Inspection Reports for
The Legacy at Battle Creek
706 North Avenue, Battle Creek, MI, 49017-3251
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
4.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
12% better than Michigan average
Michigan average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Routine
Deficiencies: 9
Date: Mar 12, 2025
Visit Reason
Routine inspection survey conducted to assess compliance with federal regulations related to resident rights, care planning, medication management, food safety, infection control, and other regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to advocate for resident rights, inadequate beneficiary notification, failure to maintain confidentiality of resident records, incomplete care plans for psychotropic medication use, insufficient meaningful activities for residents, improper use and monitoring of psychotropic medications, serving food at unsafe temperatures, poor cleaning and maintenance of food service equipment, and lapses in infection prevention and control practices.
Deficiencies (9)
F 0550: The facility failed to advocate for resident #29's rights, resulting in the resident feeling unheard and distressed due to visitation and guardian issues.
F 0582: The facility failed to provide required Notice of Medicare Non-Coverage and Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage for several residents.
F 0583: Resident medical records were left exposed on unattended computer screens, compromising confidentiality for resident #8.
F 0656: The facility failed to develop and implement a person-centered care plan addressing targeted behaviors and psychotropic medication use for resident #20.
F 0679: The facility failed to provide meaningful activities for resident #26, resulting in potential boredom and loneliness.
F 0758: The facility failed to ensure adequate indication, monitoring, and non-pharmacological interventions for psychotropic medication use in resident #20.
F 0804: Food served to residents was not held at safe temperatures, with fried chicken and mixed vegetables below required 165°F, affecting potentially all 70 residents.
F 0812: Food service equipment and areas were poorly cleaned and maintained, including soiled can opener, mixers, ovens, and leaking sinks, increasing risk of contamination.
F 0880: The facility failed to practice effective infection prevention during wound care and medication administration, including improper glove use and hand hygiene, affecting resident #59 and others.
Report Facts
Total facility census: 70
Residents affected: 1
Residents affected: 2
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing B | Director of Nursing | Interviewed regarding resident rights advocacy, care planning, medication use, and infection control expectations. |
| Licensed Practical Nurse Q | Licensed Practical Nurse | Interviewed about visitation restrictions for resident #29. |
| Social Worker H | Social Worker | Interviewed about resident #29's discharge planning and psychotropic medication use for resident #20. |
| Previous Social Worker R | Social Worker | Interviewed about resident #29's guardianship and resident rights. |
| Licensed Nursing Home Administrator A | Licensed Nursing Home Administrator | Interviewed about missing beneficiary notices for residents #2, #178, and #179. |
| Assistant Dietary Manager L | Assistant Dietary Manager | Observed and interviewed regarding food temperature issues and food service equipment maintenance. |
| Wound Care Nurse N | Wound Care Nurse | Observed performing wound care with infection control lapses on resident #59. |
| Infection Preventionist Registered Nurse P | Infection Preventionist Registered Nurse | Interviewed regarding infection control expectations and practices. |
| Certified Nursing Assistant O | Certified Nursing Assistant | Interviewed about resident #20's behavior and medication use. |
| Food Service Director D | Food Service Director | Interviewed about food service equipment maintenance and cleaning procedures. |
Inspection Report
Deficiencies: 2
Date: Apr 18, 2024
Visit Reason
The inspection was conducted to assess compliance with food service sanitation standards and hospice service coordination at the nursing home.
Findings
The facility failed to properly clean and maintain food service equipment, increasing the risk of cross-contamination affecting 68 residents. Additionally, the facility failed to ensure proper communication and documentation of hospice services for one resident, resulting in lack of coordination of care.
Deficiencies (2)
F 0812: The facility failed to effectively clean and maintain food service equipment, including soiled fryer interiors, damaged microwave oven surfaces, and encrusted food residue on mixers, affecting 68 residents and increasing risk of cross-contamination.
F 0849: The facility failed to ensure proper communication and documentation of hospice services for one resident, resulting in lack of coordination of comprehensive hospice care.
Report Facts
Residents affected: 68
Hospice nurse visits in January 2024: 5
Hospice CNA visits in February 2024: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN P | Licensed Practical Nurse | Reported lack of hospice schedule communication |
| DON B | Director of Nursing | Interviewed regarding hospice documentation and schedule issues |
| SW L | Social Worker | Provided hospice binder and discussed hospice service coordination |
| Dietary Manager Q | Dietary Manager | Interviewed regarding food service equipment cleaning |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 19, 2023
Visit Reason
The inspection was conducted in response to a complaint (intake MI000139094) regarding potential restrictions on a resident's visitation rights.
