F-F689 Accidents states:

Note: (*) Water Temperature - Water may reach hazardous temperatures in hand sinks, showers, tubs, and any other source or location where hot water is accessible to a resident. Burns related to hot water/liquids may also be due to spills and/or immersion. Many residents in long-term care facilities have conditions that may put them at increased risk for burns caused by scalding. These conditions include: decreased skin thickness, decreased skin sensitivity, peripheral neuropathy, decreased agility (reduced reaction time), decreased cognition or dementia, decreased mobility, and decreased ability to communicate.

The degree of injury depends on factors including the water temperature, the amount of skin exposed, and

the duration of exposure. Some States have regulations regarding allowable maximum water temperature. Table 1 illustrates damage to skin in relation to the temperature of the water and the length of time of exposure.

Table 1. Time and Temperature Relationship to Serious Burns

Water Time Required for a 3rd Degree

Temperature Burn to Occur

_________________________________________________________________

155 F 68 C 1 sec

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 66 235536 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235536 B. Wing 05/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pinnacle Care of Battle Creek 675 Wagner Dr Battle Creek, MI 49017

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 148 F 64 C 2 sec

Level of Harm - Immediate 140 F 60 C 5 sec jeopardy to resident health or safety 133 F 56 C 15 sec

Residents Affected - Few 127 F 52 C 1 min

124 F 51 C 3 min

120 F 48 C 5 min

100 F 37 C Safe Temperatures for Bathing (see Note)

_________________________________________________________________

NOTE: Burns can occur even at water temperatures below those identified in the table,

depending on an individual's condition and the length of exposure.

Based upon the time of exposure and the temperature of the water, the severity of the harm to the skin is identified by the degree of burn, as follows.

o First-degree burns involve the top layer of skin (e.g., minor sunburn). These may present as red and painful to touch, and the skin will show mild swelling.

o Second-degree burns involve the first two layers of skin. These may present as deep reddening of the skin, pain, blisters, glossy appearance from leaking fluid, and possible loss of some skin.

o Third-degree burns penetrate the entire thickness of the skin and permanently destroy tissue. These present as loss of skin layers, often painless (pain may be caused by patches of first- and second-degree burns surrounding third-degree burns), and dry, leathery skin. Skin may appear charred or have patches that appear white, brown, or black.

On 05/07/25 at 09:14 A.M., An interview was conducted with (ESD) E regarding the domestic hot water supply. (ESD) E stated: We consulted with Facilities Supervisor for the Battle Creek Fire Department (FS) G. (ESD) E also stated: He [(FS) G] suggested a regulator was going out on the South Unit water heater. (ESD) E additionally stated: We bled out the hot water from the hot water storage tanks. (ESD) E further stated: room [ROOM NUMBER] was at 118.2 degrees Fahrenheit. (ESD) E also stated: room [ROOM NUMBER] was at 120.5 degrees Fahrenheit. (ESD) E additionally stated: room [ROOM NUMBER] was at 124.0 degrees Fahrenheit. (ESD) E further stated: The staff/visitor restroom hand sink was at 125.0 degrees Fahrenheit. (ESD) E also stated: Temperatures were monitored at approximately 7:00 AM this morning.

On 05/07/25 at 09:40 A.M., An environmental tour of sampled resident rooms was conducted with Housekeeper H. Domestic hot water temperatures were monitored utilizing a ThermoWorks Super-Fast Thermapen model CR2032 digital thermometer. The following restroom hand sinks domestic hot water temperatures were noted:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 66 235536 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235536 B. Wing 05/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pinnacle Care of Battle Creek 675 Wagner Dr Battle Creek, MI 49017

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 117: 125.1 degrees Fahrenheit*

Level of Harm - Immediate 122: 128.1 degrees Fahrenheit* jeopardy to resident health or safety 123: 128.8 degrees Fahrenheit*

Residents Affected - Few 124: 130.3 degrees Fahrenheit*

128: 124.0 degrees Fahrenheit*

129: 124.5 degrees Fahrenheit*

131: 121.3 degrees Fahrenheit*

On 05/07/25 at 12:06 P.M., An interview was conducted with (ESD) E regarding the facility maintenance work order system. (ESD) E stated: We have TELS.

On 05/07/25 at 12:23 P.M., Domestic hot water temperatures were monitored utilizing a ThermoWorks Super-Fast Thermapen model CR2032 digital thermometer. The following domestic hot water temperatures were recorded:

South Unit

Shower Room Hand Sink - 123.8 degrees Fahrenheit*

On 05/07/25 at 12:30 P.M., An interview was conducted with Maintenance Technician F regarding the South Unit Shower Room floor drain concern. Maintenance Technician F stated: We have contacted (Contractual Vendor Name) for commercial repairs related to both plumbing and hot water heater issues.

On 05/07/25 at 01:26 P.M., Domestic hot water temperatures were monitored utilizing a ThermoWorks Super-Fast Thermapen model CR2032 digital thermometer. The following domestic hot water temperatures were recorded:

Staff/Visitor Restroom: Hand Sink - 126.4 degrees Fahrenheit*

On 05/07/25 at 01:33 P.M., An interview was conducted with Nursing Home Administrator (NHA) A regarding removal of the domestic hot water supply excessive hot water temperature immediacy. (NHA) A stated: We are not providing showers or bed baths until further notice. (NHA) A also stated: We have posted signage in all resident rooms and shower rooms.

On 05/07/25 at 01:41 P.M., Record review of the resident room and shower room posted signage revealed

the following narratives:

Resident Room posted signage states: Please do not use water without first calling for staff assist.

Shower Room posted signage states: Showers are out of order until further notice.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 66 235536 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235536 B. Wing 05/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pinnacle Care of Battle Creek 675 Wagner Dr Battle Creek, MI 49017

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 On 05/07/25 at 03:50 P.M., An interview was conducted with Commercial Contractor (CC) I regarding the domestic hot water temperature concern. (CC) I stated: The recirculation pump switch was turned off. (CC) I Level of Harm - Immediate also stated: If the recirculation pump is off, you can't get consistent hot water temperatures. (CC) I further jeopardy to resident health or stated: The cold-water supply was also closed to the tempering system. safety

On 05/08/25 at 08:45 A.M., Record review of the Policy/Procedure entitled: Safe Water Temperatures dated Residents Affected - Few (no date) revealed under Policy: It is the policy of this facility to maintain appropriate water temperatures in resident care areas. Record review of the Policy/Procedure entitled: Safe Water Temperatures dated (no date) further revealed under Policy Explanation and Compliance Guidelines: (4) Staff will report abnormal findings, such as complaints of water too cold of hot, burns or redness, or any problems with water temperature (ex. water is painful to touch or causes redness) to the supervisor and/or maintenance staff. (5) Water temperatures will be set to a temperature of no more than (120 degrees Fahrenheit) or (49 degrees Celsius), or the state's allowable maximum water temperature. (6) Maintenance staff will check water heater temperature controls and the temperatures of tap water in all hot water circuits weekly and as needed. (7) Documentation of testing will be maintained for 3 years and kept in the maintenance office.

On 05/08/25 at 09:00 A.M., Record review of the Hot Water Temperature Monitoring Log Sheets for the last 126 days revealed no specific entries related to excessive domestic hot water temperatures. Note: Numerous Hot Water Temperature Monitoring Log Sheets were observed completely missing from the requested timeframe.

46954

DPS B) Based on observation, interview and record review, the facility failed to 1) investigate falls, develop and implement post fall interventions, and prevent further falls for one of one (Resident #58) reviewed for falls and 2) facility failed to ensure resident was free from potential accidents or hazards by allowing unsupervised access to chewing tobacco for one (Resident R38) of three residents reviewed for accidents.

