Bay County Medical Care 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.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP) and, follow enhanced barrier precautions (EBP) for residents identified with qualifying wounds, for one resident #65 (R65) of three residents reviewed for infection prevention. This deficient practice has the increased potential to result in waterborne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among all residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate backflow prevention was installed at plumbing fixtures, resulting in the potential for contamination to the water supply, affecting all residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that timely care was provided in a dignified manor to 3 of 3 residents reviewed for dignity (Residents R4, R10 and R45).

Inspectors wroteBased on interview and record review, the facility failed to ensure advance directives were in place and completed appropriately for one resident (Resident #99) of one resident reviewed for advanced directives.

Inspectors wroteBased on interview and record review the facility failed to provide clinical rationale for administration of duplicate/triplicate antidepressant therapy of two (#6 & #55) residents of six reviewed for unnecessary medications. Findings Include:Resident #6On 4/28/2026 at approximately 1:00 PM, a review was completed of Resident #6's medical records and it revealed she admitted to the facility on [DATE] with diagnoses that included, Alzheimer's Disease, Major Depressive Disorder, Insomnia and Generalized Anxiety Disorder. Further review of Resident #6's chart yielded the following:Physician Orders:Escitalopram (Lexapro) Oxalate Oral Tablet 20 MG (milligrams) for Major Depressive Disorder. Trazadone HCI (hydrochloride) Oral Tablet 50 MG for Major Depressive DisorderLexapro and Trazadone are both antidepressants. Care Plan: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure peripherally inserted central catheter (PICC) dressing changes were completed timely for one resident (R23) of one reviewed for PICC lines.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure oxygen tubing was changed out weekly and nebulizers were stored properly for two residents (R2 and R75) of five residents reviewed for respiratory care.

Inspectors wroteThis citation pertains to Intake Numbers 2716028, 2716054 and 2723179. Based on observation, interview and record review, the facility failed to ensure that staff followed 2 resident's (Resident #101 and Resident #104) plans of care for safe transfers of 5 residents reviewed, resulting in falls with a fracture, and a head injury, with hospitalization. Findings Include: Resident #101:Review of the Face Sheet, physician orders and care plans dated 9/2018 through current, revealed Resident #101 was 88 years-old, admitted to the facility on [DATE], had cognitive impairment, required assistance with all Activities of daily Living/ADL's and was a two person assist for all transfers. The residents diagnosis included, Vascular Dementia with behaviors, Stroke with Hemiplegia and weakness of the right side, and Heart Disease. [...]

Inspectors wroteThis Citation Pertains to Intake 2660956. Based on interview and record review, the facility failed to protect the one (#701) resident's right to be free from sexual abuse by another resident of three residents reviewed resulting in a non-verbal, severely cognitively impaired resident (#701) having their genital area touched by Resident #702, and staff not immediately separating the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to 1) Prevent and implement preventive measures to avoid pressure ulcers for 2 residents (Resident #39 and Resident #62) of 3 residents reviewed for pressure ulcers and 2) Follow through with the intervention of an air mattress for 1 resident (Resident #39), resulting in Resident #62 having a facility-acquired, preventable, Stage IV pressure ulcer and, for both residents, an increased likelihood for infection, cross contamination, antibiotic usage with side effects, pain, and discomfort. Findings Include: Resident #39: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure clean, reusable medical equipment for one resident (Resident #12) and hand hygiene for one resident (Resident #62), resulting in cross-contamination and the likelihood of further cross-contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to update and/or revise individualized, person-centered care plans to reflect changing needs for 4 residents (#6, #39, #52, #62) of 18 residents reviewed for care plans, resulting in the potential for unmet care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure dignity for 2 residents (Resident's #39 and Resident #51) of 3 residents reviewed for dignity (call light response time) and residents from the confidential Resident Council group meeting (held on 4/16/25), regarding call light response times. Findings Include: Resident #51: Review of the Face Sheet, MDS dated 2/24, nurse's progress notes dated 2/1/24 through 4/15/25, revealed Resident #39 was [AGE] years old, mild cognitive impairment, admitted to the facility on [DATE], and dependent on staff for Activities of Daily Living/ADL's. The resident's diagnosis included, high blood pressure, heart failure, lymphedema, unsteadiness, lack of coordination, chronic kidney disease, anxiety disorder, cardiac pacemaker with a history of right breast cancer. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to inform/educate 13 of 13 residents who attended the confidential group meeting about the location of the survey results and failed to ensure that the recent State Survey and Plan of Correction were readily accessible, affecting all Residents in the facility of a census of 89, resulting in Residents, Resident Representatives, visitors and staff being unable to review the survey results and plan of correction.