Complaint Details
The complaint intake number MI000139094 triggered the investigation. The complaint was substantiated as the facility restricted a visitor's overnight stay contrary to resident preferences.
Findings
The facility failed to ensure resident rights were followed for one resident, resulting in restrictions on a visitor and potential for further resident preference violations. The facility's visitation policy did not clearly specify visitation hours or acknowledge residents' rights to visitors outside of set hours based on preferences.
Deficiencies (1)
F 0564: The facility failed to inform each resident of visitation rights and ensure all visitors enjoy equal visitation privileges, restricting a visitor's overnight stay despite later approval. The visitation policy lacked clarity on set visitation hours and did not reflect residents' rights to visitors outside those hours based on preferences.
Inspection Report
Renewal
Deficiencies: 0
Date: Aug 26, 2023
Visit Reason
The document serves as a renewal notification for the Home for the Aged license of The Legacy at the Oaks, confirming substantial compliance with public health code and administrative rules over the past year.
Findings
An administrative review revealed substantial compliance with the public health code and administrative rules regulating home for the aged facilities, resulting in the renewal of the facility's license for 12 months effective 08/26/2023.
Report Facts
License effective date: Aug 26, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Horst | Licensing Staff | Signed the renewal notification letter |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jun 28, 2023
Visit Reason
The inspection was conducted following a complaint intake MI00137630 regarding the facility's failure to properly notify the provider of a resident's change in condition and failure to thoroughly assess a change in condition, resulting in delayed identification and treatment of a fracture.
Complaint Details
The complaint intake MI00137630 alleged failure to notify the provider of a resident's change in condition and failure to properly assess the resident, leading to delayed fracture treatment. The complaint was substantiated based on interviews and record reviews.
Findings
The facility failed to ensure the provider was fully informed of a change in condition for Resident #1, resulting in delayed identification and treatment of a fracture. Additionally, the facility failed to maintain complete and accurate medical records for three residents, causing untimely entry of provider notes and potential inaccurate reflection of resident conditions.
Deficiencies (3)
F 0580: The facility failed to notify the provider of a change in condition for Resident #1, delaying fracture identification and treatment.
F 0684: The facility failed to thoroughly assess a change in condition for Resident #1, resulting in delayed fracture identification and treatment.
F 0842: The facility failed to maintain complete and accurate medical records for Residents #1, #2, and #3, resulting in untimely provider note entries and potential inaccurate resident condition reflection.
Report Facts
Therapy session duration: 15
Therapy session duration: 20
Pain level: 10
Medication dosage: 500
Medication dosage: 5
Dates of Nurse Practitioner Progress Notes added: 3
Dates of Nurse Practitioner Progress Notes added: 2
Dates of Nurse Practitioner Progress Notes added: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Practitioner N | Nurse Practitioner | Evaluated Resident #1 on 5/8/23 and prescribed medications; noted delayed documentation of progress notes. |
| Registered Nurse E | Registered Nurse | Reported Resident #1's complaints and requested NP evaluation on 5/8/23. |
| Assistant Director of Nursing O | Assistant Director of Nursing | Noted family concerns about Resident #1's condition and documented provider communication on 5/8/23. |
| Licensed Practical Nurse C | Licensed Practical Nurse | Provided information on concerning changes for residents with recent hip surgery. |
| Physical Therapy Assistant G | Physical Therapy Assistant | Reported Resident #1's difficulty walking and assisted with care on 5/8 or 5/9/23. |
| Certified Occupational Therapy Assistant H | Certified Occupational Therapy Assistant | Reported Resident #1's stiffness and pain near end of stay. |
Inspection Report
Complaint Investigation
Deficiencies: 8
Date: Jan 25, 2023
Visit Reason
The inspection was conducted based on complaints regarding resident council complaints not being followed up, advance directive documentation issues, hot water temperature problems, grievance investigations, missed showers, podiatry care delays, food preference concerns, and food service sanitation issues.
Complaint Details
The visit was complaint-related, triggered by multiple resident complaints including unresolved resident council issues, advance directive inaccuracies, hot water problems, grievance handling failures, missed showers, podiatry care delays, food preference issues, and food service sanitation concerns.