Findings include:

Resident #58

A review of the medical record revealed that Resident #58 (Resident R58) was admitted to the facility on [DATE REDACTED], with diagnoses including difficulty walking, muscle weakness, wandering, and dementia. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/24/2025, indicated that Resident R58 scored 3 out of 15 on

the Brief Interview for Mental Status (BIMS), reflecting severe cognitive impairment.

On 5/05/2025 at 12:19 PM, Resident R58 was observed ambulating independently and attempting to exit the locked memory care unit. When redirected, she became agitated and expressed a desire to go outside. Resident R58 was noted to be pleasantly confused and non-interviewable.

During an interview conducted on 5/05/2025 at 12:13 PM, Family Member DD reported that Resident R58 had experienced multiple falls, including one that resulted in hospitalization .

A review of incident and accident reports, as well as progress notes, revealed the following fall incidents:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 66 235536 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235536 B. Wing 05/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pinnacle Care of Battle Creek 675 Wagner Dr Battle Creek, MI 49017

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 On 10/26/2024 at 6:35 PM, Resident R58 was found sitting on the floor next to her bed. The care plan was updated to ensure that Resident R58's walker remained within reach while she was in bed. Level of Harm - Immediate jeopardy to resident health or On 1/28/2025 at 1:39 AM, Resident R58 was discovered lying on her back on the floor of her room. A moderate safety amount of blood was noted around her head, and a laceration was observed on the left parietal region. She was transferred to a local emergency department, where she received one staple to close the head wound. Residents Affected - Few Per the incident report, staff stated she had been ambulating with her walker at the time of the fall. Despite

the severity of this incident, no new fall interventions were added to her care plan, no incident report was completed, and no investigation was initiated.

On 1/29/2025 at 7:45 AM, Resident R58 stood up from her wheelchair, lost her balance, and fell backward, striking her head against the medication cart. Although no apparent injuries were noted, this was Resident R58's second fall in two days. Again, the care plan was not updated to include new fall interventions-only a request for a therapy screen was noted. No incident report was created, and no investigation occurred.

On 3/12/2025 at 6:00 AM, Resident R58 was found lying on her left side on the floor, leaning against the closet in her room. No injuries were reported, yet no additional fall prevention strategies were added to her care plan.

Further observation on 5/07/2025 at 9:45 AM revealed that Resident R58 was in bed with her call light draped over the headboard, out of her reach, and her walker placed against the wall, also out of reach, raising ongoing safety concerns.

In an interview on 5/08/2025 at 11:22 AM, the Director of Nursing (DON) B stated that the facility's expectations following a fall include completing an incident report and implementing an immediate intervention to prevent recurrence.

49272

Resident # 38 (Resident R38)

Review of the medical record revealed Resident R38 was admitted to the facility on [DATE REDACTED] with diagnoses that included: legal blindness, muscle weakness, need for assistance with personal care, anxiety disorder, and depression. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/18/25 revealed Resident R38 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool).

On 5/5/25 at 10:15 AM, Resident R38 was observed asleep on his back with a can of chewing tobacco on his bedside tray table, as well as a Styrofoam cup with tobacco spit in it.

On 5/5/25 at 12:24 PM, a staff member was observed entering Resident R38's room to see if he was done with his lunch tray. This staff member exited the room and reported that Resident R38 was still eating his lunch. The chewing tobacco and cup with spit in it was easily visible on Resident R38's bedside table, next to his lunch tray.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 66 235536 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235536 B. Wing 05/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pinnacle Care of Battle Creek 675 Wagner Dr Battle Creek, MI 49017

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 On 5/5/25 at 12:28 PM Resident R38 was queried about the chewing tobacco on his bedside table, Resident R38 reported that

he was told prior to his admission that it was ok for him to have it on him and to use it in his room, they let me Level of Harm - Immediate have it here. jeopardy to resident health or safety On 5/6/25 at 2:07 PM, Resident R38 was observed to still have chewing tobacco and a spit cup on his bedside table.

Residents Affected - Few On 5/6/25 at 2:12 PM, the director of nursing (DON) was asked what the facilities policy on chewing tobacco was. She reported that she would have to look it up.

On 5/6/25 at 2:14 PM, DON and this surveyor entered Resident R38's room. DON stated that she would clean up the dry tobacco on resident's clothing and bedside table. DON removed the can of tobacco and the cup of tobacco spit. DON reported that she believed chewing tobacco should be treated like a medication and would need to be assessed to determine if it would be safe for the resident to have at his bedside.

On 05/08/25 at 12:54 PM, during an interview with CNA II reported that she was aware that Resident R38 had chewing tobacco and had observed it at his bedside. She reported that it was something new. CNA II further stated that the resident was not supposed to have it unless he went outside to use it.

On 5/12/25 at 8:19 PM during a telephone interview with Resident R38's family member (FM KK), they reported that

they had been bringing in chewing tobacco to Resident R38 for a few months and that the staff was aware and that there wasn't a problem with it until this week.

On 5/08/25 at 2:01 PM, during an interview with Director of Nursing (DON) and Assistant Director of Nursing (ADON), it was reported to her that a review of the smoking policy revealed that it does not specifically address chewing tobacco and how was the facility planning to address it, she stated that what she had done for Resident R38 specifically was talked to social services staff to do an assessment to if Resident R38 could self-administer.

She further stated that he could use it during smoking breaks and that she plans to bring it to QAPI (Quality and Assurance Performance Improvement). DON reported that she took the tobacco to the nurse and had her lock it up in the narcotic drawer in the medication cart and label it. Assistant director of nursing (ADON) reported that social services staff had placed it in the lock box with the other resident's cigarettes. When asked if they would agree that it isn't safe for a visually impaired resident to have access to chewing tobacco and associated spit cup both the DON and ADON agreed, with the ADON adding especially unattended/unassisted.

On 5/6/25 at 2:41 PM a request was made via email to the facility administrator (nursing home administrator-NHA) to clarify whether the facility had a policy that specifically addressed chewing tobacco and on 5/6/25 at 2:50 PM, NHA responded that they have searched and do not have anything specific to chewing tobacco.

Review of the facilities policy titled Pinnacle Care of Battle Creek Smoking Contract, documented in part I am not allowed to have my own cigarettes, E-cigarettes, vape pens, matches of lighters while I reside at the facility. If I have any cigarettes, E-cigarettes, vape pens, matches or lighters on my person, I will turn all smoking materials in to the Activities Director before returning inside the facility . I am not allowed to give, get, or request cigarettes, E-cigarettes, or vape pens from any other resident at any time .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 66 235536 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235536 B. Wing 05/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pinnacle Care of Battle Creek 675 Wagner Dr Battle Creek, MI 49017

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Provide enough food/fluids to maintain a resident's health.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46954 potential for actual harm Based on observation, interview, and record review the facility failed to properly adhere to the physician's Residents Affected - Few order for double protein portions for one resident (Resident #20) out of one reviewed for nutrition.

Resident #20

A review of the medical record indicates that Resident #20 was admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED]. Diagnoses include heart failure and both acute and chronic respiratory failure with hypoxia.

On 05/05/25 at 11:54 AM, Resident #20 was observed seated in the dining room, where their lunch consisted of two chicken tenders, potatoes, and coleslaw. Upon further observation, it was noted that the portion size of Resident #20's meal was consistent with that of the other residents in the dining room.

The medical record shows that Resident #20's weight was recorded on the following dates: 2/28/25, 3/1/25, 3/14/25, 4/18/25, and 5/2/25. The recorded weights were as follows: 222.0 pounds on 3/14/25, 211.5 pounds

on 4/18/25, and 210.2 pounds on 5/2/25.

A Physician's Order dated 2/21/25 indicated that double protein portions were to be provided, with the order initially implemented on 10/19/25 and revised on 4/21/25.

On 05/07/25 at 12:14 PM, Resident #20's lunch was observed and did not include the double protein portions as per the order.

