The Oaks at Battle Creek

In the surveyor’s words

From the most serious findings on record at The Oaks at Battle Creek, in the surveyor’s own words.

• Actual harm, isolatedF689May 24, 2021

  This citation pertains to Intakes: MI 021, MI 041, MI 102, and MI 252. Based on interview and record review, the facility failed to: 1) ensure resident safety when using a transfer device, and 2) transfer residents according to resident's care plans, facility policy and professional standards of practice for one Resident (#14) of four residents reviewed for accidents. This deficient practice resulted in actual harm when Resident #14 sustained significant injuries (right arm fracture, left leg fracture and left ankle fracture), subsequent surgery for repair of the fractures, hospitalization and pain. Findings include: Resident #14 was admitted to the facility on [DATE] and had diagnoses including dementia, anxiety disorder, and unspecified [CONDITION(S)]. […]

• Actual harm, isolatedF689Mar 18, 2021

  This citation pertains to intake MI 7483. Based on interview, and record review the facility failed to properly transfer one out of three residents (Resident #8) resulting in a left leg tibia (shinbone) fracture. Findings Included: Per the facility face sheet Resident #8 (R8) was admitted to the facility on [DATE]. Diagnoses included fracture of left leg femur and difficulty in walking. R8 no longer resided at the facility at the time of the investigation. Review of a facility Event Report, dated 1/13/2021, revealed a note, dated 1/14/201, that R8 complained of pain to her left leg when two Certified Resident Care Associates (CRCA) assist her with a transfer. The report revealed that an X-ray was done which revealed R8 had a fracture to her left leg tibia. […]

• No harm, potential for more than minimal, widespreadF804Mar 12, 2025

  Based on observation, interview, and record review the facility failed to ensure that food was served and held at a palpable temperature. Resulting in the potential to affect all residents (total facility census of 70) that consume food from the kitchen. Findings Included: Resident #173 (R173) Review of the medical record revealed R173 was admitted to the facility 02/14/2025 with diagnoses that included prosthetic left hip joint, fracture of left femoral neck, type 2 diabetes, hypertension, hyperlipidemia (high fat content in blood), depression, anemia (low red blood cells), osteoarthritis (type of arthritis occurs when tissue at end of bones wears down), unilateral inguinal hernia, and pain in left hip. […]

• No harm, potential for more than minimal, widespreadF812Mar 12, 2025

  Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment effecting 70 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and plumbing water leaks. Findings include: On 03/10/25 at 07:35 A.M., An initial tour of the food service was conducted with Dietary [NAME] C. The following items were noted: 1 of 2 True 2-door reach-in cooler doors were observed to not automatically close completely after opening, creating an air gap (approximately 1-2-inches wide between the refrigeration unit frame and the door gasket seal). […]

• No harm, potential for more than minimal, widespreadF812Apr 18, 2024

  Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment effecting 68 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage. Findings include: On 04/16/24 at 09:30 A.M., An initial tour of the food service was conducted with Dietary Manager Q. The following items were noted: The Pitco fryer interior and adjacent flooring/wall surfaces were observed soiled with accumulated and encrusted grease/dirt deposits. Dietary Manager Q indicated he would have staff thoroughly clean and sanitize the fryer interior and adjacent flooring/wall surfaces as soon as possible. The Panasonic microwave oven interior was observed (etched, scored, particulate). […]