Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 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 failed to complete annual performance reviews for five CNAs reviewed, with personnel records showing no performance reviews for any of them. The NHA stated performance reviews had not been done since prior to COVID and that competencies were considered enough for staff who remained employed. Facility policy requires CNA performance reviews at least every 12 months, with in-service training based on review findings.
Food service area deficiencies were observed involving a kitchen hand sink that drained slowly, a walk-in freezer with ice condensation buildup on the ceiling and fan cover, and an in-line water filter for the ice machine with a discharge line running directly into the floor drain without an air gap. The DM stated the hand sink had been draining slowly for a while.
A resident with a Foley catheter, UTI, neurogenic bladder, Parkinson’s disease, and dementia was observed receiving wound care and then being transferred with a lift without the required gown use for EBP during the transfer. Staff also handled the catheter drainage bag during the move and held it above the resident before attaching it to the wheelchair. In addition, two water fountains were found out of service, not included in the flushing schedule, and later removed with brown sludge observed at the plumbing openings and in the pipeline.
CNA in-service training hours were below the required 12 hours per employment year for five CNAs. The DON stated the requirement is based on hire date and the facility uses online training, but record review and NHA-provided training printouts showed each of the five CNAs completed only 5.75 to 10 hours during their employment year, which was less than the facility policy minimum.
Improper billing for a room telephone not present. A resident and her DPOA reported the facility kept charging $23 for a phone the resident was not using, and no phone was observed in the room. Staff gave conflicting statements about whether the resident had a phone, while the billing statement still showed a phone charge.
A resident did not have a NOMNC on file, and staff confirmed they could not locate it after searching. The survey reviewed residents discharged within the last six months and found the facility did not provide timely notice about pending Medicare coverage changes and the right to appeal, despite policy requiring timely Medicare eligibility and coverage notices.
A resident with end stage lung cancer and severe, near-constant pain was prescribed Morphine Sulfate ER 30 mg BID. After the first dose was given from the back-up Cubex supply, the resident’s son reported that the evening dose was not administered. Investigation showed an RN removed two 15 mg tablets from Cubex, but the dose was not documented on the MAR, the medication could not be accounted for, and the RN did not cooperate with the inquiry, leading the facility to suspect diversion of the resident’s pain medication.
Failure to provide transfer, bed-hold, and receiving-provider information: The facility did not document written transfer or bed-hold notices for multiple residents sent to the hospital, and transfer paperwork was incomplete. For residents with complex needs, including CHF, CKD, AFib, severe cognitive impairment, diabetes monitoring, pressure injuries, a urinary catheter, and suspected sepsis, the records lacked key details such as baseline status, diagnoses, meds and last doses, diet, labs, and other information needed by the receiving ED provider.
Failure to document wound assessments and complete ordered pressure injury treatments. A resident with bilateral buttock pressure injuries was observed sitting in a recliner without a pressure reduction cushion, and later had a DTI on one buttock and a stage 2 pressure injury on the other. The EMR showed wound documentation early on, but no further wound or skin assessments after the last recorded assessment, even after the wounds worsened following a hospital stay. The TAR also showed ordered wound treatments were missed on multiple days and there was no documentation that the treatments were completed, refused, or otherwise unable to be done.
Unsafe Hot Water Temperature at Resident-Accessible Hand Sink: The facility failed to maintain safe hot water temperatures at a resident-accessible hand sink in the Trillium Dining Room. The DM stated the sink could be used by residents, yet the water temperature measured 147 degrees, and record review showed the sink was not routinely monitored or documented on a log sheet. Three residents were observed in the dining room, including one in a wheelchair passing directly in front of the sink.
A resident returned from the hospital with a Foley catheter, but the chart did not document a medical condition justifying continued use. The resident said he did not know why he had the catheter, staff confirmed he had not had one before hospitalization and had no history of urinary retention, and the EMR, physician orders, and hospital records did not identify a qualifying clinical indication.
Damaged exterior door sweeps were observed at the maintenance door and vendor entrance door, including a missing sweep and visible daylight under the door. The Maintenance Director said the facility had occasional mice and believed they were coming from attic areas, with pest traps kept up there.
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.