On 05/08/25 at 2:05 PM, Registered Dietitian (RD) M reported that she had noticed recent weight loss in Resident #20 and, in response, had implemented the intervention of double protein portions, as she was aware that Resident #20 was a good eater. RD M stated that the expectation was to adhere to the order and provide Resident #20 with double protein portions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 66 235536 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235536 B. Wing 05/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pinnacle Care of Battle Creek 675 Wagner Dr Battle Creek, MI 49017

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 38383

Residents Affected - Some Based on observation, interview and record review, the facility failed to ensure sufficient nursing staff to respond to resident needs timely for three (Resident R2, Resident R25 and Resident R37) and the Resident Council, from a census of 61 residents.

Findings include:

Resident #2 (Resident R2):

Review of the medical record reflected Resident R2 admitted to the facility on [DATE REDACTED] and readmitted [DATE REDACTED], with diagnoses that included chronic obstructive pulmonary disease and diabetes. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/1/25, reflected Resident R2 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool).

On 05/05/25 at 11:39 AM, Resident R2 was observed in a wheelchair, in their room. Resident R2 reported call light response times of 35 minutes to one hour and 45 minutes. Resident R2 reported the extended call light response times could be

on any shift, depending on who was working. Resident R2 reported they were able to determine their call light response times using the clock in their room.

Resident #25 (Resident R25):

Review of the medical record reflected Resident R25 admitted to the facility on [DATE REDACTED], with diagnoses that included hemiplegia (paralysis or weakness on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke). The Quarterly MDS, with an ARD of 2/20/25, reflected Resident R25 scored nine out of 15 (moderate cognitive impairment) on the BIMS.

On 05/05/25 at 1:06 PM, Resident R25 was observed lying in bed. Resident R25 reported at times, they had to sit in feces for hours at a time, mostly on the day shift. Resident R25 reported it took more than one person to change them.

Resident #37 (Resident R37):

Review of the medical record reflected Resident R37 admitted to the facility on [DATE REDACTED] and readmitted [DATE REDACTED], with diagnoses that included iron deficiency anemia due to blood loss, muscle weakness, difficulty walking and need for assistance with personal care. The Quarterly MDS, with an ARD of 2/13/25, reflected Resident R37 scored 15 out of 15 (cognitively intact) on the BIMS.

On 05/05/25 at 11:11 AM, Resident R37 was observed seated in a wheelchair, in their room. Resident R37 reported at times, it took one hour for their call light to be answered on day shift. Resident R37 also reported staff would respond to the call light, say they would be back but would not return. The extended call light wait times occurred when Resident R37 wanted to get out of bed for the day. Resident R37 reported they liked to be out of bed between 9:30 AM and 10:00 AM.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 66 235536 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235536 B. Wing 05/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pinnacle Care of Battle Creek 675 Wagner Dr Battle Creek, MI 49017

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 In an interview on 05/08/25 at 10:49 AM, Certified Nurse Aide (CNA) N reported when the facility was not able to cover shifts, they worked short-handed. CNA N reported that occurred more on the weekends and Level of Harm - Minimal harm or approximately three times in the prior three months. potential for actual harm

In an interview on 05/12/25 at 12:06 PM, Scheduler U reported the facility staffed based on census and Residents Affected - Some acuity. Regarding extended call light response times, Scheduler U reported there was a resident that required a higher number of staff to assist with care, which could be time consuming. When the Restorative Aide was working, they assisted with getting that resident up.

49272

On 5/7/25 at 12:24 PM, during a confidential Resident Council meeting, when asked if the residents get the help and care they need without waiting a long time and if staff respond to their call lights timely, responses included:

One resident laughed and replied not on nights

Usually takes at least a half an hour.

Staff turn off call lights and don't take care of the need.

It depends on who is working, with certain people I have to wait 45 minutes

When asked if there is enough staff, 10 of 10 residents responded no and provided the following responses:

We are always short that is why we have to wait so long for call lights.

Nights is worse.

Good luck getting something done after 6pm (resident mentioned specific concerns with delay in getting brief changed)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 66 235536 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235536 B. Wing 05/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pinnacle Care of Battle Creek 675 Wagner Dr Battle Creek, MI 49017

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0732 Post nurse staffing information every day.

Level of Harm - Potential for 38383 minimal harm Based on interview and record review, the facility failed to ensure the daily nurse staffing posting was dated Residents Affected - Many with the year and included the actual hours worked by category of licensed and unlicensed nursing staff (i.e., Registered Nurse (RN), Licensed Practical Nurse (LPN), Certified Nurse Aide (CNA)) directly responsible for resident care per shift.

Findings include:

On 05/05/25 at approximately 1:30 PM, the daily nursing staffing posting was noted on a table, in the main lobby. The posting was dated, May 5th and included the total amount of hours worked for day shift and night shift for RNs, LPNs and CNAs. The current year and shift times were not included on the posting.

On 05/06/25 at 2:11 PM, the daily nursing staffing posting was noted in the main lobby. The posting was dated, May 6th and included the total amount of hours worked for day shift and night shift for RNs, LPNs and CNAs. The current year and shift times were not included on the posting.

On 05/07/25 at 8:11 AM, the daily nursing staffing posting was noted in the main lobby. The posting was dated, May 7th and included the total amount of hours worked for day shift and night shift for RNs, LPNs and CNAs. The current year and shift times were not included on the posting.

In an interview on 05/08/25 at 2:48 PM, Director of Nursing (DON) B reported the Scheduler was responsible for the daily staffing posting and may have been using a form that was passed down.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 66 235536 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235536 B. Wing 05/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pinnacle Care of Battle Creek 675 Wagner Dr Battle Creek, MI 49017

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45038

Residents Affected - Some Based on interview and record review the facility failed to perform drug regimen reviews at least once a month by a licensed pharmacist for five Residents (#9,#33, #40, #41, and #49) of five Residents reviewed.

Findings Included:

Resident #40 (Resident R40)

Review of the medical record demonstrated Resident R40 had been admitted to the facility 01/31/2025 with diagnoses chronic obstructive pulmonary disease (COPD), asthma, type 2 diabetes, stage 4 pressure ulcer of sacral region, stage 3 pressure ulcer of right buttock, muscle weakness, bone density disorder, hyperlipidemia (high fat content in flood), urinary retention, gastro-esophageal reflux, anemia, and left below knee amputation.

Review of Resident R40's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/25/2025, revealed Resident R40 had a Brief Interview for Mental Status (BIMS) of 11 (moderate cognitive impairment) out of 15.

Review of Resident R40's medical record did not demonstrate that a Pharmacy Medication Regimen Review had been completed for March 2025.

Resident #49 (Resident R49)

Review of the medical record demonstrated Resident R49 had been admitted to the facility 09/17/2024 with diagnoses osteomyelitis (bone infection), malnutrition, asthma, paraplegia (paralysis that affects lower part of the body), stage 4 pressure ulcer sacral region, anxiety, depression, left lower leg non pressure ulcer, neuromuscular dysfunction of bladder, hypertension, atrial fibrillation, hypotension, anemia (low red blood cells), nicotine dependance, and chronic pain. Review of Resident R49's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/29/2024, revealed Resident R49 had a Brief interview of Mental Status (BIMS) of 15 (cognitively intact) out of 15.

Review of Resident R49's medical record did not demonstrate that a Pharmacy Mediation Regimen Review had been completed for March 2025.

During an interview on 05/28/2025 at 12:45 p.m. Director of Nursing (DON) B explained that a pharmacist reviewed all Resident medication orders monthly. DON B was asked to provide March 2025 Pharmacy Medication Regimen Reviews for Resident R40 and Resident R49. DON B explained that if they were not located in the Residents medical record that they would not have been completed. DON B could not verify that March 2025 Pharmacy Medication Regimen Reviews had been completed for Resident R40 and Resident R49. DON B could not explain why the March 2025 Pharmacy Medication Regimen Reviews had not been completed.

