Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bay Shores Senior Care And Rehab Center during CMS and state inspections, most recent first.
A facility failed to administer Tamiflu timely to a resident with Influenza A due to inadequate follow-up with the resident's DPOA. Additionally, a nurse did not use a barrier or properly disinfect a blood glucose machine, leading to potential contamination. The facility's policy lacked clear disinfection procedures.
A resident with Lymphedema and a leg fracture experienced missed wound care treatments due to staffing shortages, leading to non-compliance with physician's orders. The resident expressed frustration over the missed treatments, which were not documented in the progress notes, and reported that their sister had to intervene to ensure care was provided.
The facility inaccurately coded the MDS for a resident, indicating restraint usage when none was present, and failed to document another resident's Influenza A infection on the CMS 802 form. The errors were identified through observations and interviews, revealing discrepancies in the MDS coding process and infection documentation.
A facility failed to timely assess a resident's transfer and mobility needs, leading to unsupervised self-ambulation and an incomplete care plan. The resident, with Alzheimer's and other conditions, was found in a compromised state due to inadequate assistance. Staff interviews revealed confusion about the resident's needs, which were only addressed after the deficiency was noted.
The facility failed to update care plans for three residents, leading to potential missed interventions. A resident had fluids placed out of reach, contrary to care plan interventions. Another resident did not receive a shower for six days, despite care plan requirements. Additionally, a resident's care plan contained contradictory information about trauma history, not reflecting evaluation findings.
A resident did not receive scheduled showers for six days after admission, leading to family complaints. Despite the facility's policy for twice-weekly showers, the resident was not bathed until the family intervened. Staff interviews revealed communication and documentation failures, as refusals were not properly recorded, contributing to the deficiency.
Two residents in an LTC facility experienced pressure ulcer development and worsening due to the facility's failure to implement care plan interventions. One resident's Stage II ulcer progressed to Stage IV, while another developed a Deep Tissue Injury. Despite care plans including repositioning and pressure relief measures, these were not consistently followed, leading to the deterioration of their conditions.
The facility failed to provide adequate feeding assistance and prevent weight loss for two residents. One resident was observed without dining assistance, despite requiring total assistance with meals, and was found with unopened meal items. Another resident experienced significant weight loss without timely re-weighing or intervention, with water placed out of reach and inconsistent weighing methods. The facility did not adhere to its policies on weight monitoring and nutrition risk, leading to deficiencies in care.
The facility failed to properly administer insulin to a resident by not priming the insulin pen needle, contrary to policy. Additionally, another resident received an incorrect dosage of Renvela, as the facility administered 800 mg instead of the prescribed 1600 mg three times daily. These errors were identified through observations, interviews, and record reviews.
A facility failed to ensure safe medication storage when a nurse stored a resident's medications in an unlabeled cup in a medication cart drawer. The medications were not signed out as given, and the nurse stated they were stored because the resident was unavailable. The DON noted that new nurses typically do not perform medication passes, indicating a deviation from the facility's procedures.
The facility failed to obtain informed consent for psychotropic medications for two residents. One resident was prescribed Alprazolam, Lamictal, and Quetiapine Fumarate without consent for the latter two medications. Another resident had their Depakote dosage increased without a clear indication or diagnosis of seizures. The facility did not adhere to its policy on psychotropic medication use, resulting in administration without proper documentation and justification.
Infection Control and Medication Administration Deficiencies
Penalty
Summary
The facility failed to provide timely antiviral medication for a resident diagnosed with Influenza A. The resident, who had a history of Chronic Obstructive Pulmonary Disease, Vascular Dementia, Diabetes, Hypertension, and Atrial Fibrillation, was not administered Tamiflu despite testing positive for Influenza A. The facility attempted to contact the resident's son, who is the durable power of attorney, to obtain consent for Tamiflu administration. However, only one documented attempt was made, and no further follow-up was conducted, resulting in the resident being outside the efficacy window for Tamiflu. Additionally, the facility did not ensure proper infection control practices. A nurse was observed preparing medications without using a barrier and failed to properly disinfect a blood glucose machine before storing it with other supplies. The facility's policy did not specify the cleaning and disinfection procedures for the blood glucose meters between residents, leading to potential contamination of the medication cart and supplies.
Missed Wound Care Treatments Due to Staffing Issues
Penalty
Summary
The facility failed to ensure timely completion of wound care for a resident, resulting in missed treatments and not following physician's orders. Resident #93, who was readmitted on January 10, 2025, with diagnoses including Lymphedema, a left lower leg fracture, and Obesity, required assistance with all Activities of Daily Living and had intact cognition. The Treatment Administration Record for January 2025 indicated missed wound care treatments on January 21 and January 31, as the boxes were left blank. Similarly, the record for February 2025 showed a missed treatment on February 5. There was no documentation in the progress notes explaining the reasons for these missed treatments. On February 5, 2025, Resident #93 expressed frustration over missed wound care treatments, attributing them to staff shortages. The resident reported that their sister had to call the nurse to address the missed dressing change, and when the nurse arrived, they stated they did not have time to perform the dressing change. This situation highlights the facility's failure to provide care according to the resident's needs and physician's orders, leading to dissatisfaction and voiced complaints from the resident.