Missing Annual CNA Performance Reviews
Penalty
Summary
The facility failed to complete annual performance reviews at least every 12 months for five Certified Nurse Aides, identified as B, J, K, L, and M, all of whom were reviewed for performance evaluations. Personnel record review showed CNA B was hired on 11/11/19 with no performance review, CNA J was hired on 1/8/24 with no performance review, CNA K was hired on 11/6/22 with no performance review, CNA L was hired on 11/7/21 with no performance review, and CNA M was hired on 10/13/08 with no performance review. During interview, the Nursing Home Administrator stated that performance reviews had not been completed since prior to COVID and that competencies were considered sufficient for staff who remained employed after COVID. The facility policy titled In-Service Training Program, Nurse Aide states that the facility will complete a performance review of nurse aides at least every 12 months and that in-service training will be based on the outcome of the annual performance reviews.
Food Service Area Sanitation and Equipment Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain best practices in the food service area, with observations showing a kitchen hand sink that was slow to drain after handwashing, a walk-in freezer with ice condensation buildup on the ceiling and fan cover, and an in-line water filter for the ice machine with a discharge line extending directly into the floor drain without an air gap. The Certified Dietary Manager stated the hand sink had been draining slowly for a while and that a new hand sink was being installed when maintenance could get to it. The compressor fan in the freezer was running and the fan blades were heard hitting the chunk of ice condensation frozen into the fan cover. The observed water filter setup lacked an air gap between the discharge line and the floor drain.
Failure to Use EBP During Catheter Care and Transfer; Plumbing Control Deficiencies
Penalty
Summary
The facility failed to ensure the use of Enhanced Barrier Precautions (EBP) and safe handling of an indwelling urinary catheter bag during transfers for one resident with an indwelling catheter. Resident #70 had diagnoses including UTI, neurogenic bladder, Parkinson’s disease, and dementia, and had returned to the facility after hospitalization for urosepsis with a urinary catheter in place. The resident’s MAR included an order for enhanced barrier precautions related to the Foley catheter, and the care plan directed staff to use EBP during prolonged close contact such as dressing, bathing, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting. During observation, a wheeled cart with PPE and a CDC EBP sign was positioned at the resident’s doorway. CNA N and RN O provided wound care, after which RN O removed gown and gloves, performed hand hygiene, and applied clean gloves but no protective gown. RN O then assisted with turning the resident and positioning a lift sling for transfer. CNA N unhooked the dependent drainage bag from the bed frame and held it in her hand while moving the resident with the lift, with the bag held approximately 12 inches above the resident until the resident was lowered into the wheelchair. RN O did not don a protective gown during the transfer. The facility also failed to follow through with its plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing. Two water fountains on Lilac Lane were observed covered with plastic bags and out of order signs, and the Maintenance Director stated they had not been used since 2020 and that the water to the fountains had been disconnected. When he pushed the buttons, water came out of the nozzles. The flushing schedule did not include the water fountains. Later, the fountains were removed and brown sludge was observed running down the walls from the plumbing openings, and a brown sludge-like substance was observed in the bottom of the water pipeline where a fountain had been uninstalled.
CNA In-Service Training Hours Below Required Minimum
Penalty
Summary
The facility failed to ensure that five CNAs completed no less than 12 hours of in-service training per employment year based on their hire dates. During interview, the DON stated the 12-hour training requirement is based on the CNA's hire date and acknowledged the facility uses online training. Record review showed CNA B had 9.25 hours of training from 11/11/24-11/2/25, CNA J had 5.75 hours from 1/8/24-1/8/25, CNA K had 7.25 hours from 11/6/24-11/7/25, CNA L had 9.25 hours from 11/7/24-11/8/25, and CNA M had 10 hours from 10/13/24-10/31/25. The NHA provided online training printouts that verified these totals. The facility policy titled In-Service Training Program, Nurse Aide, stated annual in-services must be no less than 12 hours per employment year based on hire date.
