Above average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Paradigm At Bay City during CMS and state inspections, most recent first.
A facility failed to maintain several resident rooms and a shared restroom in a sanitary, orderly, and comfortable condition. Surveyors observed peeling paint, paint chips, a hole in the drywall near a vent, dead bugs in a bug trap, missing and cracked floor tiles, and a restroom sink with no hot water. The Maint D said some issues were not reported to him, and the ADMN stated she expected the restroom, flooring, and hot water to be in working order.
A resident with diagnoses including dementia, hypotension, acute kidney failure, and esophagitis had a 26.67% med error rate during a med pass. An MA crushed multiple meds without an order to crush, gave chewable Aspirin instead of ordered EC Aspirin, crushed Protonix despite its DR form, and did not give Carafate before meals as ordered. The MA stated the resident wanted the meds crushed, while the RN and DON stated crushing required an order and EC/DR meds should not be crushed.
Kitchen sanitation and hair restraint failures: A staff member preparing puree diets used a food processor for zucchini and then reused it for beef macaroni casserole without cleaning it between uses. Two dietary staff were observed with exposed moustaches while assisting with tray prep, and the resident water machine in the dining room was soiled with standing water and later brown water. Interviews confirmed staff and management knew hair, including moustaches, should be covered and that the processor should be cleaned between uses.
Failure to Maintain Resident Nail Care: A cognitively intact resident with significant ADL assistance needs had long, jagged fingernails with debris under the nails, and she stated staff had not trimmed or filed them despite her requests. CNA and leadership interviews confirmed staff were responsible for monitoring and providing nail care as needed, and the facility policy required assistance for residents unable to care for their own nails.
A resident with COPD was observed using oxygen via nasal cannula even though there was no physician order for oxygen therapy in the chart and no documentation showing oxygen use. The oxygen concentrator was found in the room on multiple observations, the tubing was left outside the bag or on top of the concentrator, the nasal cannula was discolored with a crusty substance, and no oxygen in use sign was posted on the door. The MDS nurse and DON stated oxygen use should have an order, documentation, proper storage, and a door sign.
Two residents' medical records were not maintained according to professional standards when one resident's hospital records were uploaded to another resident's chart, resulting in missing and misfiled documentation. Staff interviews confirmed that multiple personnel could upload documents and acknowledged the privacy issue created by this error.
The facility failed to ensure the confidentiality of resident records, as a nurse left personal information of two residents unattended and visible on computer screens. This included a resident's face sheet and another's MAR, both left unlocked at the nurse's station, posing a risk of unauthorized access to sensitive information.
Two residents with cognitive impairments and health issues were observed smoking unsupervised and keeping cigarettes in their rooms, contrary to the facility's policy requiring staff to maintain smoking materials and supervise smoking. This lack of supervision and control posed safety risks, as staff interviews revealed a lack of awareness and enforcement of the smoking policy.
The facility failed to ensure proper incontinent care for a resident, leading to a risk of urinary tract infections. An observation revealed that a CNA did not thoroughly clean the resident's urinary meatus, despite being trained and checked for competency. The resident, who was cognitively intact but dependent on staff for personal care, had a care plan indicating the need for prompt changing and protective skin barrier application.
The facility failed to provide adequate pharmaceutical services for a resident with a G-tube. Expired medications were found in the carts of two LVNs, and one LVN used improper procedures for G-tube medication administration. The resident had a recent G-tube replacement due to a weak tube.
The facility failed to secure medications properly when an LVN left eye drops unsupervised on top of a medication cart. The LVN acknowledged the risk and the facility's policy requires all medications to be locked inside the carts.
The facility failed to ensure the dumpster lids and doors were secured, which could place residents at risk of infection from improperly disposed garbage. An observation revealed that the facility's dumpster area had a commercial-sized dumpster with the top lid completely open. The Dietary Manager stated that it was the dietary department's responsibility to keep the dumpster doors closed, but noted that housekeeping might have left it open after disposing of the night's trash in the morning. The Administrator and DON confirmed that the dumpster should be completely closed to avoid trash spillage and infection control issues.
