Pinnacle Care of Battle Creek

In the surveyor’s words

From the most serious findings on record at Pinnacle Care of Battle Creek, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689May 12, 2025

  This citation has two separate DPS's: A and B. DPS A) Based on observation, interview, and record review, the facility failed to ensure hot water temperatures were in the comfortable range of 100-120 degrees Fahrenheit for two of 20 residents who resided in the dementia unit (Resident #31 and 39), resulting in Immediate Jeopardy when R31, who was independent with ambulation had a bathroom water temperature of 150 degrees Fahrenheit; and R39 who and was independent with ambulation, had a bathroom water temperature of 144.6 degrees Fahrenheit; and 2) facility wide resident bathroom water temperatures that tempted at greater than 120 degrees Fahrenheit with potential for second and/or third degree burns. […]

• Actual harm, isolatedF600Jun 18, 2026

  Based on observations, interviews, and record review the facility failed to protect the resident's (Resident #1) right to be free from physical abuse by Resident #2. Findings Included:This citation pertains to intake number 3032111. Resident #1 (R1): Review of R1's electronic medical record (EMR) revealed R1 was a [AGE] year-old male who was admitted to the facility on [DATE]. Diagnoses included repeated falls and muscle weakness, Resident #2 (R2): Review of R2's EMR revealed R2 was a [AGE] year-old male who was admitted to the facility on [DATE]. Diagnoses included psychotic disturbance, vascular dementia, severe, with behavioral disturbance. […]

• Actual harm, isolatedF686May 12, 2025

  Based on observation, interview and record review the facility 1) failed to implement and update Physician orders, 2) accurately assess and document a pressure ulcer, 3) failed to ensure pressure ulcer prevention interventions were implemented, 4) failed to adequately assess and treat pain prior to wound care and 5) failed to prevent the development of pressure ulcers for 2 (Resident #11, Resident #20) out of 3 reviewed for pressure ulcers resulting in worsening of a pressure ulcer, unrelieved pain during wound care, and an increased risk of further skin breakdown. […]

• Actual harm, isolatedF600Apr 17, 2025

  This citation pertains to MI00149061 and MI00151480 Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from abuse for three of nine residents reviewed, resulting in resident-to-resident physical abuse, bruising for R11, bruising and bleeding for R12, and a head laceration requiring sutures and hospital admission for R17. Findings include: Review of the facility reported incident (involving R11 and R12) revealed on [DATE] While these residents were playing bingo, (R11) attacked (R12). R11 wheeled his wheelchair behind R12 and then started hitting him and biting him. R12 did not retaliate and was hit twice and bit twice. […]

• Actual harm, isolatedF690Mar 19, 2024

  Based on observation, interview and record review, the facility failed to provide appropriate monitoring and treatment for a resident experiencing symptoms of repeat Urinary Tract Infection (UTI), for 1 resident (R18) of 2 residents reviewed for UTI, resulting in a lack of monitoring, a delay in the treatment of a UTI, hospitalization , and sepsis (a life threatening complication of infection.) Findings include: Review of the facility, Antibiotic Stewardships Program Policy, dated 12/1/23, reflected, Policy: It is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. […]