38383

Resident #9 (Resident R9):

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 66 235536 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235536 B. Wing 05/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pinnacle Care of Battle Creek 675 Wagner Dr Battle Creek, MI 49017

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Review of the medical record reflected Resident R9 admitted to the facility on [DATE REDACTED] and readmitted [DATE REDACTED], with diagnoses that included dementia, major depressive disorder, insomnia, Alzheimer's and psychotic disorder Level of Harm - Minimal harm or with delusions. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of potential for actual harm 3/31/25, reflected Resident R9's cognition and mood were not assessed.

Residents Affected - Some Resident R9's medical record did not reflect evidence that monthly Pharmacy Medication Regimen Reviews had been conducted for July 2024, August 2024, September 2024, October 2024 and March 2025.

On 05/07/25 at 12:59 PM, an email request was sent to Nursing Home Administrator (NHA) A and Director of Nursing (DON) B for monthly Pharmacy Medication Regimen Reviews, Pharmacy recommendations and follow-up actions for Resident R9 since 5/1/24.

On 05/07/25 at 2:28 PM, DON B reported if the Pharmacy Medication Regimen Reviews were not in the medical record, they did not have them.

During a phone interview on 05/08/25 at 11:59 AM, Pharmacist Z reported their pharmacy provided medications to the facility and reviewed medications upon request of the nursing staff. Pharmacist Z reported

an outsourced, third-party Pharmacist conducted the monthly Pharmacy Medication Regimen Reviews. Pharmacist Z reported the monthly Medication Regimen Reviews were not a service their pharmacy provided to the facility.

46954

Resident #33 (Resident R33)

Review of the medical record reflected Resident R33 was admitted to the facility on [DATE REDACTED], with diagnoses that included major depressive disorder and Alzheimer's with early onset. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/31/25, reflected Resident R33 scored 0 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool).

Review of the Medical Record revealed that Monthly Medication Reviews did not occur on July 2024, August 2024, September 2024 , October 2024 and March 2025.

Resident #41 (Resident R41)

Review of the medical record reflected Resident R41 was admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED], with diagnoses that included dementia. Resident R41 was not interviewable.

Review of the Medical Record revealed that Monthly Medication Reviews did not occur on July 2024, August 2024, September 2024, October 2024 and March 2025.

During an interview on 05/28/2025 at 12:45 p.m. Director of Nursing (DON) B explained that a pharmacist reviewed all Resident medication orders monthly. DON B was asked to provide the missing Pharmacy Medication Regimen Reviews. DON B explained that if they were not located in the Residents medical

record that they would not have been completed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 66 235536 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235536 B. Wing 05/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pinnacle Care of Battle Creek 675 Wagner Dr Battle Creek, MI 49017

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater.

Level of Harm - Minimal harm or 27446 potential for actual harm Based on observation, interview, and record review the facility failed to ensure a medication error rate of less Residents Affected - Few than 5% for three observed medication errors out of 25 opportunities, resulting in a medication error rate of 12%.

Findings Included:

During an observation of a medication administration on 5/06/2025 at 8:10 AM, Registered Nurse (RN) EE was observed to obtain an iron pill from a bottle to administer to a resident. RN EE was asked why was the observed handwritten date on the bottle there, RN EE stated she did not know other than the nurse were to write the date of the bottle being opened, but stated it meant nothing. A review of the bottle of iron revealed

the bottle did not have a manufacture's expiration date on the bottle. RN EE was asked what needed to have been done with the bottle of iron, seems it was not possible to know the expiration date of the iron pills, in which RN EE stated that she would give the iron to the resident because that was what she was supposed to do, but said she did not know the expiration date of the iron pills. RN EE was observed to administered the iron to the resident then returned the bottle to the medication cart for future use, and did not dispose of the iron pills.

During another medication pass with Licensed Practical Nurse (LPN) X on 5/07/2025 at 7:20 AM, LPN X was observed to administer a Senna Plus 8.6/50 mg tablet to the resident whom she was passing medications to.

Review of the Physician's orders revealed that the order for the Senna was not for Senna Plus 8.6/50 mg, but rather did not state a dose at all, Active Order Summary: Senna Oral Tablet (Sennosides) Give 1 tablet by mouth one time a day for constipation.

In an interview on 5/07/2025 at 12:19 PM, LPN X was asked what the Physician's order was for the Senna medication. LPN X reviewed the Physician's order, and stated that because the Physician's order did not state 8.6 mg for the dose, and did not state the dose at all, she gave the Senna (laxative) plus (stool softener) 8.6/50 mg (respectfully).

Observation of a medication pass on 5/07/2025 at 7:45 AM, LPN GG was observed during a medication administration. Amalodepine was ordered to be administered, but held for a blood pressure less than 94/64. Per LPN GG the resident's blood pressure was less that 94/64 so the Amalodepine was not to be administered. LPN GG was observed to place all medications into a med cup along with pudding. Included in

the medications was Losartin 50 mg two tabs to be held for blood pressure less than 100. Prior to LPN GG administering the Losartin 50 mg LPN GG was asked if there were any blood pressure parameters for the Losartin. LPN GG did not believe so, however did check the Physician's orders, and then discovered there were parameters for the Losartin.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 66 235536 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235536 B. Wing 05/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pinnacle Care of Battle Creek 675 Wagner Dr Battle Creek, MI 49017

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 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 Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 27446 Residents Affected - Some Based on observation, interview, and record review the facility failed to ensure medications were properly labeled and stored per professional standards of practice for two residents (Resident R35 and Resident R36) and a medication cart in a current facility census of 61 residents.

Findings Included:

During an observation of a medication administration on 5/06/2025 at 8:10 AM, Registered Nurse (RN) EE was observed to obtain an iron pill from a bottle to administer to a resident. RN EE was asked why was the observed handwritten date on the bottle there, RN EE stated she did not know other than the nurse were to write the date of the bottle being opened, but stated it meant nothing. A review of the bottle of iron revealed

the bottle did not have a manufacture's expiration date on the bottle. RN EE was asked what needed to have been done with the bottle of iron, seems it was not possible to know the expiration date of the iron pills, in which RN EE stated that she would give the iron to the resident because that was what she was supposed to do, but said she did not know the expiration date of the iron pills. RN EE was observed to administered the iron to the resident then returned the bottle to the medication cart for future use, and did not dispose of the iron pills.

In an observation and interview on 5/07/2025 at 7:45 AM, Licensed Practical Nurse (LPN) GG was observed to put pills into a medication cup and place pudding in over the pills. Prior to LPN GG administering the medications to the resident LPN GG discovered that she needed to remove two of the pills from the cup of pudding. LPN GG was observed to take a plastic spoon and remove one of the pills, and then take another plastic spoon and remove the other pill. Both pills remained on the spoons, and were observed to be tossed into the garbage can that was attached to the side medication cart. The garbage can did not have a lid, and both spoons were stuck at the top of the can on the plastic can liner due to the pudding. Both pills were visible and exposed, and easily accessible to other residents. LPN GG was observed to leave the medication cart unattended. There were observed to be three residents in the room where the medication cart was left, and two of the three residents were ambulatory.

LPN GG was asked about the facility's policy for medication disposal, in which LPN GG stated she did not know what the facility's policy and procedure was for non-controlled substances, medication disposal.

