Below 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 County Medical Care Facility during CMS and state inspections, most recent first.
Staff failed to follow established transfer care plans for two residents who required extensive assistance and mechanical support, leading to injuries. One resident with dementia, stroke-related hemiplegia, and heart disease, care planned for a two-person assist with transfers, was transferred by a single CNA, resulting in a non-displaced fibular fracture after her leg brace became caught on the wheelchair. Another bedbound resident with Alzheimer’s disease, severe contractures, and total ADL dependence, care planned for a two-person mechanical lift transfer per both the care plan and lift manufacturer guidelines, was transferred by one CNA, left unattended briefly, and was later found on the floor with a head laceration before being returned to bed and sent to the hospital.
A non-verbal, severely cognitively impaired resident was not protected from sexual abuse by another resident with a known history of inappropriate sexual behaviors. The incident occurred in a dining area, where a CNA observed the abuse but did not immediately separate the residents, allowing the contact to continue until a nurse intervened. There was also a prior unreported allegation of similar abuse involving the same individuals, which was not reported to the State Agency.
Two residents developed or experienced worsening pressure ulcers due to the facility's failure to implement timely preventive measures, inadequate documentation, and improper use of pressure-relieving devices. Staff did not promptly assess or document wounds, delayed necessary interventions such as air mattress placement, and demonstrated poor infection control during wound care. Care plans lacked specific instructions, and staff were unclear on proper air mattress settings and protocols.
Staff failed to properly disinfect shared medical equipment and did not follow hand hygiene protocols during wound care for two residents, including one with a recent wound infection and another with a stage 4 open wound requiring enhanced barrier precautions. These lapses resulted in cross-contamination and increased the likelihood of further contamination.
The facility did not update or individualize care plans for several residents, resulting in care plans that lacked current information on pressure injuries, pain management, and specific interventions such as air mattress settings. Observations included improper wound care practices and missing documentation of non-pharmacological pain interventions, with staff interviews confirming gaps in care plan updates and individualized resident information.
The facility did not provide timely responses to call lights, resulting in multiple residents experiencing incontinence and embarrassment while waiting for assistance. Residents reported delays of up to 45 minutes, especially before meals, and group interviews confirmed ongoing concerns about long wait times and inconsistent staff response, including limited help from nurses.
The facility did not inform or educate residents about the location or availability of survey results, and posted documents were inaccessible to those in wheelchairs and lacked the required plan of correction. None of the residents interviewed were aware of the survey results or how to access them.
Surveyors identified unsanitary conditions in food preparation and storage areas, including dirty equipment, food contact surfaces with debris, and improper food labeling. Opened and partly used food items were found without required use-by dates, and some items were past their labeled expiration. Both dietary staff and consultants acknowledged these lapses, which were not in accordance with facility policy or professional standards.
The facility failed to document abdominal/bowel assessments for a resident who received Fleet enemas and did not notify the physician or order timely interventions for another resident with new onset pain and swelling, resulting in delayed diagnosis and treatment of a fracture.
