Bay Bluffs-Emmet County Medical Care Facility

In the surveyor’s words

From the most serious findings on record at Bay Bluffs-Emmet County Medical Care Facility, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jan 7, 2021

  Based on observation, interview, and record review, the facility failed to adequately supervise one cognitively impaired Resident (#100) of four residents reviewed for wandering/elopement, who eloped from the facility and was found by off-duty staff and a local police officer approximately 3 hours later attempting to climb over a fence on private property. This deficient practice resulted in the likelihood of injury for Resident #100 and the potential for unsafe exit from the facility for other wandering residents. […]

• No harm, potential for more than minimal, widespreadF730May 13, 2026

  Based 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.Findings include:Review of facility personnel records demonstrated the following:CNA B was hired on 11/11/19 with no performance review.CNA J was hired on 1/8/24 with no performance review.CNA K was hired on 11/6/22 with no performance review.CNA L was hired on 11/7/21 with no performance review.CNA M was hired on 10/13/08 with no performance review.During an interview on 5/13/26 at 8:42 a.m., when queried about staff… […]

• No harm, potential for more than minimal, widespreadF812May 13, 2026

  Based 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. […]

• No harm, potential for more than minimal, widespreadF880May 13, 2026

  Based 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. Findings include: On 5/11/2026 at 1:29 PM, two water fountains were observed on Lilac Lane with clear plastic bags wrapped around them and out of order signs posted above each fountain. […]

• No harm, potential for more than minimal, widespreadF947May 13, 2026

  Based 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. Findings include:During an interview on 5/13/26 at 7:41 a.m., the Director of Nursing (DON) reported the 12-hours of training in a year is based on the CNA's hire date. The DON acknowledged the facility uses online training.Review of facility documents provided by the Nursing Home Administrator (NHA) revealed the following:CNA B was hired on 11/11/19 with 9.25 hours of training from 11/11/24-11/2/25CNA J was hired on 1/8/24 with 5.75 hours of training from 1/8/24-1/8/25.CNA K was hired on 11/6/22 with 7.25 hours of training from 11/6/24-11/7/25.CNA L was hired… […]