30 | 2022-01-17 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2021-09-30 | 2022-01-17 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-09-30 | 2022-01-17 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-09-30 | 2022-01-17 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-09-30 | 2022-01-17 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-09-30 | 2022-01-17 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-09-30 | 2022-01-17 | 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 | 2021-09-30 | 2022-01-17 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2021-09-30 | 2022-01-17 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2021-09-30 | 2022-01-17 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-08-25 | 2021-12-09 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-09-30 | 2021-11-22 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2021-09-30 | 2021-11-22 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-09-30 | 2021-11-22 | N |
| Treat residents equally regarding transfer, discharge, and provision of services for all residents, regardless of payment source | Health | 2021-09-30 | 2021-11-22 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2021-09-30 | 2021-11-22 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-09-30 | 2021-11-22 | 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 | 2021-09-30 | 2021-11-22 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-09-30 | 2021-11-22 | N |
| Provide activities to meet all resident's needs. | Health | 2021-09-30 | 2021-11-22 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2021-09-30 | 2021-11-22 | 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 | 2021-09-30 | 2021-11-22 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-09-30 | 2021-11-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-09-30 | 2021-11-22 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-09-30 | 2021-11-22 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-09-30 | 2021-11-22 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-09-30 | 2021-11-22 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-30 | 2021-11-22 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-09-30 | 2021-11-22 | 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 | 2021-09-30 | 2021-11-22 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-09-30 | 2021-11-22 | 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 | 2021-09-30 | 2021-11-22 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-09-30 | 2021-11-22 | 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 | 2021-09-30 | 2021-11-22 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-09-30 | 2021-11-22 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-08-25 | 2021-11-22 | Y |
| 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 | 2021-09-29 | 2021-11-22 | N |
| Have exits that are accessible at all times. | Fire Safety | 2021-09-29 | 2021-11-22 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-09-29 | 2021-11-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-09-29 | 2021-11-22 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-09-29 | 2021-11-22 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-09-29 | 2021-11-22 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-09-29 | 2021-11-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-09-29 | 2021-11-22 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-09-29 | 2021-11-22 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-09-29 | 2021-11-22 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-06-03 | 2021-06-18 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-06-03 | 2021-06-18 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-06-03 | 2021-06-18 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-06-03 | 2021-06-18 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-06-03 | 2021-06-18 | 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 | 2021-06-03 | 2021-06-18 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-06-03 | 2021-06-18 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2021-04-21 | 2021-05-19 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-04-21 | 2021-05-18 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-05-04 | 2021-05-14 | 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 | 2019-10-01 | 2019-12-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-01 | 2019-12-24 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-09-26 | 2019-11-06 | 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 | 2019-09-26 | 2019-11-06 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2019-09-26 | 2019-11-06 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-10-01 | 2019-11-01 | 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 | 2019-10-01 | 2019-11-01 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-10-01 | 2019-11-01 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-10-01 | 2019-11-01 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-10-01 | 2019-11-01 | N |
| Assess the resident when there is a significant change in condition | Health | 2019-10-01 | 2019-11-01 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-10-01 | 2019-11-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-01 | 2019-11-01 | 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 | 2019-10-01 | 2019-11-01 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-10-01 | 2019-11-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-10-01 | 2019-11-01 | 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 | 2019-10-01 | 2019-11-01 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-10-01 | 2019-11-01 | 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 | 2019-10-01 | 2019-11-01 | N |
| Post nurse staffing information every day. | Health | 2019-10-01 | 2019-11-01 | 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 | 2019-10-01 | 2019-11-01 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2019-10-01 | 2019-11-01 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2019-10-01 | 2019-11-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-01 | 2019-11-01 | N |