Improper Billing for a Room Telephone Not Present
Penalty
Summary
The facility billed Resident #25 for a personal room telephone even though no telephone was present in the resident’s room. During a room visit, the resident and her Durable Power of Attorney stated they were concerned about improper billing for telephone services and reported that the facility continued to charge them for a phone the resident was not using. The DPOA said the resident had been in the facility since the prior November, that he had paid the bills, and that he had spoken with the office about the charge each month. On inspection of the room, no telephone was present. An Administrative Staff member stated that residents not on skilled care were charged $23.00 for a telephone and said the admission packet should explain that, but also stated that if no phone was in the room there would not be a charge to the resident’s bill. The staff member initially stated the resident had a phone based on a recent audit, while a CNA said she did not think the resident ever had a phone and an LPN stated the resident had a phone when first admitted but it was removed because she could not hear out of it and could not use it. The billing statement for 5/1/2026 was reviewed and contained a $23.00 charge for Phone.
Failure to Provide Medicare Non-Coverage Notice
Penalty
Summary
The facility failed to provide information about pending changes in Medicare coverage and the resident’s right to appeal for one resident, R81, out of three residents reviewed for receipt of a Notice of Medicare Non-coverage (NOMNC). During the survey, the Beneficiary Notice - Residents discharged within the Last Six Months worksheet showed 14 residents discharged, and three residents were selected to determine whether timely NOMNCs had been provided. On interview, Administrative Staff A stated that she did not find a NOMNC for R81, and on follow-up she confirmed, “We looked high and low and do not have it.” The facility policy titled Advance Beneficiary Notice, last revised 12/16/2025, stated that it is the policy of the facility to provide timely notices regarding Medicare eligibility and coverage.
Suspected diversion of a resident’s morphine dose
Penalty
Summary
The facility failed to ensure a resident was free from misappropriation of property when a scheduled dose of controlled pain medication was not accounted for and was suspected to have been diverted. Resident #75 was admitted with end stage lung cancer and hospice services, and the MDS documented that he had pain almost constantly, that pain almost constantly interfered with sleep, and that his worst pain was severe. On the evening of the event, the resident was moved to a different neighborhood to allow family to stay overnight. A new order for Morphine Sulfate ER 30 mg twice daily was to begin that morning, and the first dose was given from the back-up Cubex supply because the routine pharmacy medication had not yet arrived. Later that evening, the resident’s son asked an RN about his father’s pain medication and was told the long-acting medication could not be given until after midnight when the pharmacy delivery arrived. The next morning, the son reported to the Neighborhood Coordinator that the medication had not been administered. The facility investigation found that the day shift nurse had witnessed the night shift nurse remove two Morphine Sulfate ER 15 mg tablets from the Cubex for the evening dose, but did not witness administration. The night nurse stated she removed the tablets, could not locate the order on the MAR, and later claimed she administered the medication while the resident’s son was present but intentionally did not document it. The MAR showed the evening dose remained incomplete, and the Cubex access record showed the tablets were removed by the night nurse and the day nurse. Because the medication was not found, destroyed, wasted, or reported lost, and the night nurse refused to cooperate with the investigation and did not complete requested drug testing, the facility suspected the medication had been diverted.
Failure to Provide Transfer, Bed-Hold, and Receiving-Provider Information
Penalty
Summary
The facility failed to provide written notifications of transfer and bed hold for residents who were sent to the hospital, and it also failed to document or provide the required resident-specific information to the receiving provider. For Resident #13, who had diagnoses including heart failure, atrial fibrillation, chronic kidney disease, and a cardiac pacemaker, the record showed a transfer to the hospital after shortness of breath, productive cough, diaphoresis, and use of accessory muscles for breathing. The chart did not contain written transfer or bed-hold notifications, and the Interact SNF/NF to Hospital Transfer Form was incomplete, lacking information such as usual functional status, primary admission diagnosis, indwelling urinary catheter, pressure injuries, medications and last doses, diet order, insulin use, bleeding risk from anticoagulant therapy, and relevant lab or diagnostic information. For Resident #8, who was admitted with debility and cardiorespiratory conditions and had severe cognitive impairment, staff transferred the resident to the ED for hematochezia. The Interact Transfer Form did not include the resident’s primary admission diagnosis, usual functional and mental/cognitive status, diet order, or medication information including the date and time of last administration. Written notifications of transfer and bed hold were not found in the record, and there was no documentation showing what resident-specific information was provided to the ED. For Resident #70, the record showed an emergent transfer to an acute care hospital for suspected sepsis, followed by hospitalization and return to the facility. The EMR contained no evidence that written notification of transfer/discharge or written notification of the facility’s bed-hold policy was provided to the resident or representative for that transfer. During interview, the Neighborhood Coordinator stated nursing did not provide written notifications and instead gave verbal information at the time of transfer regarding the need for transfer and whether the resident wanted to hold a bed.
