Below average — CMS composite of the measures below.
The next survey window likely opens around March 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 County Medical Care Facility during CMS and state inspections, most recent first.
Food service sanitation and temperature control deficiencies were observed in the kitchen and kitchenette areas. Surveyors found an ice machine drain line sitting inside the drain, visibly soiled microwave and oven surfaces, a food employee who touched a trash can lid after handwashing and continued food prep without rewashing, and cold foods in the cold well above the facility’s 41 F cold-holding standard.
The facility failed to maintain an active legionella and OPPP control plan, with surveyors observing an outdated ice machine filter, unused and disconnected laundry ozone equipment, dead-end pipes, uncapped water lines, and spigots and seasonal water fixtures that were not being flushed or maintained. The facility also failed to follow EBP for a resident with a dehisced knee incision: a CNA provided bath, brief change, and dressing care using gloves only, handled used bath water in the room, and did not use gowns despite the resident’s wound and the facility’s EBP policy requiring gown and glove use for high-contact care.
Backflow prevention was not properly installed at multiple plumbing fixtures. Surveyors observed a chemical feeder downstream of an AVB at the mop sink, a hose with a spray nozzle downstream of an HBVB in the trash compact area, another chemical feeder downstream of an AVB in the trash compact area, and hoses attached to outside and inside spigots without backflow prevention. The AD of Plant Ops stated the backflow preventer was on work order but had not yet been installed, and later stated the work order had not been fulfilled.
Failure to Provide Privacy, Call Light Access, and Timely Toileting Assistance: Staff did not maintain privacy during personal care for one resident with paraplegia and an open scrotal wound, leaving the resident exposed during peri-care and wound care. Another resident with dementia and hemiplegia had the touch call light and light controls placed out of reach despite needing assistance and being unable to use them. A cognitively intact resident with CKD, COPD, and PVD reported waiting up to an hour for help to the restroom and said she skipped diuretics to avoid wetting herself while waiting.
Advance Directive and DNR Form Not Completed Properly: A resident who was cognitively intact and able to make his own medical decisions had a DNR form signed by his wife instead of by him, and the chart lacked DPOA-HC documentation. Interviews with SS and nursing staff confirmed the resident was his own decision maker, the spouse was not the POA, and there was no documentation showing the resident directed the spouse to sign or that the form was completed appropriately.
Lack of Clinical Rationale for Duplicate and Triplicate Antidepressant Therapy: The facility failed to document a clinical rationale for antidepressant duplication in one resident and triplicate antidepressant therapy in another. One resident with Alzheimer’s disease, MDD, insomnia, and anxiety was ordered escitalopram and trazodone, while another resident with MDD, mood disorder, and anxiety was ordered escitalopram, trazodone, and doxepin. Review of nursing, MD, and psych notes found no documentation explaining the use of the multiple antidepressants, and the SWD stated the psychiatric provider was aware of the orders but the rationale was not documented in the new charting system.
A resident with a PICC line and diagnoses including a superficial incisional surgical site infection, acute respiratory failure, and atherosclerotic heart disease did not receive a scheduled PICC dressing change. The dressing remained dated from an earlier week, the TAR showed the change was not completed, and RN C documented that the kit was unavailable in backup supplies. RN B confirmed PICC dressings should be changed weekly, and the DON stated kits are supplied by the pharmacy with limited backup stock.
Respiratory Equipment Not Maintained or Stored Properly: The facility failed to change oxygen tubing weekly and failed to store nebulizer equipment properly for two residents with COPD and chronic respiratory failure. For one resident, oxygen tubing was dated beyond the weekly change interval and the nebulizer was found hanging in a bag with moisture in the reservoir. For another resident, the nebulizer was left assembled on the bedside table with moisture in the medication chamber, and MAR documentation showed scheduled Ipratropium-Albuterol nebulizer doses were missed.
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.
Food Service Sanitation and Cold Holding Deficiencies
Penalty
Summary
The facility failed to maintain best practices in the food service area after surveyors observed multiple sanitation and food safety issues in the kitchen and kitchenettes. During the initial kitchen tour, the drain line to the ice machine was observed sitting inside the drain. In the one east kitchenette, the interior walls of the microwave were visibly soiled, and in the one west kitchenette, the interior wall of the oven door was visibly soiled with grease. The Director of Dining Services stated the microwave was cleaned after every use, but said he was not sure how often the oven was cleaned and thought it was cleaned monthly. During lunch observation in the two west kitchenette, a food employee washed hands, then touched the trash can lid with a bare hand to discard a paper towel and continued preparing food without washing hands again. Later, cold foods in the cold well were observed above the facility's stated cold holding temperature of 41 F, including shredded lettuce at 49 F, sour cream at 45 F, and shredded cheese at 48 F. The Director of Dining Services stated cold foods should be held at 41 F and could not find the cold holding temperatures in the temperature book at the kitchenette.
