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 Bay Bluffs-emmet County Medical Care Facility during CMS and state inspections, most recent first.
The facility did not maintain required inspection, testing, and maintenance records for its automatic sprinkler and standpipe systems as per NFPA 25, and failed to provide key information about system checks and water supply sources.
Surveyors observed that both generator annunciator panels showed a high battery voltage warning, and the facility's generator contractor could not determine the cause, even though battery levels were reported as normal. This failure to resolve the generator alert meant the facility did not meet required maintenance standards for its essential electrical system.
A deficiency was found when the wildflower clean linen room door did not self-close or positively latch during three tests, as required for hazardous areas. This noncompliance with NFPA 101 standards was confirmed by the Maintenance Director and could affect 38 occupants in the event of a fire.
Surveyors found that the facility failed to properly label and date opened food items, did not discard expired foods, and did not consistently test high-temperature dish machines for sanitization. Staff were observed entering food service areas without proper hair restraints and did not consistently perform hand hygiene after potential contamination. Additionally, sanitation solutions for cleaning surfaces were not properly tested or maintained, and staff demonstrated inadequate understanding of testing procedures.
The facility did not update care plans for two residents to reflect their current needs and preferences. One resident's care plan listed them as full code despite documented DNR status, and another resident's care plan lacked new interventions after a decline in health and the development of pressure injuries. Staff confirmed that care plans should have been revised to match physician orders and changes in condition.
A resident at risk for pressure ulcers developed deep tissue injuries on both heels after spending increased time in bed, without the care plan being updated to include preventive interventions such as floating heels. Staff confirmed that no new measures were implemented despite the resident's decline, resulting in the development of unstageable and discolored pressure injuries.
A resident did not receive a required monthly medication regimen review by a licensed pharmacist, as confirmed by record review and staff interview. An audit revealed that three residents in total were missed for pharmacy MRRs during the same period, despite facility policy requiring monthly reviews.
The facility failed to prevent unauthorized access to its medication storage rooms by allowing housekeeping staff to retain keys and access these rooms without a licensed nurse in attendance. Interviews revealed a lack of awareness and control over access protocols, contrary to the facility's policy.
A resident with Alzheimer's and dementia was left unsupervised and entered an unlocked janitor's closet, resulting in a fall. The facility's safety measures were inadequate, with multiple areas having faulty locks, exposing residents to potential hazards.
Deficiency in Sprinkler System Maintenance and Documentation
Penalty
Summary
The facility failed to ensure that automatic sprinkler and standpipe systems were inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Required records of system design, maintenance, inspection, and testing were not maintained in a secure location and were not readily available for review. The report also notes missing information regarding the date the sprinkler system was last checked, the provider of the system test, and the water system supply source. Additionally, there is no information provided in the remarks section regarding coverage for any non-required or partial automatic sprinkler system. These omissions resulted in noncompliance with regulatory requirements for fire protection system maintenance and documentation.
Deficient Maintenance of Emergency Power System
Penalty
Summary
The facility failed to ensure that generators and their components, or other alternative power sources, were maintained as required by regulatory standards. During observations on two separate occasions, both generator annunciator panels displayed an illuminated "battery voltage" light, indicating a high voltage level. Despite this alert, the generator contractor was unable to determine the cause, although they confirmed that the battery levels were within normal range. This issue was identified through direct observation and interview with the Maintenance Director. The deficiency was noted because the facility did not meet the requirements for maintenance and testing of the essential electrical system, as outlined by NFPA standards. Specifically, the presence of the high voltage indicator on the generator annunciator panels was not resolved, and the underlying cause remained undetermined at the time of the survey. This failure could potentially affect all occupants in the event of a power failure, as the reliability of the emergency power system was not assured.
