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Nursing Home Violations Public inspection data, searchable
Facility profile · CCN 235536

Pinnacle Care Of Battle Creek

112 federal citations on record , including 1 at the Immediate Jeopardy level, and 5 federal enforcement actions totaling $140,507.

Abuse Icon Special Focus Status 1 Immediate Jeopardy

Record summary

Federal record · Q1 2026
112
Total citations
81
Last 3 years
4
Actual harm+
5
Federal penalties
$140,507
Total fines
1
Overall ★ rating

Most common violation categories here

Resident Rights23 Quality of Care20 Care Planning13 Medication & Pharmacy10 Abuse & Neglect9

Most common F-tags at this facility

F6004 F6844 F7254 F8124 F9254

Citation history

112 on record
SurveyF-TagViolationSeveritySource
Jan 22, 2026F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.DComplaint
Jan 22, 2026F627Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.DComplaint
Jan 22, 2026F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.DComplaint
Sep 10, 2025F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.DComplaint
May 12, 2025F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.FStandard
May 12, 2025F919Make sure that a working call system is available in each resident's bathroom and bathing area.EStandard
May 12, 2025F887Educate 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.BStandard
May 12, 2025F883Develop and implement policies and procedures for flu and pneumonia vaccinations.DStandard
May 12, 2025F880Provide and implement an infection prevention and control program.DStandard
May 12, 2025F865Have a plan that describes the process for conducting QAPI and QAA activities.FStandard
May 12, 2025F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.FStandard
May 12, 2025F809Ensure 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 eat at non-traditional times or outside of scheduled meal times.EStandard
May 12, 2025F761Ensure 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 locked, compartments for controlled drugs.EStandard
May 12, 2025F759Ensure medication error rates are not 5 percent or greater.DStandard
May 12, 2025F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.EStandard
May 12, 2025F732Post nurse staffing information every day.CStandard
May 12, 2025F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.EStandard
May 12, 2025F692Provide enough food/fluids to maintain a resident's health.DStandard
May 12, 2025F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.JStandard
May 12, 2025F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.GStandard
May 12, 2025F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.EStandard
May 12, 2025F679Provide activities to meet all resident's needs.DStandard
May 12, 2025F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.DStandard
May 12, 2025F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.DStandard
May 12, 2025F641Ensure each resident receives an accurate assessment.DStandard
May 12, 2025F637Assess the resident when there is a significant change in conditionDStandard
May 12, 2025F636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.DStandard
May 12, 2025F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.DStandard
May 12, 2025F605Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.DStandard
May 12, 2025F584Honor 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.DStandard
May 12, 2025F578Honor 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.DStandard
May 12, 2025F558Reasonably accommodate the needs and preferences of each resident.EStandard
May 12, 2025F552Ensure that residents are fully informed and understand their health status, care and treatments.DStandard
May 12, 2025F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.DStandard
Apr 17, 2025F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.EComplaint
Apr 17, 2025F677Provide care and assistance to perform activities of daily living for any resident who is unable.EComplaint
Apr 17, 2025F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.GComplaint
Dec 18, 2024F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.FComplaint
Sep 26, 2024F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.DComplaint
Sep 26, 2024F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.DComplaint
Mar 19, 2024F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.FComplaint
Mar 19, 2024F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.EComplaint
Mar 19, 2024F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.FComplaint
Mar 19, 2024F835Administer the facility in a manner that enables it to use its resources effectively and efficiently.FComplaint
Mar 19, 2024F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.DComplaint
Mar 19, 2024F625Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.DComplaint
Mar 19, 2024F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.DComplaint
Mar 19, 2024F919Make sure that a working call system is available in each resident's bathroom and bathing area.EStandard
Mar 19, 2024F887Educate 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.DStandard
Mar 19, 2024F883Develop and implement policies and procedures for flu and pneumonia vaccinations.DStandard