Failure to Maintain Plumbing Controls and Follow EBP for a Resident With a Wound
Penalty
Summary
The facility failed to have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing, as shown by multiple observations of plumbing and water-related equipment that appeared unused or disconnected. On 04/27/2026, surveyors observed an ice machine filter dated 4/30/2020, an unused ozone treatment system for washers in the laundry chemical room that had not been used for at least 10 years, two dead-end pipes in the laundry personal clothing room, an unused faucet with the hot and cold valves removed, and two uncapped water lines to an old utility sink in the B11 utility closet. Additional observations showed other water fixtures that were not being flushed or maintained as part of a legionella control measure. An inside spigot in the old garage was observed, and the Assistant Director of Plant Operations stated it was not flushed regularly to his knowledge. An inside spigot in the new garage was also observed, and the Director of Environmental Services stated it was probably not flushed. At the outside pavilion, surveyors observed a kitchenette and bathroom where the water was shut off seasonally, the hot water tank did not work, and the hot water valve was closed off; Maintenance stated the hot water tank was drained before shutdown. The facility also failed to follow enhanced barrier precautions for R65, who had a dehisced left knee incision and was on enhanced precautions. The care plan directed staff to wear appropriate PPE during direct care. During observation, CNA F performed a bed bath, brief change, and dressing care while wearing gloves only, carried used bath water through the room and emptied it in the shared restroom while still wearing gloves only, did not clean the shared restroom afterward, and stored the wet basin in the resident’s closet. R65 and her roommate both reported that staff wore gloves, but not gowns, during bath care. Interviews with staff showed that EBP required gowns and gloves for high-contact care activities such as bathing, hygiene, dressing, and brief changes, and the facility policy stated residents with wounds required EBP.
Backflow Prevention Not Installed at Multiple Plumbing Fixtures
Penalty
Summary
The facility failed to ensure appropriate backflow prevention was installed at plumbing fixtures. Surveyors observed a chemical feeder downstream of an atmospheric vacuum breaker at the mop sink in the janitor's closet adjacent to the kitchen, a hose with an attached spray nozzle downstream of a hose bib vacuum breaker in the trash compact area, and another chemical feeder downstream of an atmospheric vacuum breaker in the trash compact area. Surveyors also observed an outside spigot with an attached hose without backflow prevention and an inside spigot with an attached hose without backflow prevention in the old garage. During these observations, the Assistant Director of Plant Operations stated that the backflow preventer was on work order but had not yet been installed, and later stated that no one had fulfilled the work order yet.
Failure to Provide Privacy, Call Light Access, and Timely Toileting Assistance
Penalty
Summary
The facility failed to ensure timely care was provided in a dignified manner for three residents reviewed for dignity and resident rights. The deficiency involved resident privacy during personal care, access to a call light, and delayed assistance with toileting needs. The report cites observations, interviews, and record review showing that staff did not consistently provide privacy during care, did not keep a resident’s call light within reach, and did not respond in a timely manner to another resident’s requests for help to the restroom. For one resident with paraplegia, muscle weakness, and an open wound of the scrotum and testes, the resident was observed lying in bed while CNA care and wound care were being provided. The resident’s gown was pulled up and the incontinence brief was open, and the bed was positioned in front of a large window with the shade not pulled down. The resident’s buttocks were exposed toward the window side during wound care. The CNA stated the shade was usually pulled down because the resident did not like bright light and acknowledged it should have been down during care. For another resident with severely impaired cognition and multiple diagnoses including spastic hemiplegia, dementia, contractures, and CKD, the touch call light pad was observed out of reach on more than one occasion, including hanging over the head of the bed or lying at the far side of the bed. The resident was unable to reach the call light or the light controller and stated he could not trigger the call light when he needed assistance. Staff confirmed the call light was out of reach and moved it within reach after the observation. For the third resident, who was cognitively intact and had diagnoses including ASHD, CKD, COPD, PVD, orthostatic hypotension, anxiety, and depression, the resident reported waiting up to an hour for a response to the call light when needing help to the restroom. The resident stated she had refused Lasix at times because she had to wait too long and had wet herself while waiting for assistance, which she said was embarrassing. On follow-up, she again stated she had not taken her diuretic for a couple of days so she would not wet her pants while waiting for help to the restroom.
