Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Oaks At Battle Creek during CMS and state inspections, most recent first.
A resident reported that food was often served at incorrect temperatures, with hot food being cold and cold food being warm. During an inspection, the Assistant Dietary Manager found that a lunch tray containing a fried chicken sandwich and mixed vegetables was served at temperatures significantly below the required 165 degrees Fahrenheit. Further checks in the kitchen revealed that these items were also below the required temperature, affecting at least half of the facility's residents.
The facility failed to maintain and clean food service equipment, affecting 70 residents. Observations revealed issues such as a cooler door not closing properly, soiled can opener, and accumulated residue on various kitchen equipment. Plumbing issues and improper storage practices were also noted. Staff interviews indicated a lack of awareness about maintenance problems.
A facility failed to maintain effective infection control during wound care and medication administration. A nurse did not follow proper hand hygiene, using the same gloves for clean and soiled tasks, and placed contaminated instruments with clean supplies. The resident involved had multiple health conditions and required moderate assistance. Interviews revealed unclear infection control expectations and inconsistent hand hygiene practices.
A facility failed to advocate for a resident's rights, leading to the resident feeling unheard and experiencing mental anguish. The resident, with multiple diagnoses including cognitive impairment, wanted to change their guardian and have their fiancée as their Durable Power of Attorney. The facility did not assist in this process, and the resident was not informed about discharge plans. The resident was sent to the emergency room for suicidal ideation due to restricted visits from their fiancée. Facility staff were unaware of the process for changing guardianship, contributing to the resident's distress.
The facility failed to provide necessary Medicare and SNF Advance Beneficiary Notices to residents, resulting in a deficiency. A resident did not receive the required notices for a change in payor source, and the LNHA could not verify or explain the oversight. Another resident received a NOMNC but not the SNFABN, while a third resident did not receive either notice. These issues were identified through interviews and record reviews.
A resident's medical records were exposed when an LPN left a computer screen unlocked on a medication cart in the hallway. The screen, displaying the resident's profile, was visible to passersby. Despite being questioned, the LPN left the screen unlocked multiple times, citing a change in settings as the cause. The DON confirmed that staff are expected to secure screens to protect resident confidentiality.
A facility failed to create a person-centered care plan for a resident on anti-psychotic medication. Despite recommendations, the care plan lacked details on targeted behaviors, non-drug interventions, and behavior monitoring. Staff interviews revealed a lack of understanding of the resident's behaviors and the medication's purpose, with wandering incorrectly cited as a reason for the medication.
A resident with multiple health conditions, including stroke and depression, was not provided with meaningful activities due to staff delays in assistance, leading to potential boredom and loneliness. The resident's participation in activities was minimal, with inconsistent documentation, and personal visits were marked as activities. The DON acknowledged the need for timely assistance to enable participation in activities.
The facility failed to effectively clean and maintain food service equipment, impacting 68 residents. Observations included soiled fryer interiors, damaged microwave surfaces, encrusted food residue on mixers, and a leaking mop sink basin faucet. These deficiencies increased the likelihood of cross-contamination and bacterial harborage.
The facility failed to ensure proper communication and documentation of hospice services for a resident with severe cognitive impairment, resulting in a lack of coordination of comprehensive care. Nursing staff were not informed about hospice schedules, and there were inconsistencies and delays in the documentation of hospice visits.
Failure to Serve Food at Safe Temperatures
Penalty
Summary
The facility failed to ensure that food was served and held at a palatable temperature, affecting all residents consuming food from the kitchen. During an observation and interview, a resident reported that the food was often served at incorrect temperatures, with hot food being cold and cold food being warm. This resident, who had a moderate cognitive impairment and multiple medical conditions, including type 2 diabetes and hypertension, expressed dissatisfaction with the food temperature. On a specific occasion, the resident was served a lunch tray containing a fried chicken sandwich and mixed vegetables. The temperatures of these items were checked by the Assistant Dietary Manager (ADM) and found to be significantly below the required 165 degrees Fahrenheit, with the chicken at 101 degrees and the vegetables at 113 degrees. Further inspection in the kitchen revealed that the fried chicken and mixed vegetables on the steam table were also below the required temperature, indicating a systemic issue affecting at least half of the facility's residents at that time.
Deficiencies in Food Service Equipment Maintenance and Cleanliness
Penalty
Summary
The facility failed to maintain and clean food service equipment effectively, impacting 70 residents. During an initial tour, it was observed that one of the two doors of a True 2-door reach-in cooler did not close completely, creating an air gap. This issue was not in compliance with the 2022 FDA Model Food Code, which requires equipment to be maintained in a state of repair. Additionally, the can opener assembly was found soiled with food residue, and the Cleveland steamer, South Bend convection ovens, Globe stand mixer, and Pitco fryer were all observed with accumulated and encrusted food residue and grease. Further observations revealed that the main dining room's beverage island base cabinet doors and interior surfaces were soiled with food residue, and the 200 Hall Nourishment Room's dustpan caddy was heavily soiled. The mechanical air curtain above the food service rear entrance was also soiled with dust and dirt deposits. The flooring and wall surfaces adjacent to the Pitco fryer were similarly affected. The private dining room's hand sink basin and vanity surface were soiled, and the 200 Hall Nourishment Room's cabinet drawers were in disarray and soiled, with miscellaneous items stored within them. The facility also had plumbing issues, with a leaking faucet assembly in the two-compartment vegetable preparation sink and a loose-to-mount faucet in the main dining room's hand sink basin. The sugar storage bin in the dry storage room was left partially open, exposing the contents to potential contaminants. Interviews with staff revealed a lack of awareness regarding maintenance issues, and a review of the facility's cleaning procedures indicated that they were not being followed as required.