Mar 19, 2024F881Implement a program that monitors antibiotic use.FStandard
Mar 19, 2024F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.FStandard
Mar 19, 2024F761Ensure 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 locked, compartments for controlled drugs.EStandard
Mar 19, 2024F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.DStandard
Mar 19, 2024F757Ensure each resident’s drug regimen must be free from unnecessary drugs.DStandard
Mar 19, 2024F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.EStandard
Mar 19, 2024F740Ensure each resident must receive and the facility must provide necessary behavioral health care and services.DStandard
Mar 19, 2024F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.EStandard
Mar 19, 2024F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.GStandard
Mar 19, 2024F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.EStandard
Mar 19, 2024F688Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.DStandard
Mar 19, 2024F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.DStandard
Mar 19, 2024F677Provide care and assistance to perform activities of daily living for any resident who is unable.DStandard
Mar 19, 2024F660Plan the resident's discharge to meet the resident's goals and needs.DStandard
Mar 19, 2024F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.DStandard
Mar 19, 2024F641Ensure each resident receives an accurate assessment.EStandard
Mar 19, 2024F637Assess the resident when there is a significant change in conditionDStandard
Mar 19, 2024F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.DStandard
Mar 19, 2024F622Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.DStandard
Mar 19, 2024F565Honor the resident's right to organize and participate in resident/family groups in the facility.EStandard
Mar 19, 2024F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.DStandard
Mar 19, 2024F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.DStandard
Feb 9, 2024F610Respond appropriately to all alleged violations.BComplaint
Feb 9, 2024F558Reasonably accommodate the needs and preferences of each resident.DComplaint
May 17, 2023F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.FComplaint
May 17, 2023F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.FComplaint
May 17, 2023F802Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.FComplaint
May 17, 2023F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.EComplaint
May 17, 2023F610Respond appropriately to all alleged violations.DComplaint
May 17, 2023F585Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.FComplaint
May 17, 2023F584Honor 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.EComplaint
Dec 22, 2022F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.EStandard
Dec 22, 2022F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.EStandard
Dec 22, 2022F887Educate 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.EStandard
Dec 22, 2022F883Develop and implement policies and procedures for flu and pneumonia vaccinations.EStandard
Dec 22, 2022F880Provide and implement an infection prevention and control program.EStandard
Dec 22, 2022F849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.DStandard
Dec 22, 2022F839Employ staff that are licensed, certified, or registered in accordance with state laws.DStandard
Dec 22, 2022F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.FStandard
Dec 22, 2022F761Ensure 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 locked, compartments for controlled drugs.DStandard
Dec 22, 2022F759Ensure medication error rates are not 5 percent or greater.DStandard
Dec 22, 2022F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.EStandard
Dec 22, 2022F744Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.EStandard
Dec 22, 2022F730Observe each nurse aide's job performance and give regular training.DStandard
Dec 22, 2022F727Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.DStandard
Dec 22, 2022F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.EStandard
Dec 22, 2022F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.EStandard
Dec 22, 2022F698Provide safe, appropriate dialysis care/services for a resident who requires such services.DStandard
Dec 22, 2022F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.DStandard
Dec 22, 2022F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.EStandard

Federal enforcement history

Federal regulators have imposed 5 enforcement actions against this facility, including 3 civil money penalties totaling $140,507 and 2 payment-denial actions spanning 154 days.

DateTypeFinePayment denial
Apr 17, 2025Fine$51,094—
Apr 17, 2025Payment Denial—May 15, 2025 · 99 days
Feb 9, 2024Fine$82,071—
Feb 9, 2024Payment Denial—Apr 12, 2024 · 55 days
May 2, 2023Fine$7,342—
About this record A citation is a finding by a state survey team working under federal contract. It is not a court judgment. The description above is drawn verbatim from federal public datasets. Facilities have the right to appeal findings through an Informal Dispute Resolution (IDR/IIDR) process.

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