38383

Resident #36 (Resident R36)

Review of the medical record reflected Resident R36 admitted to the facility on [DATE REDACTED], with diagnoses that included hemiplegia (paralysis or weakness on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke) affecting left non-dominant side, vascular dementia and chronic kidney disease. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/18/25, reflected Resident R36's cognitive status was not assessed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 66 235536 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235536 B. Wing 05/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pinnacle Care of Battle Creek 675 Wagner Dr Battle Creek, MI 49017

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 On 05/06/25 at 9:55 AM, Resident R36 was not observed in their room. A medication cup with four pills was observed

on Resident R36's overbed table, including two round, white pills and two round pills that were orange/pink in color. Level of Harm - Minimal harm or Resident R36's roommate was observed in the room. potential for actual harm

On 05/06/25 at 10:07 AM, Licensed Practical Nurse (LPN) T reported administering medications to Resident R36 that Residents Affected - Some morning, including amlodipine (medication used to treat high blood pressure), hydrochlorothiazide (diuretic/water pill used to treat high blood pressure), metoprolol (medication used to treat high blood pressure) and hydralazine (medication used to treat high blood pressure). LPN T reported she took Resident R36's medications to their room between 8 AM and 9 AM that morning but did not observe Resident R36 consuming the medications. Upon entering Resident R36's room with LPN T, she removed the pills from Resident R36's bedside and stated those were the medications she provided to Resident R36 that morning. LPN T stated she was not supposed to leave

the medications at bedside for Resident R36.

Resident R36's May 2025 Medication Administration Record (MAR) reflected orders for morning medications, which included amlodipine 10 milligrams (mg) daily for high blood pressure, hydrochlorothiazide 25 mg daily for high blood pressure, hydralazine 25 mg twice daily for high blood pressure and metoprolol 25 mg twice daily for high blood pressure.

In an interview on 05/08/25 at 8:48 AM, Director of Nursing (DON) B reported the nurses were supposed to observe residents taking their medications, then mark them as administered.

49272

Resident # 35 (Resident R35)

Review of the medical record revealed Resident R35 was admitted to the facility on [DATE REDACTED] with diagnoses that included: depression and repeated falls. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/11/25 revealed Resident R35 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool).

A review of Resident R35's chart revealed:

Nursing progress note, 12/28/24 at 19:00, This resident (Resident R35) had a visitor at about 1 p.m. this afternoon who stayed only a few minutes. Shortly after the resident's visitor left, one of the CNAs (certified nursing assistant) reported to this writer that this resident (Resident R35) has marijuana gummies in his room, and that this resident had already given at least one gummy to the resident in room (room number redacted), initials (initials redacted). This writer asked this resident if he did indeed have marijuana gummies in his room. He admitted to having them, but refused to tell me where they were. This writer told the resident that they cannot stay in his room, and that he certainly cannot give these to other residents. At about 1:45 p.m. this resident gave this writer an opened bag of 200 mg gummies. There were two gummies in the bag. This writer placed

the bag in the Boardwalk med cart's narcotic box. This resident's vital signs were within normal limits, as were his affect and movements. This resident's provider was notified by voice mail; this writer awaits a response.

A request for any incident or accident reports for Resident R35 was made via email on 5/7/25 at 10:18 AM. No associated incident or accident reports were provided prior to survey end.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 66 235536 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235536 B. Wing 05/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pinnacle Care of Battle Creek 675 Wagner Dr Battle Creek, MI 49017

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 On 5/8/25 at 2:08 PM, during an interview with the director of nursing (DON) and assistance director of nursing (ADON), both reported to not have any knowledge of Resident R35 having had cannabis gummies and/or that Level of Harm - Minimal harm or he shared them with another resident. When asked what the facilities policy is related to cannabis products, potential for actual harm DON reported that she would need to look it up but would assume no drugs in the building, doesn't matter if

it is gummies. DON/ADON both reported if there was any additional information they would provide it prior to Residents Affected - Some survey exit. No additional information was provided.

A review of the facilities policy titled, Cannabidiol (CBD), documented in part It is the policy of the facility to honor a resident's right to receive Cannabidiol (CBD) within the limits of the law. CBD will be administered in oral form (oil/gummies, etc) or via vape to residents with a physician's order. (The legality of CBD and whether or not CBD is considered a controlled substance varies by state .Like all other medications, CBD will be given by licensed nurses by the physician .CBD will be considered a controlled substance in the facility and amounts will be counted at the beginning and end of each shift and signed by the licensed nurse completing the count to ensure accuracy of amounts on hand .CBD administration will be documented in the same manner as all other controlled substances.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 66 235536 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235536 B. Wing 05/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pinnacle Care of Battle Creek 675 Wagner Dr Battle Creek, MI 49017

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0809 Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to Level of Harm - Minimal harm or eat at non-traditional times or outside of scheduled meal times. potential for actual harm 49272 Residents Affected - Some Based on interview and record review the facility failed to consistently offer bedtime snacks to nine of ten residents who attended the confidential Resident Council Meeting.

Findings include:

On 5/7/25 at 12:24 PM, during the confidential Resident Council meeting, when asked if residents were offered snacks at bedtime, nine of ten reported that snacks were not offered and they would like them. Responses included:

No bedtime snacks.

They do not offer every night, it is rare when they come in and offer (several residents nodded in agreement or verbalized agreement)

They don't always have snacks available.

I use to get cottage cheese but they don't have a variety of snacks anymore, mostly only peanut butter sandwiches.

The previous kitchen staff use to be really good at asking and offering snacks every night.

A review of the resident council meeting minutes revealed the following:

January 2, 2025 Please describe the concern: snacks at night

February 5, 2025 Please describe the concern: not getting snacks at night

On 5/8/25 at 10:48 AM, during an interview with dietary cook JJ, she reported that the dietary staff provide each unit with a tray of snacks each day (around dinner time) and that the nursing staff on each unit is responsible for offering and providing them to the residents each night. Dietary [NAME] JJ reported that there are days when the kitchen staff delivers the snacks and the trays from the day before have zero or only few items missing, indicating they may not have been offered to the residents.

Review of the facilities policy, titled Offering/Serving Bedtime Snacks, documented in part It is the practice of

this facility to offer and serve residents with a nourishing snack in accordance with their needs, preferences and requests at bedtime on a daily basis .Dietary services staff delivers bedtime snacks to each nurses' station. Nursing staff is made aware of the delivery of the snacks .Nursing staff delivers and serves snacks to residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 66 235536 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235536 B. Wing 05/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pinnacle Care of Battle Creek 675 Wagner Dr Battle Creek, MI 49017

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 22050

Residents Affected - Many Based on observations, interviews, and record reviews, the facility failed to: (1) effectively clean and maintain food service equipment, and (2) effectively date mark all potentially hazardous ready-to-eat food products effecting 61 residents who consume food, resulting in the increased likelihood for cross-contamination, bacterial harborage, and resident foodborne illness.

Findings include:

On 05/05/25 at 09:10 A.M., An initial tour of the food service was conducted with Dietary Head [NAME] (DHC) K. The following items were noted:

One gallon (one-sixteenth full) of [NAME] Select 2% Milk was observed, within the Arctic Air 2-door reach-in cooler, without an effective open or discard date. The manufacturer's use-by-date read 5-15-25.

One gallon (one-eighth full) of [NAME] Select Whole Milk was observed, within the walk-in cooler, without an effective open or discard date. The manufacturer's use-by-date was observed to read 5-15-25.

The 2022 FDA Model Food Code section 3-501.17 states: (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.

Non-pasteurized shell eggs (7) were observed within the Arctic Air 2-door reach-in cooler. (DHC) K stated:

We use the eggs for breakfast. (DHC) K also stated: We do eggs over easy for those who want them.

The 2022 FDA Model Food Code section 3-202.14 states: (A) EGG PRODUCTS shall be obtained pasteurized. (B) Fluid and dry milk and milk products shall: (1) Be obtained pasteurized; and (2) Comply with GRADE A STANDARDS as specified in LAW. (C) Frozen milk products, such as ice cream, shall be obtained pasteurized as specified in 21 CFR 135 - Frozen desserts. (D) Cheese shall be obtained pasteurized unless alternative procedures to pasteurization are specified in the CFR, such as 21 CFR 133 - Cheeses and related cheese products, for curing certain cheese varieties.

The can opener assembly was observed soiled with accumulated and encrusted food residue. (DHC) K stated: We clean the can opener every Monday and Wednesday.