Inaccurate MDS Coding and Infection Documentation
Penalty
Summary
The facility failed to accurately code the MDS for Resident #24, resulting in a misclassification of restraint usage. During an observation, Resident #24 was found resting in bed without any restraints, and both the resident and Nurse O confirmed that no restraints were used. However, the MDS completed by Nurse P offsite incorrectly indicated the use of limb restraints less than daily. This error was identified when MDS Nurse Q reviewed the coding and confirmed the misclassification. Resident #24's clinical records did not support the use of restraints, highlighting a discrepancy in the MDS coding process. Additionally, the facility did not properly reflect Resident #61's infection status on the CMS 802 form. During the initial tour, it was noted that Resident #61 was positive for Influenza A and was under transmission-based precautions. However, the MDS Resident Matrix did not indicate any current infections for Resident #61. The DON confirmed that the resident's positive influenza status should have been documented on the matrix, as the resident had been symptomatic and tested positive for Influenza A prior to the survey. This oversight in documentation led to an inaccurate representation of the resident's health status on the CMS 802 form.
Failure to Timely Assess Resident's Transfer Needs
Penalty
Summary
The facility failed to ensure a timely assessment of transfer and mobility status for a resident, resulting in unsupervised self-ambulation and an incomplete baseline care plan. The resident, who was admitted with diagnoses including Alzheimer's disease, hypertension, and glaucoma, was observed in a compromised situation in their bathroom, indicating a lack of proper assistance and supervision. The care plan initially lacked specific details on the level of assistance required for the resident's transfers, which was not addressed until several days after admission. Interviews with staff revealed a lack of clarity and communication regarding the resident's transfer needs. The Rehab Director assumed the resident was signing onto hospice and did not recommend a transfer status, while the Director of Nursing was unaware of the resident's specific needs until alerted. The care plan and Kardex were subsequently updated to reflect the resident's transfer and ambulation requirements, but this was only done after the deficiency was identified.
Failure to Update Care Plans and Address Resident Needs
Penalty
Summary
The facility failed to update care plan interventions for three residents, leading to potential missed interventions and unmet needs. For Resident #23, observations revealed that fluids were consistently placed out of reach, despite care plan interventions indicating the need for accessible call lights and encouragement of fluid intake. The CNA's actions of removing the call light and placing fluids out of reach were not documented in the care plan, which lacked any rationale for these actions. Resident #164 experienced a delay in receiving showers, as reported by a family member. The resident was admitted to the facility and did not receive a shower for six days, despite the care plan indicating a need for showers twice a week. The facility's records did not document any refusals by the resident, and the family had to repeatedly request a shower, highlighting a lack of adherence to the care plan and communication with the family. For Resident #24, there was a contradiction in the care plan regarding the resident's trauma history. The care plan contained conflicting information about the resident's trauma assessment, which was not updated to reflect the Level II OBRA evaluation findings. The social worker acknowledged the discrepancy, noting that the care plan should have been updated to incorporate the evaluation information, but it was not due to the resident not sharing those specifics directly with the social worker.
Failure to Provide Scheduled Showers for Resident
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care for a resident, resulting in frustration and complaints. The facility's policy, dated 7/1/2008, aimed to assist residents in achieving maximum functional ability with dignity and self-esteem. However, the facility did not adhere to its policy, as evidenced by the lack of showers provided to a resident who had been admitted on 1/31/2025. The resident did not receive a shower until 2/5/2025, despite the facility's schedule indicating showers should occur twice a week. The resident's family member repeatedly requested a shower, highlighting the resident's unmet needs and poor hygiene. Interviews with facility staff revealed a breakdown in communication and documentation. The social work designee was informed of the issue by the family member and notified the unit manager, who assured that the resident would receive a shower. However, the resident was only offered a shower on 2/4/2025, which was refused, and no further attempts were documented. The facility's failure to document refusals and ensure the resident received scheduled showers led to the family member's complaint to the state surveyor. The lack of adherence to the shower schedule and inadequate documentation contributed to the deficiency in care.
Failure to Prevent Pressure Ulcer Development and Worsening
Penalty
Summary
The facility failed to implement and operationalize policies and procedures to prevent the development and worsening of pressure ulcers for two residents. Resident #4's Stage II pressure ulcer progressed to a Stage IV ulcer while at the facility. Despite being cognitively intact and requiring assistance for mobility and hygiene, Resident #4 was not repositioned regularly by staff, as confirmed by the resident and staff interviews. The resident's care plan included interventions such as an air mattress and education on repositioning, but these were not effectively implemented, leading to the deterioration of the pressure ulcer. Resident #217 developed an unstageable Deep Tissue Injury (DTI) on their heel while at the facility. The resident was severely cognitively impaired and dependent on staff for transfers. Despite being at risk for pressure ulcer development, the resident's care plan interventions, such as floating heels and repositioning, were not consistently followed. Observations revealed the resident's heel was often positioned directly against the mattress, and staff were unaware of the pressure ulcer until it had developed. Interviews with facility staff, including the DON, confirmed the lack of consistent implementation of care plan interventions for both residents. The facility's policy on wound management aimed to prevent skin breakdown and promote healing, but the failure to adhere to these guidelines resulted in the development and worsening of pressure ulcers for the residents. The DON acknowledged the deficiencies in care and the need for appropriate interventions to prevent further deterioration.