Plan Of Correction
Bay Bluffs maintains compliance with NFPA 101 requirements related to maintenance of emergency generator and other essential electrical systems. All residents and staff have the potential to be impacted if essential electrical systems are not functioning properly. On May 2, 2025, Cummins Bridgeway completed maintenance on the generator and attempted to complete work to address the generator battery voltage light on the annunciator panels. Unfortunately, due to a faulty panel, work could not be completed at that time. New panels were ordered, and a temporary waiver was requested of LARA on May 15, 2025, via email. On June 18, 2025, Cummins Bridgeway was able to complete repairs on the annunciator panels, which eliminated the error message on both panels and on the generator itself. Monitoring of the generator annunciator panels will take place during monthly safety rounds by the Plant Operations Director or designee. The Plant Operations Director is responsible for coordination and monitoring of this plan of correction.
Failure of Hazardous Area Door to Self-Close and Latch
Penalty
Summary
A deficiency was identified when the door to the wildflower clean linen room failed to close and positively latch during three separate tests. This observation was made during a facility inspection and was confirmed by the Maintenance Director at the time. The report specifies that hazardous areas, such as linen rooms, are required to have doors that are self-closing or automatic-closing to comply with NFPA 101 standards. The failure of the door to function as required represents noncompliance with these fire safety regulations. The deficiency could potentially affect 38 occupants in the event of a fire, as noted in the findings, but no specific details about individual residents or their medical conditions are provided in the report.
Plan Of Correction
All residents have the potential to be affected by deficient practices related to fire safety compliance. On June 16, 2025, the door to the Wildflower clean linen closet was adjusted through tightening of the door latch mechanism. Following this, the door latched properly 3 out of 3 times when tested by the Maintenance Director, as observed by the Administrator. Monitoring of door structure function and proper latching of hazardous area doors will continue to be included in regular safety rounds and on the annual door inspection completed by the Plant Operations Director, with any deficient items reported for replacement or repair.
Deficient Food Service Practices and Infection Control
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's food service operations, including improper labeling and dating of food products. During inspections of the main kitchen and satellite kitchens, opened food items such as pancakes, waffles, half and half, liquid egg mix, and milk were found without use-by dates or proper labeling. Some food items were left uncovered or unsealed, and expired foods were not discarded as required. The Certified Dietary Manager confirmed that all opened food products should be labeled and discarded according to policy, but this was not consistently followed. The facility also failed to ensure that high-temperature dish machines were routinely tested for proper sanitizing of food contact surfaces. Review of the dishwasher temperature log revealed multiple missing entries for meal services over the past month, indicating that required temperature checks were not consistently performed. Additionally, the kitchen area was not adequately restricted to food service staff during meal service, as an unidentified staff member entered the kitchen without a hair net, and another staff member was observed with loose hair hanging out of a hair net while working on the service line. Hand hygiene practices were not consistently followed by staff. Observations included staff members picking up items from the floor, coughing into their hands, and then handling food or utensils without performing hand hygiene. Sanitation buckets used for cleaning meal preparation countertops and dining room surfaces were not properly tested or maintained at the correct concentration, as indicated by test strips showing out-of-compliance results. Staff responsible for these tasks demonstrated a lack of understanding of proper testing procedures, and the facility's own policies and manufacturer guidelines for sanitizing solutions were not adhered to.
Failure to Update Care Plans to Reflect Resident Needs and Preferences
Penalty
Summary
The facility failed to revise and update care plans to accurately reflect the current needs and preferences of two residents. For one resident, although there was a physician order and a signed document indicating a Do Not Resuscitate (DNR) status, the care plan incorrectly stated that the resident was a full code and wished to be sent to the hospital for respiratory illness. The Director of Nursing confirmed that the care plan should have matched the resident's advanced directives and physician orders, but it did not. For another resident who experienced a decline in health, including increased time spent in bed and the development of two deep tissue pressure injuries, the care plan did not include new interventions to address the increased risk of skin breakdown, such as floating heels. The wound treatment nurse confirmed that the care plan should have been updated to reflect the resident's change in condition and to include additional pressure reduction interventions. Facility policy requires that care plans be revised as residents' conditions change, but this was not done in these cases.