Findings
The facility failed to follow up on resident council complaints, maintain accurate advance directive documentation, provide consistent hot water, investigate and resolve grievances, ensure scheduled showers, provide timely podiatry care, honor food preferences, and maintain clean food service equipment, resulting in potential resident frustration, discomfort, and risk of harm.
Deficiencies (8)
F 0565: The facility failed to ensure resident council complaints were followed-up with a response for resolution, causing potential resident frustration and unmet needs.
F 0578: The facility failed to ensure updated and accurate advance directive information was in place for one resident, risking non-adherence to medical care preferences.
F 0584: The facility failed to maintain comfortable hot water temperatures affecting multiple residents, increasing risk of discomfort and poor hygiene.
F 0585: The facility failed to investigate and resolve grievances for four residents and failed to implement grievance policy, causing resident frustration and feelings of not being heard.
F 0676: The facility failed to provide scheduled showers twice per week for one resident, resulting in unmet personal care needs.
F 0687: The facility failed to properly assess and identify the need for podiatry services for one resident, causing frustration, long toenails, pain, and delayed treatment.
F 0806: The facility failed to provide food preferences for two residents, resulting in unhonored preferences and potential resident frustration.
F 0812: The facility failed to effectively clean and maintain food service equipment, including improper sanitizer concentration and a soiled air conditioner, increasing risk of cross-contamination and bacterial harborage.
Report Facts
Residents affected: 5
Residents affected: 17
Residents affected: 67
Sanitizer concentration: 150
Sanitizer concentration: 400
Shower temperature: 92
Sink temperature: 90
Shower temperature: 96
Sink temperature: 82
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker D | Social Worker | Named in findings related to resident council complaints and podiatry care |
| Administrator A | Administrator | Named in findings related to resident council complaints and grievance handling |
| Certified Nurse Aid F | Certified Nurse Aid | Named in findings related to resident council complaints |
| Maintenance Director T | Maintenance Director | Named in findings related to hot water issues and kitchen air conditioner maintenance |
| Licensed Practical Nurse P | Licensed Practical Nurse | Named in findings related to hot water issues |
| Certified Nurse Aid V | Certified Nurse Aid | Named in findings related to hot water issues |
| Nursing Home Administrator A | Nursing Home Administrator | Named in findings related to grievance handling and podiatry care |
| Director of Food Services J | Director of Food Services | Named in findings related to food preference and meal service issues |
| Assistant Director of Food Services I | Assistant Director of Food Services | Named in findings related to food preference and meal service issues |
| Certified Nursing Assistant G | Certified Nursing Assistant | Named in findings related to food preference and meal service issues |
| Certified Nursing Assistant H | Certified Nursing Assistant | Named in findings related to food preference and meal service issues |
| Certified Nursing Assistant L | Certified Nursing Assistant | Named in findings related to shower documentation |
| Kitchen Manager X | Kitchen Manager | Named in findings related to food service sanitation and sanitizer testing |
| Regional Maintenance Staff W | Regional Maintenance Staff | Named in findings related to hot water issues and kitchen air conditioner maintenance |
Inspection Report
Original Licensing
Capacity: 30
Deficiencies: 0
Date: Jun 7, 2011
Visit Reason
The visit was conducted as an opening survey to increase the bed capacity of The Legacy at the Oaks from 29 to 30 by renovating a room to become a licensed bed location.
Findings
The Bureau of Fire Services granted final approval of the renovation project on 2011-06-29, allowing the increase in licensed bed capacity from 29 to 30.
Report Facts
Licensed bed capacity increase: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Linda Denniston | Licensing Staff | Conducted and signed the licensing study addendum |
| Betsy Montgomery | Area Manager | Approved the licensing study addendum |
Inspection Report
Original Licensing
Capacity: 29
Deficiencies: 0
Date: Nov 19, 2008
Visit Reason
The visit was conducted as an original licensing study to determine compliance with applicable licensing statutes and administrative rules for The Legacy at the Oaks facility.
Findings
The facility was found to be in substantial compliance with no rule or statutory violations. The home for the aged has a capacity of 29 beds and provides a residential setting with 24-hour staffing for residents, including those with Alzheimer's or related dementia.
Report Facts
Capacity: 29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Krausmann | Licensing Staff | Author of the licensing study report and recommendation |
| Betsy Montgomery | Area Manager | Approved the licensing study report |
| Jackie Zimmerman | Administrator and Authorized Representative | Facility administrator and authorized representative mentioned in the report |
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