Pinnacle Care of Battle Creek
675 Wagner Drive · Battle Creek, MI · 49017 · 2699696244
82 certified beds For profit - Partnership
Why this verdict
- Carries CMS’s abuse warning icon.
- Inspectors found immediate jeopardy — danger of serious harm or death — in the most recent cycle (1 citation).
- Inspection record is far worse than the national median (deficiency count and severity).
- Staffing levels are well below research benchmarks for safe care.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
Special Focus Facility candidate
CMS lists this facility as a candidate for its Special Focus program for persistently poor inspection performance.
CMS abuse warning
CMS flags this facility with its abuse icon: cited for abuse that caused harm in the past year, or potential harm in the past two years.
1 immediate-jeopardy citation in the most recent inspection cycle
Immediate jeopardy is the most serious finding an inspector can make: a situation likely to cause serious injury, harm, or death.
1 abuse-related citation at the actual-harm level
Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.
$51,875 in federal fines in the last 24 months
1 fine — CMS fines are reserved for verified, serious non-compliance.
RN staffing in the bottom 10% nationally
0.00 registered-nurse hours per resident per day, vs a 0.58 national median and 0.75 benchmark.
Total nurse staffing below 3.0 hours per resident-day
2.05 reported hours vs the 3.48 minimum CMS's own staffing study recommends.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 2 of 5 Inspections: 1 of 5 Staffing: 1 of 5 Quality measures: 5 of 5
| Total nurse hours / resident-day | 2.05 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.00 | 0.55–0.75 |
| Weekend hours / resident-day | 2.05 | ≈ weekday level |
| Nursing turnover / year | — | median 45% |
| Fines (3-yr window) | 2 · $133,946 |
Inspection citations (111 in the current record)
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Potential for harm · E March 6, 2026 · found via complaint
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected March 27, 2026 · Quality of Life and Care
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Potential for harm · D March 6, 2026 · found via complaint
Ensure the activities program is directed by a qualified professional.
Corrected March 27, 2026 · Quality of Life and Care
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Potential for harm · E March 6, 2026 · found via complaint
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected May 15, 2026 · Nursing and Physician Services
-
Potential for harm · F March 6, 2026 · found via complaint
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected May 15, 2026 · Nutrition and Dietary
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Potential for harm · F March 6, 2026 · found via complaint
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected May 15, 2026 · Administration
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Potential for harm · E March 6, 2026 · found via complaint
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected May 15, 2026 · Nursing and Physician Services
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Potential for harm · D January 22, 2026 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected February 20, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D January 22, 2026 · found via complaint
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Corrected February 20, 2026 · Resident Rights
-
Potential for harm · D January 22, 2026 · found via complaint
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected February 20, 2026 · Resident Rights
-
Potential for harm · D September 10, 2025 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected October 4, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Immediate jeopardy · J May 12, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected August 15, 2025 · Quality of Life and Care
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Actual harm · G May 12, 2025
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected June 20, 2025 · Quality of Life and Care
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Potential for harm · D May 12, 2025
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected June 20, 2025 · Resident Rights
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Potential for harm · D May 12, 2025
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected June 20, 2025 · Resident Rights
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Potential for harm · E May 12, 2025
Reasonably accommodate the needs and preferences of each resident.
Corrected August 15, 2025 · Resident Rights
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Potential for harm · D May 12, 2025
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected June 20, 2025 · Resident Rights
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Potential for harm · D May 12, 2025
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected June 20, 2025 · Resident Rights
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Potential for harm · D May 12, 2025
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected June 20, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D May 12, 2025
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected June 20, 2025 · Resident Rights
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Potential for harm · D May 12, 2025
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected August 15, 2025 · Resident Assessment and Care Planning
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Potential for harm · D May 12, 2025
Assess the resident when there is a significant change in condition
Corrected June 20, 2025 · Resident Assessment and Care Planning
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Potential for harm · D May 12, 2025
Ensure each resident receives an accurate assessment.
Corrected August 15, 2025 · Resident Assessment and Care Planning
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Potential for harm · D May 12, 2025
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected August 15, 2025 · Resident Assessment and Care Planning
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Potential for harm · D May 12, 2025
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected August 15, 2025 · Resident Assessment and Care Planning
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Potential for harm · D May 12, 2025
Provide activities to meet all resident's needs.
Corrected June 20, 2025 · Quality of Life and Care
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| April 17, 2025 | Fine | $51,875 |
| April 17, 2025 | Payment Denial | 99 days |
| February 9, 2024 | Fine | $82,071 |
| February 9, 2024 | Payment Denial | 55 days |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 235536 · certified since June 26, 1993. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.