1 of 2 [NAME] convection oven interior and exterior surfaces were observed soiled with accumulated and encrusted food residue.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 66 235536 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235536 B. Wing 05/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pinnacle Care of Battle Creek 675 Wagner Dr Battle Creek, MI 49017

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 The Bunn Coffee Machine (backsplash, under splash, drip tray) was observed soiled with accumulated and encrusted food residue. The coffee machine drip tray was also observed completely full of liquid waste. Level of Harm - Minimal harm or (DHC) K stated: We clean the coffee machine daily. potential for actual harm

The Panasonic microwave oven interior was observed soiled with accumulated and encrusted food residue. Residents Affected - Many

The 2022 FDA Model Food Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.

The Panasonic microwave oven interior door surface protective mesh screen was observed (etched, scored, torn), creating a microwave safety issue. The damaged door screen measured approximately .25-inches wide by 2-inches-long.

The 2022 FDA Model Food Code section 4-501.13 states: Microwave ovens shall meet the safety standards specified in 21 CFR 1030.10 Microwave ovens. Failure of microwave ovens to meet the CFR standards could result in human exposure to radiation leakage, resulting in possible medical problems to consumers and employees using the machines.

The Ecolab mechanical dish machine pounds-per-square inch (PSI) gauge was observed to read 33 (PSI)

during the final rinse cycle. The (PSI) reading should be between 5-30 (PSI) during the final rinse cycle. (DHC) K indicated she would have Dietary Manager L contact the contractual vendor for necessary repairs as soon as possible.

The 2022 FDA Model Food Code section 4-501.113 states: The flow pressure of the fresh hot water SANITIZING rinse in a WAREWASHING machine, as measured in the water line immediately downstream or upstream from the fresh hot water SANITIZING rinse control value, shall be within the range specified on the machine manufacturer's data plate and may not be less than 35 kilopascals (5 pounds per square inch) or more than 200 kilopascals (30 pounds per square inch).

The Walk-In Cooler flooring surface was observed covered with laminate pattern rolled vinyl. 2 of 3 anti-skid strips near the entrance of the Walk-In Cooler were also observed loose-to-mount and partially missing.

The 2022 FDA Model Food Code section 6-201.11 states: Except as specified under S 6-201.14 and except for antislip floor coverings or applications that may be used for safety reasons, floors, floor coverings, walls, wall coverings, and ceilings shall be designed, constructed, and installed so they are SMOOTH and EASILY CLEANABLE.

The Walk-In Cooler automatic door closer assembly was observed out-of-adjustment, allowing the door to not close and latch completely.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 66 235536 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235536 B. Wing 05/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pinnacle Care of Battle Creek 675 Wagner Dr Battle Creek, MI 49017

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 The 2022 FDA Model Food Code section 4-501.11 states: (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) EQUIPMENT Level of Harm - Minimal harm or components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted potential for actual harm in accordance with manufacturer's specifications. (C) Cutting or piercing parts of can openers shall be kept sharp to minimize the creation of metal fragments that can contaminate FOOD when the container is opened. Residents Affected - Many

On 05/08/25 at 12:00 P.M., Record review of the Policy/Procedure entitled: Sanitation Inspection dated (no date) revealed under Policy: It is the policy of this facility, as part of the department's sanitation program, to conduct inspections to ensure food service areas are clean, sanitary, and in compliance with applicable state and federal regulations. Record review of the Policy/Procedure entitled: Sanitation Inspection dated (no date) further revealed under Policy Explanation and Compliance Guidelines: (1) All food service areas shall be kept clean, sanitary, free from litter, rubbish, and protected from rodents, roaches, flies, and other insects.

On 05/08/25 at 12:15 P.M., Record review of the Policy/Procedure entitled: Cleaning and Sanitizing Dietary Areas and Equipment dated (no date) revealed under Policy: All kitchen areas and equipment shall be maintained in a sanitary manner and be free of buildup of food, grease, or other soil. The facility will provide sanitary foodservice that meets state and federal regulations.

On 05/08/25 at 12:30 P.M., Record review of the Policy/Procedure entitled: Culinary Operating Procedures 501 Sanitation-General dated (no date) revealed under Policy: It is the policy of this facility to maintain the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule.

On 05/08/25 at 12:45 P.M., Record review of the Policy/Procedure entitled: Culinary Operating Procedures 502 Cleaning Equipment and Utensils dated (no date) revealed under Policy: Equipment and utensils will be properly cleaned, sanitized, and stored to prevent contamination.

On 05/08/25 at 12:55 P.M., Record review of the Policy/Procedure entitled: Date Marking for Food Safety dated (no date) revealed under Policy: The facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for safety food. Record review of the Policy/Procedure entitled: Date Marking for Food Safety dated (no date) further revealed under Policy Explanation and Compliance Guidelines for Staffing: (1) Refrigerated, ready-to-eat, time/temperature control for safety food (i.e. perishable food) shall be held at a temperature of 41 degrees or less for a maximum of 7 days. (2) The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. (5) The discard day or date may not exceed the manufacturer's use-by-date, or four days, whichever is earliest. The date of opening or preparation counts as day 1. (For example, food prepared on Tuesday shall be discarded on or by Friday.)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 66 235536 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235536 B. Wing 05/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pinnacle Care of Battle Creek 675 Wagner Dr Battle Creek, MI 49017

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0865 Have a plan that describes the process for conducting QAPI and QAA activities.

Level of Harm - Minimal harm or 27446 potential for actual harm Based on interview and record review the facility failed to maintain an effective Quality Assurance and Residents Affected - Many Performance Improvement program that identified areas of focus and improvement in a current facility census of 61 residents.

Findings Included:

During the survey a concern was identified at an Immediate Jeopardy level regarding hot water temperatures

in which the facility was unaware off. Also, it was identified during the survey a concern of accommodation of resident needs regarding call light accessibility.

Review of resident council meeting minutes, dated 3/5/2025, revealed a concern was brought up regarding not having hot water in the resident rooms. The facility's response was to check the hot water temperatures, and to also check them weekly.

Review of QAPI minutes revealed no further discussion of weekly hot water temperatures, nor were any documented logs noted.

In an interview on 5/08/2025 at 2:35 PM, Administrator A was not able to verify that a QAPI meeting had been held for the month of April 2025. Administrator A stated that she had no idea if there had been QAPI discussion regarding water temperatures not being at a comfortable level. Administrator A also stated that

she was not aware of any perfomance improvement plan (PIP) that was in place regarding the resident call light system or accessibility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of 66 235536 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235536 B. Wing 05/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pinnacle Care of Battle Creek 675 Wagner Dr Battle Creek, MI 49017

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 27446 potential for actual harm Based on observation, interview, and record review the facility failed to ensure oxygen tubing was changed Residents Affected - Few every seven days for one out of two residents (Resident #61).

Findings Included:

In an observation on 5/05/2025 at 12:25 PM, an oxygen concentrator (tank that delivers oxygen) was observed to be on. Tubing was observed to go from the tank to Resident #61's (Resident R61) nose and was administering oxygen to the Resident R61. The tubing was observed to have a tapped label on it which had a date of 4/20/2025.

In another observation on 5/07/2025 at 3:07 PM, Resident R61 was observed to have the same oxygen tubing in place as observed on 5/5/2024 and was still labeled 4/20/2025.

In an interview on 5/07/2025 at 3:45 PM, Infection Control Preventionist (ICP), who was also a Registered Nurse (RN) J stated that she did not monitor and track the use of oxygen tubing via the infection control program. ICP/RN J stated she did not perform audits to ensure oxygen tubing was being changed every seven days.

In an interview on 5/07/2025 at 3:59 PM, the Director of Nursing (DON) B stated the oxygen tubing was to be changed every seven days and dated. DON B stated her that her expectation was that the ICP/RN J perform monthly audits and random checks of resident's oxygen tubing for dates, assuring staff are changing the tubing per policy.