A facility failed to maintain accurate clinical records for a resident with diabetes, as an LVN did not document insulin administration on multiple occasions despite elevated blood glucose levels. This lack of documentation could lead to inappropriate medication administration and a decline in the resident's health status.
The facility failed to maintain an infection prevention and control program when two CNAs did not perform proper hand hygiene during incontinence care for a resident with multiple health conditions. This included not changing gloves or sanitizing hands after touching soiled areas and before handling clean items, placing the resident at risk for infections.
Unsafe and Disrepair Conditions in Resident Rooms and Shared Restroom
Penalty
Summary
The facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior in four resident rooms that were observed for environmental conditions. During an observation and interview, the shared restroom for rooms 150 and 152 had peeling paint on both interior restroom doors, paint chips on the restroom floor, a hole in the drywall near the restroom vent in the ceiling, and a sticky bug trap under the sink with dead bugs in it. Visitors in the room stated they did not like that the restroom was in disrepair and said the peeling paint and dead bugs upset them when they visited the resident in the room. In another room, a missing floor tile and many cracked floor tiles were observed. The resident in that room could not answer questions and was sitting in a recliner. In a separate room, the restroom sink hot water knob would not move and no hot water came out of the faucet during observation. The resident stated the water was cold at first but would warm up when asked about hot water function in the restroom and did not complain about not having access to hot water. The Maintenance Director stated he had been working with staff to use the computerized system to report maintenance issues and said the hot water issue, the intact tile issue, and the drywall gap issue should have been repaired. He stated the peeling paint issue had been on the maintenance log and was waiting to be repaired, while the other issues were not reported to him. The Administrator stated she expected the shared restroom to be bug free with intact paint and no holes in the drywall, expected room tiles to be intact, and expected working running hot water in residents' restrooms. Record review showed an open work order for bathroom walls needing attention, but there was no evidence of drywall repair, tile repair, or faucet repair in progress before the survey date.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure that the medication error rate remained below 5% for one resident reviewed for medication administration. For Resident #15, the surveyor identified a medication error rate of 26.67%, based on 30 opportunities with 8 medication errors. The resident’s record showed diagnoses including hypotension, acute kidney failure, esophagitis, dementia, major depressive disorder, and abdominal hernia, and physician orders included Aspirin EC 81 mg daily, Ferrous Sulfate 325 mg daily, a multivitamin with minerals daily, Protonix 40 mg daily, Thiamine 100 mg daily, Vitamin B-12 1000 mcg daily, Risperdal 0.5 mg twice daily, and Carafate 1 gm before meals. During observation, MA B administered the resident’s medications by crushing tablets together and mixing them with vanilla pudding. There was no physician order allowing medications to be crushed. The Aspirin ordered was enteric coated, but the medication given was a chewable Aspirin rather than the ordered EC formulation. The crushed medications included Protonix, which was a delayed-release medication, and Carafate was not given before meals as ordered. The resident took the medications with pudding and water, and the MAR documented the medications as given. In interview, MA B stated she had been crushing the resident’s medications because he wanted them crushed, but she acknowledged there should have been an order to crush them and that she should have informed the nurse first. RN A stated medications should not be crushed without an order and that delayed-release and enteric-coated medications should not be crushed. The DON stated medications should not be crushed without an order, that EC and DR medications should not be crushed, and that Carafate should be given before meals. The facility policy required checking crushing guidelines and only crushing medications if indicated by the prescriber’s order, and the facility’s list of medications not to be crushed included Aspirin EC and Protonix.
