Majestic Care of Battle Creek

In the surveyor’s words

From the most serious findings on record at Majestic Care of Battle Creek, in the surveyor’s own words.

• Immediate jeopardy, patternF686Mar 24, 2022

  This citation pertains to intake numbers MI 737, MI 399 and MI 930. Based on observation, interview and record review facility failed to: 1) accurately assess, monitor and prevent the development and worsening of pressure ulcers consistent with professional standards of practice to prevent avoidable pressure ulcers; 2) follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficient practice resulted in the development of a stage 4 pressure ulcer and wound infection and subsequent death for R110, worsening of pressure wounds requiring re-hospitalization for [CONDITION(S)] for R103, re-admission to the hospital, nine days after admission, with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Actual harm, isolatedF684May 23, 2023

  This citation pertains to complaint #MI00132727. Based on observation, interview and record review, the facility failed to follow physician's orders and perform a wound vacuum (vac) dressing change within standards of practice for two out of three residents, resident's #22 and #3 (R22 and R3), failed to identify, provide timely treatment and appropriate care and services to meet the needs of one resident out of one resident (R#22). Resident 3 (R3) Review of the medical record reflected R3 was an initial admission to the facility on [DATE], readmitted on [DATE] with diagnoses of non-pressure chronic ulcer of unspecified part of the right lower leg with unspecified severity and venous insufficiency and unspecified intellectual disability. […]

• Actual harm, isolatedF686May 23, 2023

  This citation pertains to intake numbers MI00132727 and MI00135356. Based on observation, interview, and record review the facility failed to ensure two out of four residents (Resident #3 and 18) received appropriate care and treatment for pressure ulcers (PU) resulting in the development of pressure ulcers. Findings Included: Resident #18 (R18): Per the facility face sheet R18 was admitted to the facility on [DATE]. Review of a Pressure Ulcer-Weekly Observation-V 2 assessment dated [DATE], revealed R18 had a pressure ulcer to his outer right ankle that measured 2.1 x 3 x 0 (length, width, and depth). The assessment revealed that the PU was acquired while R18 was a resident at the facility. […]

• Actual harm, isolatedF684Aug 31, 2022

  This citation pertains to intake MI 147. This tag has two deficient practice statements. A. Based on interview and record review, the facility failed provide intravenous medication as ordered and respond to critical laboratory findings for 1 of 1 resident (R37) reviewed for intravenous medication usage, resulting in R37's medical needs not being addressed timely and the potential for a life-threatening infection to become resistant to treatment. Findings include: Review of R37's face sheet dated 8/30/22 revealed he was [AGE] year-old male admitted to the facility on [DATE] due to [CONDITION(S)] (a life-threatening complication of an infection). Other pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Actual harm, isolatedF686Aug 31, 2022

  This deficient practice pertains to intake MI 052 and MI 426. Based on observation, interview and record review, the facility failed to measure, monitor, and promote the healing of a pressure ulcer for 1 resident (R25) reviewed for pressure ulcers. The deficient practice resulted in R25 having a nonhealing stage 3 pressure ulcer and the increased risk for infection and further decline. Findings include: Resident #25 (R25) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed Resident #25 admitted to the facility on [DATE]. […]