Failure to Update Care Plan and Prevent Pressure Ulcers
Penalty
Summary
A resident who was identified as being at risk for pressure ulcers, as indicated by their Minimum Data Set (MDS) assessment and Braden scale, developed deep tissue injuries (DTIs) on both heels after experiencing a decline in health and spending increased time in bed. The resident's care plan, which noted their risk for skin breakdown due to decreased mobility and incontinence, did not include updated interventions such as floating heels, despite the resident's change in condition and increased immobility. Progress notes and staff interviews confirmed that no new preventive measures were implemented when the resident's health status declined. The wound treatment nurse acknowledged that the care plan should have been updated to include heel-floating interventions and that the pressure injuries were avoidable. Observations revealed the presence of an unstageable pressure injury on the left heel and skin discoloration on the right heel, with the left heel requiring a dressing. The lack of timely intervention and care plan updates led to the development of these pressure injuries.
Missed Monthly Pharmacy Medication Regimen Review
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed a monthly medication regimen review (MRR) for one resident out of five reviewed for pharmacy services. Review of pharmacy consultation progress notes showed that the resident did not have a pharmacy MRR completed for the month of October 2024. During interviews, the DON was unable to locate the MRR for that month and later confirmed through an audit that the review had not been completed. The DON also revealed that a total of three residents were overlooked for pharmacy MRRs during the same period. Facility policy requires that the consultant pharmacist review the medication regimen of each resident at least monthly, but this was not followed for the identified residents.
Unauthorized Access to Medication Storage Rooms by Unlicensed Personnel
Penalty
Summary
The facility failed to prevent unauthorized access to its three medication storage rooms by allowing unlicensed personnel, specifically housekeeping staff, to retain keys and access these rooms. On multiple occasions, the Housekeeping Supervisor and other housekeeping staff were observed using magnetic swipe-cards to enter the medication storage rooms without a licensed nurse in attendance. These rooms contained various medications and biological agents, including ophthalmic solutions, insulins, syringes, and over-the-counter medications. Housekeeping staff confirmed that they had access to these rooms for cleaning purposes and were not accompanied by nurses during these tasks. Interviews with the Registered Nurse, Nursing Home Administrator, and Director of Nursing revealed a lack of awareness and control over who had access to the medication storage rooms. The Nursing Home Administrator was surprised to learn that housekeeping staff had access, while the Director of Nursing was unsure about the access protocol. The facility's policy on the storage of medications clearly stated that only authorized personnel, specifically those preparing and administering medications, should have access to the medication rooms. This discrepancy between policy and practice led to the identified deficiency.
Resident Safety and Supervision Failure
Penalty
Summary
The facility failed to ensure supervision and safety for a resident with a history of unsafe wandering, resulting in the resident entering a janitor's closet and falling. The incident occurred when the resident, who has Alzheimer's disease and dementia, was left unsupervised and managed to open a janitor's closet door that was supposed to be locked but could be opened without entering a passcode. The resident was found on the floor with her pants pulled down and had urinated, indicating a lack of adequate supervision and safety measures in place to prevent such incidents. The resident's medical record revealed a high risk for falls, with a history of falling and a recent fracture. Despite having a care plan that included measures to keep her safe, such as a wander/elopement alarm and structured activities, the resident was able to wander unsupervised. The video footage confirmed that the resident was in the janitor's closet for approximately 3.5 minutes before being found by staff. Further investigation revealed that other areas in the facility also had faulty locks, including the kitchen storage room and the maintenance storage room, which contained hazardous chemicals. The facility's policy on hazardous areas and equipment was not adequately followed, as evidenced by the unlocked doors and the presence of dangerous chemicals accessible to residents. Interviews with staff confirmed the deficiencies in the facility's safety measures and the potential risks posed to residents with dementia or Alzheimer's disease.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 17 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Harbor Springs
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Villa At The Bay | 4.9 mi | ★★★★★ | 3 | 0 |
| Boulder Park Terrace | 16.9 mi | ★★★★★ | 12 | 0 |
| Grandvue Medical Care Facility | 18.8 mi | ★★★★★ | 2 | 0 |
| Medilodge Of Cheboygan | 27.4 mi | ★★★★★ | 13 | 0 |
| Medilodge Of Gaylord | 30.8 mi | ★★★★★ | 13 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Bay Bluffs-emmet County Medical Care Facility.
100% money-back within 48 hours.
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.