Kitchen sanitation and hair restraint failures
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the kitchen. During an observation on 07/21/2026, a Dietary Aide was observed with his mustache exposed and not covered by a beard restraint or hair net, and the water machine used by residents in the dining room was observed to be soiled with water standing in the basin. Later that morning, a staff member preparing puree diets used a food processor to prepare puree zucchini, placed the zucchini in a pan without removing all of it from the processor, and did not wash the food processor between uses before placing beef macaroni casserole into the same processor with the remaining zucchini. Additional observations on 07/21/2026 and 07/22/2026 showed the same Dietary Aide and another staff member assisting with food tray preparation while their mustaches remained exposed and uncovered. On 07/22/2026, the resident water machine in the dining room remained soiled with brown water standing in the basin. Interviews confirmed that the staff members did not know why the food processor was not cleaned between uses and did not know whether moustaches should be covered, while the Dietary Manager and Administrator stated that all hair, including moustaches, should be covered and that the food processor should be cleaned between each use. The Dietary Manager also stated she did not know who was responsible for cleaning the residents' water machine.
Failure to Maintain Resident Nail Care
Penalty
Summary
The facility failed to provide the necessary services for a resident who was unable to carry out activities of daily living to maintain good grooming and personal hygiene. Resident #14, a cognitively intact female with diagnoses including seizure disorder, cerebral infarct, atherosclerotic heart disease, and bilateral foot drop, was assessed as needing supervision or touching assistance with personal hygiene and substantial to maximal assistance with bathing. Her care plan also identified that she required extensive assistance with bathing and grooming and was bedbound. On 07/21/2026, an observation and interview found the resident's fingernails on both hands were approximately 1/4 inch long, jagged, and had a brown substance under the third and fourth fingernails of the left hand. The resident stated the long nails bothered her, that she wanted them cut and filed, and that she had asked staff to do so but they had not. On 07/22/2026, the resident again stated her fingernails had not been cut and that she wanted them cut and filed. She said she had asked someone to cut them and was told it would be done when they had time. During interviews, CNA F stated nails should be cut, filed, and trimmed during showers or as needed, and that staff should respond if a resident requested nail care. The DON stated nurses were responsible for monitoring and maintaining residents' nails, and that CNAs provided nail trimming and grooming during shower days or as needed. The Administrator stated charge nurses and staff providing care were responsible for ensuring fingernails remained trimmed and filed. The facility policy stated staff would assist residents with nail care as needed and that residents unable to care for their own nails required assistance in keeping nails clean and trimmed.
Missing Oxygen Order, Improper Tubing Storage, and No Oxygen Sign
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met for Resident #41, a cognitively intact male with COPD. His record showed a history of COPD and monitoring of oxygen saturation, but there was no physician order for oxygen therapy in the chart, no mention of oxygen therapy in progress notes, and the quarterly MDS did not indicate that he received oxygen therapy. Despite this, the care plan included an intervention for oxygen via nasal cannula at 3-4 L/min as needed for wheezing or shortness of breath. During observations on 07/21/2026, 07/22/2026, and 07/23/2026, an oxygen concentrator was present in Resident #41's room. When he was not in the room, the tubing was found lying on top of the concentrator or outside of the bag, the nasal cannula had brown discoloration and a crusty substance, and there was no oxygen in use sign posted on the room door. When observed in the room, he was wearing oxygen via nasal cannula and the concentrator was set to 5 L/min. He stated he turned on the concentrator and put on the tubing when he returned because he got short of breath, and he said he only wore oxygen when he needed it. The MDS nurse stated there should be an order for oxygen if a resident was receiving oxygen therapy and that oxygen tubing should be stored in a bag when not in use. She also stated she was not aware Resident #41 received oxygen therapy because there was no order and no documentation from nursing, and she did not know why the care plan included oxygen use. The DON stated that if a resident was utilizing oxygen there should be an order, documentation of oxygen saturations and therapy dose, and an oxygen in use sign on the door. The facility policy required review of the physician order, posting an oxygen in use sign, and changing oxygen tubing with any discoloration or contamination.
