Inspection Reports for
The Legacy at Battle Creek
706 North Avenue, Battle Creek, MI, 49017-3251
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Inspection Report — Sep 15, 2023
Renewal
Date: Sep 15, 2023
Visit Reason
License renewal notice; no inspection report attached. Administrative review without an on-site visit.
Findings
The home was found in substantial compliance with the public health code and administrative rules regulating home for the aged facilities; the license has been renewed for 12 months.
Report Facts
License length: 12
Inspection Report — Jun 7, 2011
Date: Jun 7, 2011
Visit Reason
Increase capacity from 29 to 30 beds.
Findings
The Bureau of Fire Services granted final approval of this project on 6/29/2011. The licensed bed count of the facility was increased by 1 for a total licensed bed count of 30.
Report Facts
Inspection Report — Nov 19, 2008
Original Licensing
Date: Nov 19, 2008
Visit Reason
Original license application for a home for the aged facility.
Findings
The facility was found in substantial compliance with applicable licensing statutes and administrative rules. No rule or statutory violations were identified.
5 CMS Surveys
Inspection Report — Mar 12, 2025
Complaint Investigation
Date: Mar 12, 2025
Visit Reason
Investigation of a complaint received on 2025-03-12 about resident rights, medication administration, wound care, food safety, and infection control.
Complaint Details
Resident rights not advocated: established. Medicare notices missing: established. Confidentiality breaches: established. Lack of person-centered care plan for psychotropic use: established. Inadequate meaningful activities: established. Failure to implement gradual dose reductions for psychotropics: established. Unsafe food temperatures: established. Unsanitary food service equipment and plumbing issues: established. Infection control failures during wound care and medication administration: established.
Findings
Multiple deficiencies were found including failure to advocate for resident rights, failure to provide required Medicare notices, failure to maintain confidentiality of resident records, failure to develop person-centered care plans for psychotropic medication use, failure to provide meaningful activities, failure to implement gradual dose reductions and non-pharmacological interventions for psychotropic medications, failure to serve food at safe temperatures, failure to maintain clean and sanitary food service equipment, and failure to practice effective infection prevention and control during wound care and medication administration.
Deficiencies (9)
F 0550 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights: the facility failed to advocate for Resident #29 who was distressed about visitation restrictions, guardian issues, and discharge plans.
F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered: the facility failed to provide required Notice of Medicare Non-Coverage and Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage for multiple residents.
F 0583 Keep residents' personal and medical records private and confidential: medication cart computer screen was repeatedly left unlocked and visible to passersby.
F 0656 Develop and implement a complete care plan that meets all the resident's needs: Resident #20 lacked a person-centered care plan addressing targeted behaviors and use of antipsychotic medication.
F 0679 Provide activities to meet all resident's needs: Resident #26 was not provided meaningful activities and was often left isolated and unstimulated.
F 0758 Implement gradual dose reductions and non-pharmacological interventions prior to initiating or continuing psychotropic medication: Resident #20 was prescribed antipsychotic medication without adequate indication, clinical rationale, or documentation of failed gradual dose reduction.
F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature: food served to Resident #173 and others was below safe temperature standards.
F 0812 Procure food from approved sources and store, prepare, distribute and serve food in accordance with professional standards: food service equipment and areas were soiled with accumulated food residue, grease, and dust; plumbing leaks and maintenance issues were noted.
F 0880 Provide and implement an infection prevention and control program: wound care nurse failed to change gloves or sanitize hands between wounds and used soiled instruments; medication administration lacked proper hand hygiene; infection control standards were not followed.
Inspection Report — Apr 18, 2024
Date: Apr 18, 2024
Visit Reason
Investigation of a complaint regarding hospice services communication and documentation for Resident #48.
Findings
The facility failed to ensure proper communication and documentation of hospice services provided to one resident, resulting in lack of coordination of comprehensive services and care.
Deficiencies (2)
F 0849 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: the facility failed to ensure proper communication and documentation of hospice services for Resident #48, including missing hospice visit documentation and lack of accessible hospice schedules for nursing staff.
F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards: food service equipment including the Pitco fryer, Panasonic microwave oven, and stand mixers were observed soiled with accumulated grease, dirt, and food residue, increasing risk of cross-contamination.
Inspection Report — Sep 19, 2023
Plan of Correction
Date: Sep 19, 2023
Visit Reason
An acceptable corrective action plan has been received.
Findings
The facility failed to ensure resident rights in accordance with preferences for one resident, resulting in restrictions of a visitor and potential further resident preference violations.
Inspection Report — Jun 28, 2023
Complaint Investigation
Date: Jun 28, 2023
Visit Reason
Investigation of a complaint received about quality of care, medical record accuracy, and notification of change in condition.
Complaint Details
Notification of change in condition for Resident #1: established. Thorough assessment of change in condition for Resident #1: established. Maintenance of complete and accurate medical records for Residents #1, #2, and #3: established.
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. The facility also failed to thoroughly assess the change in condition and failed to maintain complete and accurate medical records for three residents, resulting in untimely entry of provider notes.
Deficiencies (3)
F 0580 Immediately tell the resident, the resident's doctor, and a family member of situations that affect the resident: 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.
F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals: the facility failed to thoroughly assess a change in condition for Resident #1, resulting in delayed identification and treatment of a fracture.
F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards: the facility failed to maintain complete and accurate medical records for Residents #1, #2, and #3, resulting in untimely entry of provider notes and potential for inaccurate reflection of resident conditions.
Inspection Report — Jan 25, 2023
Complaint Investigation
Date: Jan 25, 2023
Visit Reason
Investigation of complaints received about resident rights, care, and facility conditions.
Findings
Multiple deficiencies were found including failure to address resident council complaints, inadequate advance directive documentation, failure to maintain hot water temperatures, unresolved resident grievances, missed scheduled showers, inadequate foot care, failure to honor food preferences, and improper cleaning and maintenance of food service equipment.
Deficiencies (8)
F 0565 Honor the resident's right to organize and participate in resident/family groups in the facility: facility failed to ensure resident council complaints were followed-up with a response for a resolution, resulting in potential resident frustration and unmet needs.
F 0578 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: facility failed to ensure updated and accurate advance directive information was in place for one resident, including proper timing of signatures.
F 0584 Honor the resident's right to a safe, clean, comfortable and homelike environment: facility failed to maintain comfortable hot water temperatures affecting multiple residents and hall residents, resulting in resident discomfort and poor hygiene.
F 0585 Honor the resident's right to voice grievances without discrimination or reprisal: facility failed to ensure grievances were investigated and resolved for four residents and failed to implement grievance policy, resulting in resident frustration and feelings of not being heard.
F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason: facility failed to provide scheduled showers twice per week for one resident, resulting in unmet personal care needs.
F 0687 Provide appropriate foot care: facility failed to properly assess and identify the need for podiatry services for one resident, resulting in resident frustration, long toenails, pain, and delay in needed treatment.
F 0806 Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options: facility failed to provide food preferences for two residents, resulting in frustration and a non-pleasurable dining experience.
F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards: facility failed to effectively clean and maintain food service equipment, including improper sanitizing solution concentrations and a soiled air conditioner blowing debris over clean dish area, increasing risk of cross-contamination.
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