Infection Control Deficiencies in Wound Care and Medication Administration
Penalty
Summary
The facility failed to adhere to effective infection prevention standards during wound care and medication administration. Specifically, during an observation of wound care on a resident with multiple diagnoses including congestive heart disease and diabetes, the wound care nurse did not follow proper hand hygiene and infection control protocols. The nurse used the same gloves to handle both clean and soiled items, did not sanitize hands between treating different wounds, and placed contaminated instruments back into a container of clean supplies. The resident, who was cognitively intact and required moderate assistance with activities of daily living, had wounds on both feet. During the wound care procedure, the nurse used soiled scissors and gloves to handle clean dressing supplies and did not change gloves or sanitize hands between treating the right and left foot. The nurse also placed clean supplies on a dirty bed sheet, further compromising infection control. Interviews with the Director of Nursing and the Infection Preventionist revealed a lack of clear expectations and adherence to infection control policies. The Infection Preventionist acknowledged that gloves should be changed if soiled, but there was uncertainty about the necessity of changing gloves between different wounds. Additionally, there was a noted deficiency in hand hygiene practices during medication administration, with nurses not consistently using hand sanitizer despite having access to it.
Failure to Advocate for Resident's Rights and Dignity
Penalty
Summary
The facility failed to advocate for a resident's rights, resulting in the resident feeling unheard and experiencing mental anguish. The resident, who was admitted to the facility with multiple diagnoses including aphasia, anxiety, and cognitive impairment, expressed a desire to change their court-appointed guardian and to have their fiancée as their Durable Power of Attorney. However, the facility did not assist the resident in pursuing these changes, and the resident was not informed about their discharge plans. The resident's current guardian, who is also their sister, restricted visits from the fiancée, which contributed to the resident's distress. The resident was sent to the emergency room for suicidal ideation after expressing a desire to harm themselves due to the inability to see their fiancée. Despite being cleared of suicidal ideations and returning to the facility, there was no follow-up by social work until several days later. Interviews with facility staff revealed a lack of awareness and action regarding the resident's rights and the process for changing guardianship. The social worker and Director of Nursing acknowledged the resident's rights but were unsure of the steps to assist the resident in exercising those rights. The facility's inaction and lack of knowledge regarding the resident's rights and guardianship process contributed to the resident's feelings of frustration and decreased quality of life. The social worker and previous social worker did not initiate the process for changing guardianship, and the facility staff did not adequately support the resident in exercising their rights. This deficiency highlights the facility's failure to ensure the resident's dignity and self-determination.
Failure to Provide Required Beneficiary Notices
Penalty
Summary
The facility failed to provide the required Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) to residents, resulting in a deficiency. Specifically, Resident #2 did not receive the NOMNC and SNFABN that were due for completion on 12/02/2024, despite a change in payor source scheduled for 12/04/2024. The Licensed Nursing Home Administrator (LNHA) was unable to verify the completion of these notices and could not explain the oversight. Similarly, Resident #178 received a NOMNC, but the SNFABN was not provided as required. The LNHA could not account for the missing SNFABN. Additionally, Resident #179 did not receive either the NOMNC or SNFABN, which were due on 10/08/2024 for a payor source change on 10/10/2024. The LNHA again could not verify the completion of these notices or provide an explanation for the failure. These deficiencies were identified through interviews and record reviews conducted by surveyors.
Resident Medical Records Exposed Due to Unsecured Computer Screen
Penalty
Summary
The facility failed to ensure the confidentiality of resident medical records for one resident, resulting in exposed medical information. On multiple occasions, the medication cart was observed in the hallway outside the resident's room with the computer screen open and displaying the resident's profile. This information was visible to anyone passing by, and no nurse was present at the time to secure the information. The LPN responsible for the cart, LPN E, was observed leaving the computer screen unlocked on three separate occasions, despite being questioned about the issue. LPN E mentioned that the computer screen was supposed to lock automatically after three seconds, but it did not, possibly due to a change in settings over the weekend. The Director of Nursing (DON) confirmed that the facility's expectation is for no protected health information to be left open or exposed on an unattended computer screen. Staff are expected to lock their screens or close the laptop when leaving the computer unattended. The facility's admission packet also emphasizes the residents' right to personal privacy and confidentiality, including medical treatment and communications. Despite these policies, the failure to secure the computer screen led to a breach of confidentiality for the resident involved.