Failure to Maintain Accurate and Resident-Specific Medical Records
Penalty
Summary
The facility failed to maintain accurate and resident-specific medical records in accordance with accepted professional standards for two residents. Specifically, one resident's hospital records were incorrectly uploaded and attached to another resident's medical chart, while the correct resident's chart did not contain her own hospitalization records. This error was identified during a review of the medical charts, where it was found that the hospital records for one resident were present in the chart of another, and missing from the appropriate chart. Interviews with facility staff, including the DON, MDS Nurse, and RSC, confirmed that multiple staff members have the ability to upload documents to resident charts. Staff acknowledged that uploading documents to the wrong chart is a privacy issue and that there are procedures in place to notify administration and correct such errors. The facility's policy requires that medical records be maintained in a manner that protects electronic protected health information from unauthorized use or access, but this standard was not met in this instance.
Confidentiality Breach of Resident Records
Penalty
Summary
The facility failed to maintain the confidentiality of personal and medical records for two residents. RN A left Resident #3's personal information unattended and visible on a computer screen in the resident data portal. During an interview, RN A was distracted by a resident's call light and left the computer screen unlocked, displaying Resident #3's face sheet. This incident was observed twice, indicating a lapse in securing sensitive information. Additionally, Resident #4's Medication Administration Record (MAR) was left unlocked and unattended on a laptop at the nurse's station. The laptop was not properly secured, allowing unauthorized access to the resident's medical information. The Director of Nursing (DON) acknowledged that leaving resident information exposed constitutes a HIPAA violation, highlighting the risk of unauthorized access to personal information for 55 residents stored in the data portal.
Inadequate Supervision and Control of Smoking Materials
Penalty
Summary
The facility failed to ensure adequate supervision and control of smoking materials for two residents, leading to potential safety hazards. Resident #1, a 67-year-old man with COPD and cognitive impairment, was observed smoking unsupervised and keeping cigarettes in his room, contrary to the facility's policy that smoking materials should be maintained by staff. His care plan indicated he was a supervised smoker, yet he reported that he usually smoked alone and was not prevented from keeping cigarettes in his possession. This lack of supervision and control over smoking materials posed a risk of injury. Similarly, Resident #2, a 57-year-old man with multiple health issues including COPD and cognitive impairment, was seen taking a cigarette from his room and smoking unsupervised. His care plan also required supervision while smoking, and he was to be informed of the facility's smoking policy. Despite these measures, he was able to access cigarettes independently. Interviews with staff revealed a lack of awareness and enforcement of the smoking policy, as residents were not supposed to have cigarettes in their rooms or smoke unsupervised. The Director of Nursing was unaware of the residents' access to cigarettes and acknowledged the safety concerns associated with this practice.
Inadequate Incontinent Care Leading to Risk of UTIs
Penalty
Summary
The facility failed to ensure that a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections. Specifically, the facility did not ensure that CNAs properly cleaned the resident during incontinent care. During an observation, it was noted that a CNA did not spread the resident's labia to thoroughly clean the area and the urinary meatus, which is necessary to prevent infections. The CNA admitted to not performing the task correctly because she was nervous, despite having been trained and checked for competency in peri care. The resident involved was an elderly female with a history of pneumonia, congestive heart failure, and dysphagia. She was cognitively intact but dependent on staff for toileting hygiene and other personal care needs. The resident's care plan indicated that she was at risk for skin breakdown due to bowel and bladder incontinence and required prompt changing and application of a protective skin barrier. Despite these instructions, the facility did not provide a policy on perineal care when requested, and the CNA's failure to follow proper procedures was confirmed by the Director of Nursing.
Expired Medications and Improper G-Tube Medication Administration
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for a resident with a gastrostomy tube (G-tube). During an observation, it was noted that LVN A's cart contained expired medications, including an insulin Glargine injection pen and glucose control solutions. Additionally, LVN B's cart contained expired Enoxaparin syringes. These expired medications were not removed from the carts as required by the facility's policy. LVN A admitted to using a plunger to administer water and medications through the G-tube, which is against proper procedures, and acknowledged the risks associated with using expired medications and control solutions. The resident involved was a male with a history of a displaced fracture of the right humerus, aphasia, and aphonia. The resident had a recent change in condition due to a weak G-tube, which required replacement. The facility's policy on medication storage and expiration was not followed, as expired medications were found in the medication carts and were not discarded promptly. The ADON confirmed the presence of expired medications in LVN B's cart and acknowledged that they should have been removed immediately.
