Bay Shores Senior Care and Rehab Center

In the surveyor’s words

From the most serious findings on record at Bay Shores Senior Care and Rehab Center, in the surveyor’s own words.

• Actual harm, isolatedF684Dec 13, 2022

  Based on observation, interview and record review, the facility 1) Failed to provide wound care as ordered and prevent an infection for one resident (Resident #48) and 2) Failed to follow hospital discharge instructions for one resident (Resident #285) of two residents reviewed for quality of care, resulting in a missed dressing change, pain, infection, distended bladder and abdomen, and hospitalization with the likelihood of a further complication of ruptured bladder and/or death. Findings include: Resident #48: On 12/07/22, at 9:53 AM, Resident #48 was lying in their bed. There was a white dressing to their right lower leg that was dated 12/3. […]

• No harm, potential for more than minimal, widespreadF812Mar 12, 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 who consume food from the kitchen. Findings include: On 03/10/2026 at 8:44 AM, during the initial kitchen tour, observed residue on the blade of a carving fork, stored inside the knife holder. On 03/10/2026 at approximately 9:08 AM, observed built up residue on juice nozzles. During this observation, Dietary Manager F was asked how often the juice nozzles are cleaned, and he stated the nozzles are soaked after each meal.According to the 2022 Food Code, 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, Equipment food-contact surfaces and utensils shall be clean to… […]

• No harm, potential for more than minimal, widespreadF880Mar 12, 2026

  Based on observation, interview, and record review, the facility failed to have an active plan for reducing the risk of l\Legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in waterborne pathogens being allowed to exist and spread in the facility's plumbing system with an increased risk of respiratory infection among all residents in the facility. Findings include: On 03/10/2026 at 1:07 PM, during the environmental tour with Maintenance Director H, free chlorine residual was tested at a bathroom hand sink, and the result was zero parts per million (ppm) in room [ROOM NUMBER]. During this observation, Maintenance Director H stated that free chlorine is usually at 0.5 ppm. […]

• No harm, potential for more than minimal, widespreadF880Feb 7, 2024

  Based on observation, interview and record review, the facility failed to follow infection control practices related to the use of: (1.) Personal Protective Equipment (PPE), follow-up with employee health call-ins and (2.) proper hand hygiene, clean accu-check machine properly during medication pass and keep wound vac tubing off floor resulting in the likelihood for cross contamination and prolonged illness. Findings include: Record review of the facility 'Infection Prevention and Control Program' policy dated 11/22/2019 revealed the purpose of this policy is to provide guidelines for maintaining an infection prevention and control program that provides a safe, sanitary, and comfortable environment to help prevent the development and transmission of infection. […]

• No harm, potential for more than minimal, widespreadF550Dec 13, 2022

  Based on observation, interview, and record review, the facility 1) Failed to ensure resident dignity by not allowing all residents to dine in dining rooms daily and during holiday meals (Michigan, Superior and [NAME] dining rooms; total of 28 tables, one resident with family members per table, leaving 46 residents to eat in their rooms), and 2) Failed to ensure adequate daily and holiday meal servings for all residents to eat in dining rooms of 19 residents sampled for dignity of a total census of 85 residents, resulting in verbalizations of anger, unfairness, and frustration, with the likelihood for isolation, decreased socialization and low self-esteem. […]