Bay Bluffs-Emmet County Medical Care Facility

Inspectors wroteBased on interview and record review, the facility failed to complete an annual performance review at least every 12 months for five Certified Nurse Aides (CNA's) [B, J, K, L, & M] of five CNA's reviewed for performance reviews. This deficient practice resulted in the potential for inadequate care and unmet resident care needs for all 68 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include:On 05/12/2026 at 7:57 AM observed the kitchen hand sink was slow to drain after washing hands. The Certified Dietary manager (DM) stated that it has been draining slow for a while now and a new hand sink is being installed as soon as maintenance can get to it. According to the 2022 FDA Food Code section 5-205.15 System Maintained in Good Repair. A PLUMBING SYSTEM shall be: (A) Repaired according to LAW; and (B) Maintained in good repair. On 05/12/2026 at 8:07 AM observed ice condensation buildup on the ceiling and fan cover of the walk-in freezer. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed toEnsure the use of Enhanced Barrier Precautions (EBP) and safe handling of an indwelling urinary catheter bag during transfers according to current infection control standards for one Resident (#70) of two residents reviewed for catheter care, and Follow through with their plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP), resulting in the potential for increased risk of respiratory infection among all residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure training of no less than 12 hours per year was completed for five Certified Nurse Aide (CNA's) [B, J, K, L & M) of five CNA's reviewed for nurse aide training hours.

Inspectors wroteBased on interview and record review, the facility billed for a personal room telephone which was not present for one Resident (#25) of one resident reviewed for billed services.

Inspectors wroteBased on interview and record review, the facility failed to provide information of pending changes in Medicare coverage and the right to appeal this decision for one Resident (R81) of three residents reviewed for reception of a Notice of Medicare Non-coverage (NOMNC) form.

Inspectors wroteThis citation pertains to intake 2979976. Based on interview and record review, the facility failed to ensure residents were free from misappropriation of resident property when a dose of controlled pain medication was diverted from one Resident (#75) of one resident reviewed for misappropriation. This deficient practice resulted in the potential for ongoing or increased pain and anxiety.

Inspectors wroteBased on interview and record review, the facility failed to provide written notifications of transfers and bed holds, and provide requisite resident information to the receiving provider for three Residents (#13, #8, & #70) of four residents reviewed for hospitalizations.

Inspectors wroteBased on interview and record review, the facility failed to ensure pressure injury assessments and wound measurements were consistently documented and treatments were completed as ordered by the physician for one Resident (#13) of four residents reviewed for pressure injuries.

Inspectors wroteBased on observation and interview, the facility failed to maintain safe water temperatures in the resident's environment.

Inspectors wroteBased on interview and record review, the facility failed to ensure the clinical record documented a medical condition justifying the continued use of an indwelling urinary catheter for one Resident (#8) of four residents reviewed for urinary catheters.

Inspectors wroteBased on observation and interview, the facility failed to maintain general repair of one exterior door, resulting in the potential for pest entry. Findings Include: On 05/12/2026 at 10:00 AM observed the door sweep missing from 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 damaged and partially detached from the base. The Maintenance Director MD said that they do have occasional mice but felt those were getting in from the attic areas, and that pest traps were kept up there to prevent the pests from getting down into the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety as evidenced by: A. Failure to properly label and date food products. B. Failure to ensure expired foods were discarded on or before the identified expiration date. C. Failure to ensure high temperature dish machines were routinely tested for proper sanitizing of food contact surfaces. D. Failure to ensure the kitchen area was restricted to food service staff during meal service. E. Failure to ensure staff washed their hands during identified opportunities for hand hygiene. F. Failure to demonstrate proper testing of sanitizing solution and maintain acceptable concentration parameters for meal preparation countertops and dining room surfaces. [...]

Inspectors wroteBased on interview and record review, the facility failed to revise care plans to reflect the needs of two Residents (R24 and R29) of 12 residents reviewed for care plans.

Inspectors wroteBased on interview and record review, the facility failed to ensure a comprehensive discharge summary was completed for one Resident (#2) of two residents reviewed for a discharge to the community.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent the development of deep tissue injuries for one Resident (R29) of one resident reviewed for the pressure ulcers.

Inspectors wroteBased on interview and record review, the facility failed to ensure monthly pharmacy medication regimen reviews were performed for one Resident (R30) of five residents reviewed for pharmacy services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent unauthorized access to the facility's three medication storage rooms by allowing unlicensed personnel to retain keys and access the three medication storage rooms.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure supervision and safety for one Resident (R162) of two residents reviewed for unsafe wandering. This deficient practice resulted in R162 wandering into a non-resident area where chemicals were located and fell.