Review of the facility policy and procedure, not dated, revealed oxygen tubing was to be changed weekly and as needed. The policy revealed under #5. b. Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of 66 235536 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235536 B. Wing 05/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pinnacle Care of Battle Creek 675 Wagner Dr Battle Creek, MI 49017

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 32064 potential for actual harm Based on interview and record review, the facility failed to document education provided regarding the Residents Affected - Few benefits and potential side effects of the pneumococcal immunization for two (Resident R2 and Resident R22) of five reviewed.

Findings include:

Resident #22 (Resident R22)

Review of the medical record revealed Resident R22 admitted to the facility on [DATE REDACTED] with diagnoses that included chronic obstructive pulmonary disease (COPD) and diabetes. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/23/25 revealed Resident R22's cognitive skills for daily decision making were not assessed. The MDS with an ARD of 12/21/24 revealed Resident R22 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool).

Review of the Pneumonia Vaccine Consent Form revealed Resident R22 declined the pneumonia vaccine on 5/9/24.

Review of the Nurses Note dated 8/28/24 revealed PCP [primary care physician] ordered pneumonia immunization, resident consented . Resident R22 received the pneumonia vaccine on 8/30/24.

The medical record did not reflect the education provided to Resident R22 regarding the benefits and potential side effects of the pneumonia vaccine.

In an interview on 05/08/25 at 1:14 PM, Director of Nursing (DON) B and Assistant Director of Nursing/Infection Preventionist (ADON/IP) J reported they were not employed at the facility when Resident R22's pneumonia vaccine was administered. DON B and ADON/IP J reported the Centers for Disease Control and Prevention Vaccine Information Statement should be given prior to any vaccine administered. Further information was requested regarding the documentation of the education given to Resident R22 prior to administering

the pneumonia vaccine. Documentation was not received prior to the survey exit.

38383

Resident #2 (Resident R2):

Review of the medical record reflected Resident R2 admitted to the facility on [DATE REDACTED] and readmitted [DATE REDACTED], with diagnoses that included chronic obstructive pulmonary disease and diabetes. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/1/25, reflected Resident R2 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool).

Review of the Pneumonia Vaccine Consent Form reflected Resident R2 declined the pneumonia vaccine on 4/22/24.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 58 of 66 235536 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235536 B. Wing 05/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pinnacle Care of Battle Creek 675 Wagner Dr Battle Creek, MI 49017

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 The medical record reflected Resident R2 received the Prevnar 20 pneumococcal (pneumonia) immunization on 8/30/24. Level of Harm - Minimal harm or potential for actual harm A Progress Note for 8/30/24 reflected, Resident received prevnar20 and shingles immunization to deltoid. Resident tolerated administration well . Residents Affected - Few

The medical record did not reflect the education provided to Resident R2 regarding the benefits and potential side effects of the pneumonia immunization.

In an interview on 05/08/25 at 9:42 AM Director of Nursing (DON) B and Assistant Director of Nursing/Infection Preventionist (ADON/IP) J reported the Centers for Disease Control and Prevention Vaccine Information Statement should have been provided prior to any vaccine administered.

On 05/08/25 at approximately 10:30 AM, Resident R2 was observed in their room. Resident R2 acknowledged providing consent for the facility to administer a pneumococcal immunization, however, when asked if they had been provided with education on the risks and/or benefits of the pneumococcal immunization, Resident R2 reported they had not received education.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 59 of 66 235536 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235536 B. Wing 05/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pinnacle Care of Battle Creek 675 Wagner Dr Battle Creek, MI 49017

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0887 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. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 32064

Residents Affected - Some Based on interview and record review, the facility failed to administer a COVID-19 vaccine per consent for one (Resident R33) of five reviewed.

Findings include:

Review of the medical record revealed Resident R33 was admitted to the facility on [DATE REDACTED] with diagnoses that included Alzheimer's Disease and diabetes. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/31/25 revealed Resident R33 scored 00 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Resident R33's spouse was their Durable Power of Attorney (DPOA) for Healthcare.

According to Resident R33's immunization history, the most recent COVID-19 vaccine was administered on 11/7/23.

Review of the COVID-19 Vaccine Consent Form revealed Resident R33's DPOA gave verbal consent for the COVID-19 vaccine on 8/28/24. Resident R33 did not receive the COVID-19 vaccine per consent.

In an interview on 05/08/25 at 1:14 PM, Director of Nursing (DON) B and Assistant Director of Nursing/Infection Preventionist (ADON/IP) J were not able to provide documentation or information as to why Resident R33 did not receive an updated COVID-19 vaccine.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 60 of 66 235536 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235536 B. Wing 05/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pinnacle Care of Battle Creek 675 Wagner Dr Battle Creek, MI 49017

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 22050 potential for actual harm Based on observations, interviews, and record reviews, the facility failed to effectively maintain the resident Residents Affected - Some call system effecting 61 residents, resulting in the increased likelihood for delayed emergency response and/or negative resident outcomes.

Findings include:

On [DATE REDACTED] at 02:01 P.M., The resident call system was monitored for functionality for the following resident rooms:

South Unit

Resident room [ROOM NUMBER]: Functioning

Resident room [ROOM NUMBER]: Functioning

Resident room [ROOM NUMBER]: Functioning

Resident room [ROOM NUMBER]: Functioning

Resident room [ROOM NUMBER]: Functioning

Resident room [ROOM NUMBER]: Functioning

Resident room [ROOM NUMBER]: Functioning

Resident room [ROOM NUMBER]: Functioning

Resident room [ROOM NUMBER]: Functioning

Resident room [ROOM NUMBER]: Functioning

On [DATE REDACTED] at 02:55 P.M., An interview was conducted with Resident R25 regarding the resident call system provided by the facility. Resident R25 stated: I wish I had the old call system to push.

On [DATE REDACTED] at 12:06 P.M., An interview was conducted with Environmental Services Director (ESD) E regarding the facility maintenance work order system. (ESD) E stated: We have TELS.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 61 of 66 235536 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235536 B. Wing 05/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pinnacle Care of Battle Creek 675 Wagner Dr Battle Creek, MI 49017

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0919 On [DATE REDACTED] at 10:30 A.M., Record review of the Policy/Procedure entitled: Call Lights: Accessibility and Timely Response dated (no date) revealed under Policy: The purpose of this policy is to assure the facility is Level of Harm - Minimal harm or adequately equipped with a call light at each resident's bedside, toilet, and bathing facility to allow residents potential for actual harm to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. Record review of the Policy/Procedure entitled: Call Lights: Accessibility and Timely Residents Affected - Some Response dated (no date) further revealed under Policy Explanation and Compliance Guidelines: (1) All staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light. (2) All residents will be educated on how to call for help by using the resident call system. (5) Staff will ensure the call light is within reach of residents and secured, as needed. (8) Staff will report problems with a call light or the call system immediately to the supervisor and/or maintenance director and will provide immediate or alternative solutions until the problem can be remedied . (Examples include: replace call light, provide a bell or whistle, increase frequency of rounding, etc.). (9) Ensure the call system alerts staff members directly or goes to a centralized staff work area.

On [DATE REDACTED] at 01:00 P.M., Record review of the Direct Supply TELS Work Orders for the last 60 days revealed no specific entries related to the resident call system.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 62 of 66 235536 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235536 B. Wing 05/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pinnacle Care of Battle Creek 675 Wagner Dr Battle Creek, MI 49017

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Level of Harm - Minimal harm or potential for actual harm 22050

Residents Affected - Many Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 61 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, decreased air quality, and potential cross-connections between the potable (drinking) and non-potable (non-drinking) water supplies.

