Pinnacle Care Of Battle Creek

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 (R38) of three residents reviewed for accidents.

Findings include:

Resident #58

A review of the medical record revealed that Resident #58 (R58) was admitted to the facility on [DATE], 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 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, 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. 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 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:

235536

Form Approved OMB

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