Failure to Follow Transfer Care Plans Resulting in Resident Injuries
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff followed comprehensive care plans for safe transfers for two residents, resulting in injuries. One resident, an 88-year-old with vascular dementia with behaviors, stroke with right-sided hemiplegia and weakness, heart disease, cognitive impairment, and requiring assistance with all ADLs, had a care plan indicating a two-person assist for all transfers. Despite this, on the early morning of 12/27/25, a CNA attempted to transfer the resident from a wheelchair to bed alone. During the transfer, the resident began screaming, was immediately seated on the bed, and later complained of right knee pain with bruising and swelling. An x-ray on the same date showed a non-displaced fracture of the right fibula. The same resident’s care plan, dated 12/18/25, clearly documented the need for a two-person assist for transfers. The facility’s accident/incident report for 12/27/25 also noted that the resident’s leg brace became caught on the wheelchair, preventing her from turning and contributing to the injury. The CNA involved acknowledged in the facility’s investigation that she did not follow the resident’s care plan and transferred the resident by herself. At the time of surveyor observation and interview in late January, the resident was in bed, denied pain, and was unable to recall the incident due to cognitive impairment. A second resident, a 75-year-old who was non-ambulatory, bedbound, required total assistance with all ADLs, and had diagnoses including Alzheimer’s disease, dementia with severe mood disturbance, anxiety, weakness, contractures of the elbows, knees, and left hand, and failure to thrive, also had a care plan requiring use of a mechanical lift with two-person assist for all transfers. Manufacturer guidelines for the lift specified that conditions such as contractures may dictate the need for a two-person transfer. On 12/25/25, a CNA transferred this resident from wheelchair to bed using the mechanical lift with only one staff member assisting, then left the room with the lift and returned to find the resident on the floor with a laceration above the left eyebrow. The CNA then lifted the resident back to bed and notified the nurse. Hospital evaluation, including CT and imaging, showed no significant intracranial hemorrhage and no active findings on chest and pelvic x-rays. The resident’s death certificate later listed Alzheimer’s disease as the cause of death and the manner of death as natural.
Failure to Protect Resident from Sexual Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a non-verbal, severely cognitively impaired resident was not protected from sexual abuse by another resident, who was also the individual's father. The incident involved the father touching the resident's genital area in a public dining area, as witnessed by a CNA. The CNA observed the inappropriate contact and, instead of immediately intervening and separating the residents, went to notify a nurse. During this time, the inappropriate contact continued until the nurse arrived and confronted the resident, at which point the contact ceased. Documentation and interviews confirmed that the residents were not immediately separated upon the initial observation of the abuse. The resident who was the victim of the abuse had a history of traumatic brain injury, intellectual disabilities, and was dependent on staff for all activities of daily living, with documentation indicating she was non-verbal and unable to communicate her needs. The perpetrating resident had a documented history of inappropriate sexual behaviors, including making sexual comments and attempting to touch staff and other residents. Care plans for this resident included interventions such as not placing him near female residents and providing close supervision, but these interventions were not always consistently implemented, as evidenced by the incident. Additionally, there was a prior unreported allegation of sexual abuse involving the same two residents, where staff observed the perpetrator with his hand possibly inside the victim's brief. This previous incident was not reported to the State Agency, as facility leadership determined it was unsubstantiated due to lack of physical evidence and uncertainty from the observer. The failure to immediately intervene during the observed abuse and the lack of reporting of prior allegations contributed to the deficiency cited in the report.
Failure to Prevent and Manage Pressure Ulcers and Inadequate Use of Pressure-Relieving Devices
Penalty
Summary
The facility failed to prevent and implement adequate preventive measures for pressure ulcers in two residents, resulting in the development and progression of pressure injuries. One resident, who was dependent on staff for activities of daily living and had multiple comorbidities, reported pain and the presence of open areas on her lower buttocks. Despite her complaints and visible wounds, there was no timely assessment, documentation, or physician orders regarding the pressure ulcers. The wound nurse only became aware of the wounds after the resident reported pain, and there was a delay in initiating appropriate interventions, such as the use of an air mattress. The resident stated she was not asked to get up for the air mattress to be installed, contrary to staff claims that she refused, and the air mattress was not put in place in a timely manner despite being marked as a critical request. Another resident developed a facility-acquired Stage IV pressure ulcer. Initial skin assessments documented intact skin, but within days, the resident developed a macerated area that progressed to an open wound with slough, and eventually to a Stage IV ulcer. The resident was incontinent and sometimes refused care, but there was a lack of consistent documentation and timely escalation of care. During wound care observations, improper infection control practices were noted, including cross-contamination during dressing changes and failure to perform hand hygiene between cleaning stool and applying wound dressings. The air mattress in use for this resident was not set or managed according to any documented protocol, and staff demonstrated a lack of understanding regarding the appropriate settings and functions of the mattress. Care plans and in-room care guides for both residents lacked specific instructions regarding air mattress settings and pressure ulcer prevention measures. Staff interviews revealed confusion and lack of knowledge about air mattress operation, and there was no facility policy or procedure for their use. The absence of clear protocols, timely interventions, and proper documentation contributed to the development and worsening of pressure ulcers in both residents.