Failure to Implement Person-Centered Care Plan for Anti-Psychotic Medication
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for a resident (R20) who was prescribed an anti-psychotic medication. R20 was admitted with diagnoses including Alzheimer's disease, unspecified dementia with psychotic disturbance, and depression, and was on an anti-psychotic medication. Despite the pharmacy's recommendations to establish a behavioral monitor and address the use of the medication in the care plan, the facility did not include targeted behaviors, non-drug interventions, or monitoring of behaviors in R20's care plan. The care plan only noted the risk of adverse consequences related to the medication without specifying the symptoms being managed or the interventions tried. Interviews with facility staff revealed a lack of awareness and understanding of R20's behaviors and the rationale for the anti-psychotic medication. The Social Worker (SW) was unable to identify specific behaviors that warranted the medication, and the Director of Nursing (DON) could not explain why a person-centered care plan was not in place. The report highlights that wandering, which was mentioned by the staff, is not an acceptable justification for the use of anti-psychotic medication, indicating a deficiency in the facility's care planning process.
Failure to Provide Meaningful Activities for Resident
Penalty
Summary
The facility failed to provide meaningful activities for a resident who is dependent on staff for transferring and mobility, resulting in potential boredom, lack of stimulation, and loneliness. The resident, who was admitted with diagnoses including stroke, hypertension, coronary artery disease, hemiplegia, malnutrition, depression, and anxiety, expressed that he was unable to participate in activities due to delays in being assisted by staff. Observations revealed that the resident was often left waiting for assistance, impacting his ability to attend meals and activities in a timely manner. Interviews and record reviews indicated that the resident's participation in activities was minimal, with only five activities attempted over several months, and three of those were declined. The documentation of activities was inconsistent, with personal visits and phone calls being marked as activities. The Life Enrichment Director confirmed that activity participation was documented in a separate program, not in the electronic medical records. The Director of Nursing acknowledged the expectation for the resident to be involved in one-on-one programs and to be assisted in time to participate in activities and engage with other residents during meals.
Failure to Maintain Cleanliness of Food Service Equipment
Penalty
Summary
The facility failed to effectively clean and maintain food service equipment, impacting 68 residents. During an initial tour of the food service area, several deficiencies were noted. The Pitco fryer interior and adjacent flooring/wall surfaces were observed to be soiled with accumulated and encrusted grease and dirt deposits. The Panasonic microwave oven had a damaged interior surface and door panel face, exposing the metal subsurface. Both the Globe and KitchenAid stand mixers were found with accumulated and encrusted food residue. Additionally, the Walk-In Freezer refrigeration unit's Freon supply line was observed with accumulated ice. The mop sink basin faucet assembly was also leaking water, which had been an ongoing issue for several days according to the Dietary Manager. The facility's policies and procedures for cleaning the mixers and fryer were reviewed and found to be comprehensive, but the actual cleaning practices did not align with these procedures. The Cooks Cleaning List indicated that the microwave should be cleaned daily and the fryer oil changed weekly, but these tasks were not being performed adequately. The 2017 FDA Model Food Code sections 4-601.11 and 5-205.15 were cited, which require food-contact surfaces and equipment to be clean and plumbing systems to be maintained in good repair. The failure to adhere to these standards increased the likelihood of cross-contamination and bacterial harborage, posing a risk to the residents' health and safety.
Failure to Ensure Proper Communication and Documentation of Hospice Services
Penalty
Summary
The facility failed to ensure proper communication and documentation of hospice services provided to a resident, resulting in a lack of coordination of comprehensive services and care. The resident, a female with severe cognitive impairment due to dementia, was receiving hospice care. However, the nursing staff were not informed about the hospice schedules and did not have access to a calendar or schedule for hospice visits. The Licensed Practical Nurse (LPN) reported that the hospice nurse would inform the facility staff about the schedule only when they arrived, and there was no information provided about visits from the hospice Social Worker, Chaplain, or volunteer. A binder labeled 'Hospice' was observed at the nurse's station, but it was reported to be obsolete as all documentation was electronic. The Director of Nursing (DON) and Social Worker (SW) later presented the binder, which was kept in the SW's office and not accessible to nursing staff on all shifts, including weekends when the office was locked. Further review of the resident's clinical record revealed inconsistencies and delays in the documentation of hospice visits. There were missing entries and delays of up to five weeks in uploading hospice documentation into the resident's medical record. The DON could not account for the missing documentation or the delays and stated that the facility Social Worker was in charge of hospice services. This lack of proper communication and documentation resulted in the failure to coordinate comprehensive hospice care for the resident.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Battle Creek
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Majestic Care Of Battle Creek | 0.2 mi | ★★★★★ | 12 | 0 |
| Pinnacle Care Of Battle Creek | 1.8 mi | ★★★★★ | 15 | 0 |
| The Laurels Of Bedford | 2.6 mi | ★★★★★ | 14 | 0 |
| Calhoun County Medical Care Facility | 3.6 mi | ★★★★★ | 5 | 0 |
| Evergreen Manor Senior Care Center | 4.5 mi | ★★★★★ | 19 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.