Inspectors wroteBased on observation, interview and record review, the facility failed to 1) Maintain food preparation and kitchen equipment in a sanitary condition, and 2) Ensure that all partly used, opened foods had a use-by date. Findings Include: Review of the Public Health Service 2009 Food Code, adopted by the Michigan Food Law, effective October 1, 2012, Chapter 4-501.14 directs that equipment cleaning frequency is to be throughout the day at frequency necessary to prevent recontamination of equipment and utensils. 4-602.11 Equipment Food-Contact Surfaces and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be cleaned: (5) At any time during the operation when contamination may have occurred. During the initial kitchen tour done on 3/11/25 at 7:35 AM, accompanied by Dietary [NAME] C, the following observations were made: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to adequately supervise and prevent injuries/falls for three residents (Resident #7, Resident #18, Resident #279), resulting in multiple injuries of residents and prolonged illness and hospitalizations.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow policies and procedures for medication labeling and storage in 3 of 3 Medication carts reviewed, 1 of 2 Medication rooms reviewed and narcotic reconciliation, resulting in opened and undated multi-dose medications, and the disposal of expired medications and altered medication efficiency with the likelihood of misappropriation going unnoticed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly wash food contact surfaces, resulting in an increased risk of foodborne illness, affecting all residents that consume food from the kitchen.

Inspectors wroteDeficient Practice Statement (DPS) One: Based on observation, interview and record review, the facility failed to implement and operationalize a comprehensive infection control program, encompassing effective outcome and process surveillance, accurate data collection/documentation/analysis and failed to ensure appropriate Personal Protective Equipment (PPE) utilization and staff knowledge for transmission-based isolation precautions resulting in lack of accurate and comprehensive infection control tracking, surveillance and data monitoring/analysis and the likelihood for spread of microorganisms and illness to all 71 facility residents.

Inspectors wroteThis Citation Pertains to Intake Number MI00143143. Based on interview and record review, the facility failed to prevent staff-to-resident verbal abuse for one resident (Resident #47) of three residents reviewed, resulting in a staff yelling at and calling Resident #47 derogatory names, Resident #47 expressing signs and symptoms of distress and fear, and the likelihood for ongoing psychosocial distress utilizing the reasonable person concept.

Inspectors wroteBased on interview and record review, the facility 1) Failed to document abdominal/bowel assessment and treatment for a change of condition for one resident (Resident #279) and 2) Failed to thoroughly assess a resident with new onset pain and swelling, notify the physician and provide timely interventions for one resident (Resident #18) resulting in the likelihood for missed identification and assessment of changes in condition and delays in treatment.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow up on a change in nutritional status for one (Resident #12) resulting in weight changes going unassessed with the likelihood of further weight change going unassessed.

Inspectors wroteBased on observation, interview and record review, the facility failed to properly label and date an Intravenous (IV) medication for one (Resident #32), resulting in the lack of date and time of administration with the likelihood of reuse of IV tubing and/or wrong administration times.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement and operationalize procedures to ensure accurate documentation, reconciliation, and oversight of controlled drugs in one (Two East) of six medication carts resulting in inaccurate narcotic medication documentation and reconciliation.

Inspectors wroteBased on record review the facility failed to follow up on an as needed (PRN) psychotropic medication (Ativan) for one (Resident #7), resulting in the lack of documented assessment of the need for the continued PRN medication.