Failure to document wound assessments and complete ordered pressure injury treatments
Penalty
Summary
The facility failed to ensure pressure injury assessments and wound measurements were consistently documented for a resident with bilateral buttock pressure injuries. The resident was admitted with two stage 2 pressure injuries on the buttocks, later returned from the hospital with worsening wounds, and was observed sitting in a recliner without a pressure reduction cushion beneath him. When repositioned for wound care, he was noted to have a shallow linear dark purple area of deep tissue injury on the left buttock and a linear stage 2 pressure injury on the right buttock. The electronic medical record showed wound documentation on admission and again after the hospital return, including measurements and descriptions of worsening pressure/shearing wounds. After that, no wound assessments, wound monitoring, or skin assessments were documented. The nurse manager reviewed the record and confirmed that no wound assessments, wound monitoring, or skin assessments had been completed since the last documented assessment, despite the wounds having worsened after the hospital stay. The treatment record also showed that physician-ordered wound treatments were not consistently completed or documented. Daily treatments were ordered after admission, but the record showed they were completed only twice before the resident went to the hospital. In May, ordered treatments were not documented as completed on multiple days, including after the order changed to twice daily treatments. There was no documentation showing the missed treatments were performed, refused, or otherwise unable to be completed. The DON stated wounds were expected to be assessed weekly and treatments completed as ordered and documented on the TAR.
Unsafe Hot Water Temperature at Resident-Accessible Hand Sink
Penalty
Summary
The facility failed to maintain safe water temperatures in the resident environment. On 05/11/2026 at 12:42 PM, the Dietary Manager stated that hot water at a hand sink should not be above 140 degrees, then corrected herself and said it should not be above 120 degrees. A temperature taken at the hot water hand sink in the Trillium Dining Room measured 147 degrees, and the Dietary Manager stated that this sink could be used by residents. Three residents were observed in the dining room, and a resident in a wheelchair was seen passing directly in front of the hand sink. Record review showed that this sink temperature was not monitored or documented on a routine log sheet.
Lack of Documentation Supporting Continued Foley Catheter Use
Penalty
Summary
The facility failed to ensure the clinical record documented a medical condition justifying the continued use of an indwelling urinary catheter for one resident. Resident #8 was observed with catheter tubing draining light yellow urine with sediment, and the resident said he did not know why he had the catheter. The record showed he was transferred to the hospital without a urinary catheter and returned with one, but the prior MDS documented him as always continent of bowel and bladder and did not indicate catheter use before hospitalization. Review of the resident’s EMR, including the comprehensive assessment, care plan, progress notes, physician documentation, and hospital records, did not identify a qualifying medical condition supporting continued catheter use. The physician order for catheter changes did not include a diagnosis, clinical condition, or reason for the catheter, and a diagnosis of urinary retention added after the hospital return was not supported by documentation. Staff interviews confirmed the resident had not had a catheter before hospitalization, had no history of urinary retention, and there was no trial discontinuance after readmission; the nurse manager also stated the record did not contain documentation supporting the catheter’s continued use.
Damaged Exterior Door Sweep
Penalty
Summary
The facility failed to maintain general repair of an exterior door, with the missing door sweep at the base of the maintenance door and approximately a half inch of daylight visible underneath. The exterior door sweep on the vendor entrance door was also damaged and partially detached from the base. During interview, the Maintenance Director stated that the facility had occasional mice and believed they were entering from attic areas, with pest traps kept up there to prevent pests from getting down into the facility.
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
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Illustrative
What surveyors actually found near you
We read the 25 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
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Illustrative
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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 | ★★★★★ | 9 | 0 |
| Grandvue Medical Care Facility | 18.8 mi | ★★★★★ | 13 | 0 |
| Medilodge Of Cheboygan | 27.4 mi | ★★★★★ | 13 | 0 |
| Medilodge Of Gaylord | 30.8 mi | ★★★★★ | 13 | 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 August 2026) and official state health department websites.