Findings include:

On 05/06/25 at 09:20 A.M., A common area environmental tour was conducted with Environmental Services Director (ESD) E. The following items were noted:

South Unit

Occupational Therapy/Physical Therapy: The wall mounted grab bar, located directly in front of the wheelchair scale, was observed loose-to-mount. 2 of 2 oval shaped mobile swivel chair cushions were also observed (etched, scored, particulate). 1 of 2 chair cushions were additionally observed with green duct tape covering the damaged vinyl surface. (ESD) E indicated she would have staff repair the loose-to-mount grab bar and remove the damaged chairs as soon as possible.

Shower Room: 2 of 2 shower wand assemblies were observed missing an atmospheric vacuum breaker. (ESD) E stated: I will have them installed this week.

Janitor Closet: The flooring surface and mop sink basin were observed soiled with accumulated and encrusted dust/dirt and debris (paper products, dust balls, etc.). (ESD) E indicated she would have housekeeping staff thoroughly clean the room as soon as possible.

Nurses Station: The restroom return-air-exhaust ventilation grill was observed soiled with accumulated and encrusted dust/dirt deposits. (ESD) E indicated she would have housekeeping staff thoroughly clean the ventilation grill as soon as possible.

Soiled Utility Room: The return-air-exhaust ventilation grill was observed soiled with accumulated and encrusted dust/dirt deposits. (ESD) E indicated she would have housekeeping staff thoroughly clean the ventilation grill as soon as possible.

Lift Storage Room: 2 of 2 overhead light assemblies were observed non-functional. (ESD) E indicated she would have staff make necessary repairs as soon as possible.

North Unit

Dining Room: 9 of 9 overhead light assembly clear plastic protective lens covers were observed soiled with accumulated and encrusted (dust, dirt, dead insect carcasses). (ESD) E indicated she would have staff thoroughly clean the soiled lens covers as soon as possible.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 63 of 66 235536 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235536 B. Wing 05/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pinnacle Care of Battle Creek 675 Wagner Dr Battle Creek, MI 49017

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Activities Storage Room: The return-air-exhaust ventilation grill was observed heavily soiled with accumulated and encrusted dust/dirt deposits. (ESD) E indicated she would have housekeeping staff Level of Harm - Minimal harm or thoroughly clean the ventilation grill as soon as possible. potential for actual harm Beauty Shop: 2 of 2 hand sink basins were observed draining very slowly. (ESD) E stated: I will have Residents Affected - Many (Maintenance Technician F) clear the drains.

Storage Room: The flooring surface was observed missing vinyl tiles. The damaged flooring surface measured approximately 3 feet-wide by 5 feet-long. (ESD) E indicated she would have staff make necessary repairs as soon as possible.

On 05/07/25 at 09:40 A.M., An environmental tour of sampled resident rooms was conducted with Housekeeper H. The following items were noted:

101: The Bed 2 overbed light assembly clear plastic protective lens cover was observed cracked/broken. Human fecal material was also observed on the drywall surface, located directly above the restroom waste receptacle. The restroom commode base caulking was additionally observed (etched, scored, stained, particulate).

102: The restroom commode base caulking was observed (etched, scored, stained, particulate).

111: The restroom commode base caulking was observed (etched, scored, stained, particulate).

117: The Bed 1 overbed light assembly lower 48-inch-long fluorescent bulb was observed non-functional.

The restroom entrance door was also observed ill-mounted and not latching.

122: The Bed 1 overbed light assembly was observed missing the light switch and pull string extension. The wall mounted thermostat was also observed loose-to-mount and missing a protective cover plate. The restroom hand sink faucet assembly was additionally observed loose-to-mount. The restroom commode base caulking was further observed (etched, scored, stained, particulate).

123: The restroom commode seat was observed loose-to-mount. The Bed 1 overbed light assembly pull string extension was also observed missing. The vinyl base coving strip was further observed loose-to-mount. The damaged vinyl base coving strip measured approximately 6-inches-wide by 6-inches-long, along the corner edge of the drywall partition.

124: The restroom return-air-exhaust ventilation grill was observed heavily soiled with accumulated and encrusted dust/dirt deposits. The restroom commode base caulking was also observed (etched, scored, stained, particulate).

127: The Bed 2 metal frame was observed in the retracted position without a mattress, creating a potential safety hazard for Resident R21.

128: The Bed 1 overbed light assembly pull string extension was observed missing. The restroom commode base caulking was also observed missing. The restroom commode seat was additionally observed loose-to-mount.

129: The Bed 2 overbed light assembly pull string extension was observed missing.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 64 of 66 235536 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235536 B. Wing 05/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pinnacle Care of Battle Creek 675 Wagner Dr Battle Creek, MI 49017

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 130: The restroom commode base caulking was observed missing. The restroom return-air-exhaust ventilation grill was also observed heavily soiled with accumulated and encrusted dust/dirt deposits. Level of Harm - Minimal harm or potential for actual harm 131: The restroom commode base caulking was observed missing. The restroom return-air-exhaust ventilation grill was also observed heavily soiled with accumulated and encrusted dust/dirt deposits. Residents Affected - Many 133: The restroom commode support was observed loose-to-mount. The restroom commode seat was also observed loose-to-mount. The restroom interior door surfaces were additionally observed (etched, scored, particulate).

135: The Bed 1 overbed light assembly upper 48-inch-long fluorescent bulb was observed non-functional.

The Bed 1 overbed light assembly pull string extension was also observed missing. The Bed 2 enable bar was additionally observed loose-to-mount. The restroom shower stall overhead light assembly was further observed non-functional. Human fecal material was also observed, adjacent to the restroom shower stall unit. The restroom toilet tissue holder center pin was also observed missing. The restroom commode base caulking was additionally observed missing.

143: The restroom commode base caulking was observed missing. The resident room entrance overhead light assembly clear plastic protective lens cover was also observed soiled with (dust, dirt, dead insect carcasses).

On 05/07/25 at 12:06 P.M., An interview was conducted with (ESD) E regarding the facility maintenance work order system. (ESD) E stated: We have TELS.

On 05/07/25 at 12:30 P.M., An interview was conducted with Maintenance Technician F regarding the South Unit Shower Room floor drain concern. Maintenance Technician F stated: We have contacted (Contractual Vendor Name) for commercial repairs related to both plumbing and hot water heater issues.

On 05/08/25 at 11:00 A.M., Record review of the Policy/Procedure entitled: Maintenance Inspection dated (no date) revealed under Policy: It is the policy of this facility to utilize a maintenance inspection checklist in order to assure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public.

On 05/08/25 at 11:15 A.M., Record review of the Policy/Procedure entitled: Preventative Maintenance Program dated (no date) revealed under Policy: A Preventative Maintenance Program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Record review of the Policy/Procedure entitled: Preventative Maintenance Program dated (no date) further revealed under Policy Explanation and Compliance Guidelines: (1) The Maintenance Director is responsible for developing and maintaining a schedule of maintenance services to ensure that the buildings, grounds, and equipment are maintained in a safe and operable manner.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 65 of 66 235536 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235536 B. Wing 05/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pinnacle Care of Battle Creek 675 Wagner Dr Battle Creek, MI 49017

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 On 05/08/25 at 11:30 A.M., Record review of the Policy/Procedure entitled: Routine Cleaning and Disinfection dated (no date) revealed under Policy: It is the policy of this facility to ensure the provision of Level of Harm - Minimal harm or routine cleaning and disinfection in order to provide a safe, sanitary environment, and to prevent the potential for actual harm development and transmission of infections to the extent possible. Record review of the Policy/Procedure entitled: Routine Cleaning and Disinfection dated (no date) further revealed under Policy Explanation and Residents Affected - Many Compliance Guidelines: (1) Routine cleaning and disinfection of frequently touched or visibly soiled surfaces will be performed in common areas, resident rooms, and at the time of discharge.

On 05/08/25 at 11:45 P.M., Record review of the Direct Supply TELS Work Orders for the last 60 days revealed no specific items related to the aforementioned maintenance concerns.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 66 of 66 235536