Failure to Follow Infection Control Practices for Equipment Disinfection and Hand Hygiene
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices regarding the cleaning and disinfection of reusable medical equipment and hand hygiene during resident care. In one instance, a nurse used shared scissors for a resident's care and cleaned them with an alcohol pad after use, rather than using the EPA-approved disinfectant as required by facility policy. The scissors were confirmed to be shared among staff, and the standard disinfection process described by staff did not align with the facility's infection control policy. The resident involved had a history of stroke, diabetes, seizure disorder, and a recent wound infection, and required enhanced barrier precautions due to a urinary catheter and a wound dressing change. In another instance, staff failed to perform appropriate hand hygiene and glove changes during a dressing change for a resident with a stage 4 open wound in the coccyx area. The nurse changed only one glove after cleaning a bowel-soiled area and did not perform hand hygiene before proceeding with the wound dressing, resulting in possible cross-contamination. The infection preventionist confirmed that both gloves should be changed and hands washed before continuing with the dressing change, and that failure to do so can cause cross-contamination. The resident involved required extensive assistance with activities of daily living and had enhanced barrier precautions in place due to the wound.
Failure to Update and Individualize Resident Care Plans
Penalty
Summary
The facility failed to update and revise individualized, person-centered care plans to reflect the changing needs of four residents, as observed through direct care, interviews, and record reviews. For one resident with a Stage 4 pressure injury, staff did not document air mattress settings or provide clear instructions for adjusting the mattress, and wound care was performed without proper infection control, including cross-contamination during dressing changes. The care plan lacked specific interventions for the air mattress and did not reflect the current wound status, despite the wound progressing from Moisture Associated Skin Damage to a Stage 4 pressure ulcer. Another resident with a tracheostomy and multiple comorbidities was found to have three small pressure ulcers during observation, but the care plan had not been updated to document these open areas. The care plan continued to state that the resident's skin would remain intact, failing to reflect the actual skin condition. Similarly, a third resident dependent on dialysis and with multiple diagnoses reported significant pain, but the pain management care plan only included pharmacological interventions and omitted non-pharmacological approaches, despite facility policy requiring such interventions. The resident confirmed that staff did not implement non-pharmacological pain relief measures. A fourth resident with multiple pressure ulcers and cognitive impairment had a care plan that referenced the use of an air mattress and psychotropic medication monitoring but lacked individualized details such as specific air mattress settings and resident-specific information on behaviors or medication side effects. Staff interviews revealed uncertainty about where to find or how to document these individualized interventions, and the care plan did not provide clear guidance for staff. Across all cases, the care plans were not timely or adequately updated to reflect the residents' current conditions and needs as identified through assessments and observations.
Failure to Ensure Timely Call Light Response and Resident Dignity
Penalty
Summary
The facility failed to ensure resident dignity by not providing timely responses to call lights for at least two residents who were dependent on staff for activities of daily living. One resident with mild cognitive impairment, multiple chronic conditions, and a history of incontinence reported that delayed call light responses led to episodes of incontinence and feelings of embarrassment. This resident described waiting up to 45 minutes for assistance during a health scare and noted that staff were often too busy to respond promptly, especially before lunch. Another resident, who was alert and dependent on staff due to respiratory failure and other serious health issues, also reported having to wait for extended periods, sometimes resorting to calling out in the hallway for help. Resident Council meeting notes and group interviews further corroborated these findings, with multiple residents expressing concerns about long call light wait times. Several residents reported experiencing incontinence while waiting for assistance, and some stated that nurses did not consistently help with answering call lights. The facility's own policy affirms residents' rights to timely assistance, but documentation and resident feedback indicated ongoing issues with delayed responses, particularly during busy periods and before meals.