Failure to Provide Feeding Assistance and Prevent Weight Loss
Penalty
Summary
The facility failed to provide adequate feeding assistance and prevent weight loss for two residents, leading to deficiencies in their care. Resident #43 was observed without dining assistance at her bedside, despite her care plan indicating she required total assistance with meals. During an observation, she was found alone with her lunch tray, which included unopened items, indicating she was not receiving the necessary help to consume her meal. The facility's staff, including the Administrator and Culinary Specialist, acknowledged that the resident should have been assisted with her meal, as per her meal ticket instructions. Resident #23 experienced significant weight loss, losing 10 pounds within a short period, without timely re-weighing or intervention. Observations revealed that water was consistently placed out of reach, and a CNA expressed concern about the resident drinking too fast, which could lead to choking. Despite the resident's care plan indicating the need for encouragement of fluid intake and offering snacks/drinks, these interventions were not effectively implemented. The resident's weight log showed inconsistent weighing methods, contributing to the lack of timely response to the weight loss. The facility's policies on weight monitoring and nutrition risk were not adequately followed, as evidenced by the lack of re-weighing and intervention for Resident #23's weight loss. The Registered Dietitian confirmed the inconsistency in weighing methods and the absence of a re-weight after the initial 10-pound loss. These deficiencies highlight the facility's failure to adhere to its own policies and provide necessary nutritional support to residents at risk.
Medication Administration Errors in Insulin and Renvela Dosage
Penalty
Summary
The facility failed to ensure proper insulin administration for Resident #57, as observed on February 6, 2025. Nurse H prepared the insulin pen without priming the needle with the required 2 units of insulin before administering the dose into the resident's abdomen. This action was against the facility's Medication Administration Subcutaneous Insulin policy, which mandates performing a safety test to ensure accurate dosing and proper functioning of the pen and needle. The Director of Nursing was informed of this deviation from protocol. Additionally, the facility did not provide the correct medication dosage for Resident #164. The resident was supposed to receive 1600 mg of Renvela (sevelamer carbonate) three times daily, as per hospital discharge instructions. However, the facility ordered and administered only 800 mg three times daily. This discrepancy was noted by the resident's family member and was confirmed through a review of the resident's Medication Administration Record and hospital discharge paperwork. The error was acknowledged by a Registered Nurse, who stated that the family had brought it to their attention, and it was subsequently corrected.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure safe medication storage practices, as observed during a medication storage task. A clear plastic unlabeled medication cup filled with numerous medications was found in a medication cart drawer labeled 227-1. This cup contained the morning oral medications for a resident, and the medications were not signed out as given by the nurse responsible for the cart. The nurse explained that the medications were placed in the cup because the resident was unavailable at the time. Further investigation revealed that the nurse's competency for medication administration was questioned, as the Director of Nursing (DON) indicated that new nurses typically do not perform medication passes. The facility's guidelines state that medications should be administered at the time they are prepared when using a mobile cart. This incident highlights a deviation from the facility's medication administration procedures, leading to the deficiency in medication storage and administration practices.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure appropriate indication and informed consent for psychotropic medication administration for two residents. Resident #46 was prescribed multiple psychotropic medications, including Alprazolam, Lamictal, and Quetiapine Fumarate, without obtaining informed consent for Lamictal and Quetiapine Fumarate. The facility's policy required informed consent and education regarding potential side effects, but these were not documented for these medications. Interviews with the RN Clinical Care Coordinator and the Social Worker confirmed the absence of consent forms and medication information sheets for these drugs. Resident #47 experienced an inappropriate increase in Depakote dosage without a clear indication or diagnosis of seizures, which was the reason given for the dosage increase. The resident's medical record indicated diagnoses of Anxiety Disorder, Alzheimer's Disease, and Dementia, but not seizures. Despite a recommendation from the Behavioral Care Services to maintain the current medication plan, the dosage was increased based on low lab levels of valproic acid. The Director of Nursing confirmed the increase but could not provide a rationale consistent with the resident's documented conditions. The facility's failure to adhere to its policy on psychotropic medication use and informed consent resulted in the administration of medications without proper documentation and justification. This oversight increased the potential for serious side effects and adverse reactions in the residents involved, as the necessary risk versus benefit analysis and consent process were not completed.
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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) |
|---|---|---|---|---|
| Carriage House Nursing And Rehabilitation | 1.6 mi | — | 1 | 0 |
| Hampton Nursing And Rehabilitation | 3.1 mi | — | 0 | 0 |
| Caretel Inns Of Tri-cities | 4.1 mi | — | 2 | 0 |
| Bay County Medical Care Facility | 6.2 mi | — | 2 | 0 |
| Huron Woods Nursing Center | 7 mi | — | 14 | 0 |
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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 August 2026) and official state health department websites.