Cycle 1
Health 2025-02-07 · Fire 2025-02-07
10 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Bay City, MI
Bay Shores Senior Care and Rehab Center
3-star overall rating with 3-star inspections with 10 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
3254 E Midland Rd, Bay City, MI
(989) 686-3770
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
126
Certified beds
Average residents
117
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Nexcare Health Systems
Operator or chain grouping
Approved since
1979-04-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.78
Registered nurse staffing
LPN hours / resident day
0.55
Licensed practical nurse staffing
Aide hours / resident day
2.34
Nurse aide staffing
Weekend hours
3.26
Weekend nurse staffing
RN turnover
32%
Annual RN turnover
Total nurse turnover
44%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
1.7
0.2 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.5
0.7 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
95.0%
4.4 pts better
|
93.4%
6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.0% |
95.0%
4 pts better
|
95.5%
3.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.0% |
3.1%
0.9 pts worse
|
3.3%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 3.4% |
4.1%
0.7 pts better
|
11.4%
8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 5.8% |
5.5%
0.3 pts worse
|
5.4%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.0% |
19.6%
4.6 pts better
|
19.6%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 13.5% |
16.5%
3 pts better
|
16.7%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 8.0% |
13.9%
5.9 pts better
|
16.3%
8.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.4% |
11.7%
2.3 pts better
|
14.9%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.9% |
0.9%
1 pts worse
|
1.0%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.9% |
1.7%
0.8 pts better
|
1.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 6.3% |
20.4%
14.1 pts better
|
19.8%
13.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 3.0% |
5.6%
2.6 pts better
|
5.1%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.7% |
82.8%
8.9 pts better
|
81.7%
10 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.8% |
11.5%
1.7 pts better
|
12.0%
2.2 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.2% |
1.3%
0.1 pts better
|
1.6%
0.4 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.5% |
79.5%
11 pts better
|
79.7%
10.8 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.0% |
24.2%
0.8 pts worse
|
23.9%
1.1 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-07 · Fire 2024-02-07
10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-12-13 · Fire 2022-12-13
12 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-25
E · Potential for more than minimal harm
2025-02-07
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-02-25
F · Potential for more than minimal harm
2024-02-07
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-03-05
E · Potential for more than minimal harm
2024-02-07
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-03-05
E · Potential for more than minimal harm
2024-02-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-05
E · Potential for more than minimal harm
2022-12-13
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 2023-01-10
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-02-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-25
D · Potential for more than minimal harm
2025-02-07
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-02-25
D · Potential for more than minimal harm
2025-02-07
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-02-25
D · Potential for more than minimal harm
2025-02-07
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 2025-02-25
D · Potential for more than minimal harm
2025-02-07
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-02-25
D · Potential for more than minimal harm
2025-02-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-25
D · Potential for more than minimal harm
2025-02-07
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-02-25
D · Potential for more than minimal harm
2025-02-07
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-02-25
D · Potential for more than minimal harm
2025-02-07
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2025-02-25
D · Potential for more than minimal harm
2025-02-07
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-02-25
D · Potential for more than minimal harm
2025-02-07
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 2025-02-25
F · Potential for more than minimal harm
2024-02-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-05
E · Potential for more than minimal harm
2024-02-07
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-03-05
E · Potential for more than minimal harm
2024-02-07
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-03-05
E · Potential for more than minimal harm
2024-02-07
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-03-05
D · Potential for more than minimal harm
2024-02-07
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-03-05
D · Potential for more than minimal harm
2024-02-07
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-03-05
D · Potential for more than minimal harm
2024-02-07
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-03-05
D · Potential for more than minimal harm
2024-02-07
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 2024-03-05
D · Potential for more than minimal harm
2024-02-07
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 2024-03-05
G · Actual harm
2022-12-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-01-10
F · Potential for more than minimal harm
2022-12-13
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-01-10
F · Potential for more than minimal harm
2022-12-13
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 2023-01-10
E · Potential for more than minimal harm
2022-12-13
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2023-01-10
E · Potential for more than minimal harm
2022-12-13
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-01-10
D · Potential for more than minimal harm
2022-12-13
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-01-10
D · Potential for more than minimal harm
2022-12-13
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-01-10
D · Potential for more than minimal harm
2022-12-13
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-01-10
D · Potential for more than minimal harm
2022-12-13
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-01-10
D · Potential for more than minimal harm
2022-12-13
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-01-10
D · Potential for more than minimal harm
2022-12-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-01-10
D · Potential for more than minimal harm
2022-12-13
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2023-01-10
Penalties and ownership
What sits behind the stars
Ownership
Nexcare Holdings, LLC
5% Or Greater Direct Ownership Interest · Organization
Branscum, James
5% Or Greater Indirect Ownership Interest · Individual
Eisenberg, Leo
5% Or Greater Indirect Ownership Interest · Individual
Koch, William
W-2 Managing Employee · Individual
Nexcare Health Systems, LLC
Operational/Managerial Control · Organization
Perry, Michael
Corporate Officer · Individual
Robin Eisenberg 2014 Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Sangster, Todd
Corporate Officer · Individual
Wronski, Frank
5% Or Greater Indirect Ownership Interest · Individual
Nearby options
Other facilities in reach
#1
Carriage House Nursing and Rehabilitation
Bay City, MI
3-star overall rating with 3-star inspections with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Hampton Nursing and Rehabilitation
Bay City, MI
4-star overall rating with 3-star inspections with 9 recent health deficiencies
#3
Caretel Inns of Tri-Cities
Bay City, MI
1-star overall rating with 1-star inspections with $251,642 in total fines with 20 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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