Failure to Provide Accessible Survey Results and Plan of Correction
Penalty
Summary
The facility failed to inform or educate all 13 residents who attended a confidential group meeting about the location and availability of the nursing home's survey results. During the meeting, none of the residents were aware of what survey results were, that they should be available without having to ask, or where to find them. Most of the residents present were in wheelchairs, and all reported a lack of knowledge regarding the survey results' existence or accessibility. Observation in the facility revealed that the posted survey results were placed too high on a bulletin board, making them inaccessible to residents in wheelchairs. The documents were also in small print, further impeding readability. Additionally, the most recent survey and plan of correction were not posted, and the available documents did not include the required plan of correction. The facility's policy states that residents have the right to examine the most recent survey and any plan of correction, but this was not being followed.
Unsanitary Food Service Practices and Improper Food Labeling
Penalty
Summary
Surveyors observed multiple failures in the facility's food service operations, including unsanitary conditions and improper food labeling. During a kitchen tour, equipment such as a silver cart and a large can opener were found with dried food splatters and chipped paint, respectively. A Robot Coupe, labeled as clean and ready for use, contained a piece of hair under the blade, and a backer's drawer with clean utensils had a sticky substance at the bottom. In the East Kitchenette, the microwave had dried food on the glass plate, and the freezer door seal was covered in crumbs. These findings indicate that food preparation and storage equipment were not maintained in a sanitary condition as required by professional standards and the Michigan Food Law. Additionally, the facility failed to ensure that all opened or partly used food items were labeled with a use-by date. Surveyors found a half loaf of bread and three large pans of peanut butter pie without any use-by dates, and a container of sunflower seeds with an expired date. In the kitchenette, a container of lettuce was found with a use-by date that had already passed. Both the Dietary Manager and Dietary Consultant confirmed that opened food items should be dated, and the facility's own policy requires dating and discarding food past the use-by or expiration date.
Failure to Document Assessments and Notify Physician
Penalty
Summary
The facility failed to document abdominal/bowel assessment and treatment for a change of condition for Resident #279. The resident, who had multiple diagnoses including coronary artery disease, heart failure, and Alzheimer's disease, received Fleet enemas on two consecutive days without any documented assessments of abdominal bowel sounds or abdominal distention. The last bowel and bladder assessment for the resident was recorded over two months prior, and there were no progress notes or assessments related to the administration of the enemas during the critical period. The Director of Nursing (DON) acknowledged that there should have been nursing documentation on the assessment of bowels/abdominal sound/distention. The facility also failed to thoroughly assess a resident with new onset pain and swelling, notify the physician, and provide timely interventions for Resident #18. The resident, who was on hospice care and had diagnoses including muscle weakness and osteoporosis, experienced significant pain and swelling in the right knee and hip. Despite multiple complaints of pain and visible symptoms such as swelling and warmth, the nursing staff did not notify the physician or order an x-ray in a timely manner. The resident's pain was managed with medication, but the underlying issue—a right femoral neck fracture—was not identified until several days later when an x-ray was finally ordered. The DON admitted that the nursing staff had the autonomy to make decisions and use their judgment for resident care but could not explain why the physician was not notified sooner or why an x-ray was not ordered earlier. The facility's failure to follow its own 'Acute Change in Condition' policy, which mandates notifying the physician of significant changes in a resident's condition, contributed to delays in diagnosing and treating the resident's fracture. The lack of timely intervention and proper documentation highlights significant deficiencies in the facility's care protocols.
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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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Nursing homes near Essexville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hampton Nursing And Rehabilitation | 4 mi | ★★★★★ | 0 | 0 |
| Bay Shores Senior Care And Rehab Center | 6.2 mi | ★★★★★ | 13 | 0 |
| Carriage House Nursing And Rehabilitation | 7.8 mi | ★★★★★ | 1 | 0 |
| Caretel Inns Of Tri-cities | 9.1 mi | ★★★★★ | 3 | 0 |
| Huron Woods Nursing Center | 10.1 mi | ★★★★★ | 15 | 0 |
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