Failure to Secure Medications Properly
Penalty
Summary
The facility failed to ensure drugs and biologicals were secured properly for one of five medication carts reviewed. Specifically, LVN A left an optic medication (eye drops) on top of the medication cart unsupervised. This was observed on 3/27/24 at 10:42 a.m. During an interview at 10:45 a.m., LVN A acknowledged that all medications should be locked inside the carts and recognized the risk of leaving eye drops out, as another resident could pick it up and use it or drink it. The facility's policy and procedure titled 'Storage of Medications' states that medication carts should be locked when not attended by authorized personnel.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure the dumpster lids and doors were secured, which could place residents at risk of infection from improperly disposed garbage. An observation revealed that the facility's dumpster area had a commercial-sized dumpster with the top lid completely open. The Dietary Manager stated that it was the dietary department's responsibility to keep the dumpster doors closed to prevent insects and trash from entering the facility, but noted that housekeeping might have left it open after disposing of the night's trash in the morning. The Administrator and the Director of Nursing (DON) confirmed that the dumpster should be completely closed to avoid trash spillage and infection control issues. A review of the facility's waste disposal policy indicated that waste containers and dumpsters should be covered and closed at all times to prevent disease transmission and pest infestation.
Failure to Document Insulin Administration
Penalty
Summary
The facility failed to ensure clinical records were maintained in accordance with accepted professional standards and practices for one resident reviewed. Specifically, LVN B did not document the administration of insulin on the eMAR for multiple dates in March 2024, despite the resident having elevated blood glucose levels that required intervention. The resident, a male with type 2 diabetes mellitus, hypertension, and a history of cerebral infarction, had several instances of high blood sugar readings without corresponding documentation of insulin administration or physician contact as required by the sliding scale orders. This lack of documentation could lead to inappropriate and inadequate medication administration and a decline in the resident's health status. During interviews, the DON and Regional Nurse were unaware of the elevated blood glucose levels and stated that the expectation was to contact the MD immediately if levels were outside the sliding scale parameters. LVN B admitted to administering insulin and contacting the doctor but failed to document these actions in the eMAR and nurse's notes. The failure to document interventions meant that other nurses were not aware of the resident's condition and necessary follow-up actions. The Nurse Practitioner confirmed that LVN B had contacted her regarding the resident's high blood sugar and received new orders for insulin administration, which were also not documented properly.
Infection Control Deficiency During Incontinence Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program, as evidenced by the actions of two CNAs during the provision of incontinence care to a resident. The resident, an elderly female with diagnoses including pneumonia, congestive heart failure, and dysphagia, was observed to be dependent on staff for toileting hygiene and other personal care needs. During the care, the CNAs did not perform proper hand hygiene, which included not changing gloves or sanitizing hands after touching soiled areas and before handling clean items, such as the resident's brief and clothing. This failure was observed by a surveyor and confirmed through interviews with the involved CNAs and the Director of Nursing (DON). The DON acknowledged that the CNAs' actions were not in compliance with the facility's infection control policies and placed the resident at risk for infections. The facility's hand hygiene policy and infection control program were reviewed, revealing that proper hand hygiene is a critical component for preventing the spread of infection. The CNAs' failure to follow these protocols during incontinence care was a clear deficiency in the facility's infection prevention and control program.
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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 Bay City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Bay City | 0.7 mi | ★★★★★ | 13 | 0 |
| Matagorda Nursing & Rehabilitation Center | 2.2 mi | ★★★★★ | 4 | 1 |
| Paradigm At Sweeny | 17.4 mi | ★★★★★ | 3 | 1 |
| Wharton Nursing And Rehabilitation Center | 23.9 mi | ★★★★★ | 8 | 4 |
| Paradigm At The Prairies | 24 mi | ★★★★★ | 33 | 2 |
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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 October 2026) and official state health department websites.