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.
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)
-
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
-
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
-
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
-
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.