Advance Directive and DNR Form Not Completed Properly
Penalty
Summary
The facility failed to ensure advance directives were in place and completed appropriately for one resident who was admitted with diagnoses including cerebral infarction, heart disease, heart failure, atrial fibrillation, and dysphagia. The medical record showed the resident was cognitively intact and able to make his own informed medical decisions. A Resident Code Status and Specific Treatments form indicated DNR was selected, but the resident did not sign the form; instead, his wife signed it. The record also did not contain any Durable Power of Attorney for Health Care documentation. During interview, the Social Service Assistant reviewed the record and stated the resident was his own decision maker, that the spouse was not the health care POA, and that the resident should have signed the code status form. The assistant also stated there was no documentation from nursing witnesses showing the resident directed the spouse to sign. Nurses who witnessed the form reported the resident was competent and agreed to DNR, but they also stated the spouse signed for him and no POA paperwork was provided at the time. The facility policy stated advance directive documents should be saved in the resident's chart upon admission and that the resident's decision-making ability should be assessed periodically.
Lack of Clinical Rationale for Duplicate and Triplicate Antidepressant Therapy
Penalty
Summary
The facility failed to provide a clinical rationale for duplicate and triplicate antidepressant therapy for two residents reviewed for unnecessary medications. Resident #6 was admitted with diagnoses including Alzheimer’s disease, major depressive disorder, insomnia, and generalized anxiety disorder, and her physician orders included escitalopram 20 mg and trazodone 50 mg, both antidepressants. Her care plan noted depression, anxiety, panic disorder, insomnia, and dementia, and review of nursing, physician, and psychiatric progress notes found no documentation explaining the use of dual antidepressant therapy. Resident #55 was admitted with diagnoses including major depressive disorder, mood disorder, and anxiety, and her physician orders included escitalopram 10 mg, trazodone 50 mg, and doxepin 10 mg, all antidepressant medications. Her care plan referenced mood disturbance, insomnia, anxiety, depression, and visual hallucinations, but review of nursing, physician, and psychiatric progress notes found no documentation explaining the use of three antidepressants. The Social Work Director stated both residents were stable on their current medication regimen and that the psychiatric provider was aware of the antidepressant orders, but also explained that the old charting system had documented the rationale and the new system did not. The facility policy on psychotropic medication use did not address duplicate therapy.
Missed PICC Dressing Change
Penalty
Summary
The facility failed to ensure a PICC dressing change was completed on time for a resident admitted with diagnoses including infection of a superficial incisional surgical site, acute respiratory failure, and atherosclerotic heart disease. A PICC line was observed in the resident’s right upper arm with a dressing dated 4/15/26, and the physician’s order required the PICC line dressing to be changed every Wednesday. Record review showed the 4/22/26 dressing change was signed out as not completed, with a nurse’s note stating it was not done because the dressing change kit was not available in the backup system. During interviews, RN B confirmed the dressing date and stated PICC dressings should be changed weekly. The DON stated that Remedi Pharmacy supplies the PICC dressing change kits and that some are kept in the building’s backup system, but supplies are limited. RN C stated the dressing change was not completed because supplies were not available, that the backup system was checked, and that the pharmacy did not send the supplies either. The facility policy titled Catheter Insertion and Care states CVAD and midline dressings are to be changed every 5-7 days and when the dressing integrity is compromised.
Respiratory Equipment Not Maintained or Stored Properly
Penalty
Summary
The facility failed to ensure oxygen tubing was changed weekly and failed to store nebulizer equipment properly for two residents receiving respiratory care. Resident #2 had diagnoses including COPD, chronic respiratory failure, heart failure, and tachycardia. During observations on 04/27/2026 and 04/28/2026, R2’s oxygen tubing was dated 4/20/26, and the nebulizer was found hanging in a bag on the wall next to the bed, stored together with moisture noted in the medication reservoir. The ADON stated that oxygen tubing is changed every 7 days and that after each use nurses take nebulizer equipment apart, rinse it, dry it, and place it on the wall in a bag. The facility policy required tubing to be changed weekly with the date, time, and nurse initials, and nebulizer equipment to be disassembled, rinsed with sterile saline, and placed in a wiki bag to air dry. Resident #75 was admitted and readmitted with diagnoses including heart failure, acute respiratory failure with hypoxia, chronic respiratory failure with hypercapnia, and COPD. During observations on 04/27/2026 and 04/28/2026, R75’s nebulizer was found assembled and sitting on the bedside table with moisture in the medication chamber. The DON stated the nebulizer equipment should be disassembled, the medication cup rinsed out, and the equipment allowed to dry or placed in a special bag that lets it air dry. The MAR showed Ipratropium-Albuterol inhalation ordered three times daily, but documentation showed doses were not administered as scheduled on 04/27 and 04/28.
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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Illustrative
What surveyors actually found near you
We read the 195 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — 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 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 | ★★★★★ | 12 | 0 |
| Caretel Inns Of Tri-cities | 9.1 mi | ★★★★★ | 3 | 0 |
| Huron Woods Nursing Center | 10.1 mi | ★★★★★ | 15 | 0 |
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