Cycle 1
Health 2025-04-17 · Fire 2025-04-17
5 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Harbor Springs, MI
Bay Bluffs-Emmet County Medical Care Facility
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
750 East Main Street, Harbor Springs, MI
(231) 526-2161
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
69
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.51
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.70
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
3.22
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
5.43
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
2.21
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
4.33
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.74
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
1.76
CMS adjusted RN staffing hours
Adjusted total hours
6.35
CMS adjusted total nurse staffing hours
Case-mix index
1.17
Higher values indicate more complex resident acuity
RN turnover
17%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
21%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
320
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
73.27
Composite VBP score used to determine payment impact.
Payment multiplier
1.0238
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.64
Baseline 18.35% · Performance 18.36% · Measure score 6.64 · Achievement 6.64 · Improvement 0
Healthcare-associated infections
2.67
Baseline 5.71% · Performance 7.04% · Measure score 2.67 · Achievement 2.67 · Improvement 0
Total nurse turnover
10
Baseline 23.08% · Performance 18.42% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
10
Baseline 5.46 hours · Performance 5.90 hours · Measure score 10 · Achievement 10 · Improvement 9
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.66% |
10.72%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 105 · Observed rate 10.48% · Lower 95% interval 8.47% |
| Discharge to community | 56.78% |
50.57%
6.2 pts better
|
No Different than the National Rate · Eligible stays 99 · Observed rate 59.6% · Lower 95% interval 47.06% |
| Medicare spending per beneficiary | 0.75 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 98% |
95.27%
2.7 pts better
|
Numerator 49 · Denominator 50 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 50 |
| Discharge self-care score | 47.73% |
53.69%
6 pts worse
|
Numerator 21 · Denominator 44 |
| Discharge mobility score | 34.09% |
50.94%
16.8 pts worse
|
Numerator 15 · Denominator 44 |
| Pressure ulcers or injuries, new or worsened | 2% |
2.29%
0.3 pts better
|
Numerator 1 · Denominator 50 · Adjusted rate 2.65% |
| Healthcare-associated infections requiring hospitalization | 7.04% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 62 · Observed rate 4.84% · Lower 95% interval 4.19% |
| Staff COVID-19 vaccination coverage | 2.82% |
8.2%
5.4 pts worse
|
Numerator 4 · Denominator 142 |
| Staff flu vaccination coverage | 44.17% |
42%
2.2 pts better
|
Numerator 72 · Denominator 163 |
| Discharge function score | 65.91% |
56.45%
9.5 pts better
|
Numerator 29 · Denominator 44 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 29 · Denominator 29 |
| Resident COVID-19 vaccinations up to date | 38.1% |
25.2%
12.9 pts better
|
Numerator 8 · Denominator 21 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.4 |
1.7
1.3 pts better
|
1.9
1.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.3 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
1.5
0.9 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.5 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
95.0%
5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.7% |
95.0%
0.3 pts worse
|
95.5%
0.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.8% |
3.1%
1.3 pts better
|
3.3%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 1.9% · Q3 1.9% · Q4 1.6% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
4.1%
4.1 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 5.6% |
5.5%
0.1 pts worse
|
5.4%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 4.2% · Q3 4.4% · Q4 7.7% · 4Q avg 5.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.5% |
19.6%
10.1 pts better
|
19.6%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 8.3% · Q3 11.1% · Q4 11.1% · 4Q avg 9.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.9% |
16.5%
3.6 pts better
|
16.7%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 18.4% · Q3 10.3% · Q4 12.5% · 4Q avg 12.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 20.3% |
13.9%
6.4 pts worse
|
16.3%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 20.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.4% |
11.7%
9.7 pts worse
|
14.9%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.8% · Q2 25.0% · Q3 21.6% · Q4 21.7% · 4Q avg 21.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.4% |
0.9%
2.5 pts worse
|
1.0%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 5.0% · Q3 4.5% · Q4 1.7% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.5% |
1.7%
1.2 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.9% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.0% |
20.4%
1.6 pts worse
|
19.8%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.5% · Q2 32.3% · Q3 19.2% · Q4 21.4% · 4Q avg 22.0% |
| Percentage of long-stay residents with pressure ulcers | 5.4% |
5.6%
0.2 pts better
|
5.1%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 8.3% · Q3 7.2% · Q4 1.9% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.3% |
82.8%
15.5 pts better
|
81.7%
16.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.5% · Q2 98.6% · Q3 100.0% · Q4 94.6% · 4Q avg 98.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.0% |
11.5%
1.5 pts better
|
12.0%
2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.0% · Observed 8.6% · Expected 9.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.3%
0.6 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.8% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 47.3% |
79.5%
32.2 pts worse
|
79.7%
32.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 47.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 13.2% |
24.2%
11 pts better
|
23.9%
10.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 13.2% · Observed 8.6% · Expected 15.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-17 · Fire 2024-04-17
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-05-11 · Fire 2023-05-11
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
11 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-17
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2025-04-21
F · Potential for more than minimal harm
2025-04-17
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-04-28
F · Potential for more than minimal harm
2025-04-17
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-04-28
F · Potential for more than minimal harm
2025-04-17
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-04-30
F · Potential for more than minimal harm
2025-04-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-30
F · Potential for more than minimal harm
2025-04-17
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2025-04-30
F · Potential for more than minimal harm
2025-04-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-06-18
E · Potential for more than minimal harm
2025-04-17
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-06-17
E · Potential for more than minimal harm
2025-04-17
K361 · Smoke Deficiencies
Fire Safety
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Corrected 2025-04-30
F · Potential for more than minimal harm
2024-04-17
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-05-13
E · Potential for more than minimal harm
2024-04-17
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-04-26
D · Potential for more than minimal harm
2024-04-17
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-04-24
F · Potential for more than minimal harm
2023-05-11
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-05-23
F · Potential for more than minimal harm
2023-05-11
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-05-22
F · Potential for more than minimal harm
2023-05-11
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-06-07
F · Potential for more than minimal harm
2023-05-11
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-05-23
F · Potential for more than minimal harm
2023-05-11
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-05-23
F · Potential for more than minimal harm
2023-05-11
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-05-23
F · Potential for more than minimal harm
2023-05-11
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2023-08-23
F · Potential for more than minimal harm
2023-05-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-07-17
E · Potential for more than minimal harm
2023-05-11
K343 · Smoke Deficiencies
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2023-06-26
E · Potential for more than minimal harm
2023-05-11
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2023-05-12
D · Potential for more than minimal harm
2023-05-11
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-05-23
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-04-17
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-04-17
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-04-17
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-04-17
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-04-17
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-05-15
F · Potential for more than minimal harm
2024-04-17
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-04-26
D · Potential for more than minimal harm
2024-04-17
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-04-26
F · Potential for more than minimal harm
2023-05-11
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-06-15
D · Potential for more than minimal harm
2023-05-11
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-05-26
Penalties and ownership
What sits behind the stars
Ownership
County Of Emmet
5% Or Greater Direct Ownership Interest · Organization
Becker, Sherry
W-2 Managing Employee · Individual
Greer, Michael
Corporate Officer · Individual
Hansen, Carol
Corporate Director · Individual
Horrom, Mary
Corporate Director · Individual
Mroczkowski, Gayle
Corporate Director · Individual
Nearby options
Other facilities in reach
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1-star overall rating with 1-star inspections with $241,488 in total fines with 18 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#2
Boulder Park Terrace
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1-star overall rating with 1-star inspections with abuse icon flag with 29 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
#3
Grandvue Medical Care Facility
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3-star overall rating with 2-star inspections with abuse icon flag with 11 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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