L' Anse, MI

Bayside Village

1-star overall rating with 1-star inspections with Special Focus status with $39,897 in total fines with 22 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle

832 Sicotte Street, L' Anse, MI

(906) 524-6531

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

1 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

1 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

59

Certified beds

Average residents

54

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1977-12-01

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

0.76

Registered nurse staffing · state 0.77 · national 0.68

LPN hours / resident day

0.57

Licensed practical nurse staffing · state 0.88 · national 0.87

Aide hours / resident day

1.90

Nurse aide staffing · state 2.38 · national 2.35

Total nurse hours

3.23

All reported nurse hours · state 4.03 · national 3.89

Licensed hours

1.34

RN + LPN hours · state 1.65 · national 1.54

Weekend hours

2.81

Weekend nurse staffing · state 3.52 · national 3.43

Weekend RN hours

0.54

Weekend registered nurse coverage · state 0.49 · national 0.47

Physical therapist

0.02

Reported PT staffing · state 0.07 · national 0.07

Adjusted RN hours

0.93

CMS adjusted RN staffing hours

Adjusted total hours

3.93

CMS adjusted total nurse staffing hours

Case-mix index

1.13

Higher values indicate more complex resident acuity

RN turnover

0%

Annual RN turnover

Total nurse turnover

0%

Annual nurse turnover

SNF VBP

Value-based purchasing

Program rank

6,796

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

31.67

Composite VBP score used to determine payment impact.

Payment multiplier

0.9866

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Healthcare-associated infections

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Total nurse turnover

5.25

Performance 42.22% · Measure score 5.25 · Achievement 5.25 · This facility did not have sufficient data to calculate a baseline period measure result.

Adjusted total nurse staffing

1.08

Baseline 2.58 hours · Performance 3.09 hours · Measure score 1.08 · Achievement 0 · Improvement 1.08

SNF QRP

Medicare quality reporting measures

Measure Facility National Note
Potentially preventable 30-day readmission Not Available
10.72%
Not Available · Eligible stays 19 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Discharge to community Not Available
50.57%
Not Available · Eligible stays 18 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Medicare spending per beneficiary Not Available
1.02
Too few residents or stays to report publicly.
Drug regimen review with follow-up Not Available
95.27%
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly.
Falls with major injury Not Available
0.77%
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly.
Discharge self-care score Not Available
53.69%
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly.
Discharge mobility score Not Available
50.94%
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened Not Available
2.29%
Numerator Not Available · Denominator 9 · Adjusted rate Not Available · Too few residents or stays to report publicly.
Healthcare-associated infections requiring hospitalization Not Available
7.12%
Not Available · Eligible stays 12 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage 1.15%
8.2%
7 pts worse
Numerator 1 · Denominator 87
Staff flu vaccination coverage 38.68%
42%
3.3 pts worse
Numerator 41 · Denominator 106
Discharge function score Not Available
56.45%
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly.
Transfer of health information to provider Not Available
95.95%
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly.
Transfer of health information to patient Not Available
96.28%
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date Not Available
25.2%
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure Facility State National Note
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 96.7%
95.0%
1.7 pts better
95.5%
1.2 pts better
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.7%
Percentage of long-stay residents experiencing one or more falls with major injury 3.6%
3.1%
0.5 pts worse
3.3%
0.3 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.8% · Q3 3.6% · Q4 8.9% · 4Q avg 3.6% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms 1.2%
4.1%
2.9 pts better
11.4%
10.2 pts better
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 0.0% · Q3 0.0% · Q4 2.8% · 4Q avg 1.2%
Percentage of long-stay residents who lose too much weight 5.2%
5.5%
0.3 pts better
5.4%
0.2 pts better
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 11.8% · Q3 1.9% · Q4 1.9% · 4Q avg 5.2%
Percentage of long-stay residents who received an antianxiety or hypnotic medication 24.5%
19.6%
4.9 pts worse
19.6%
4.9 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 23.5% · Q3 25.5% · Q4 24.1% · 4Q avg 24.5%
Percentage of long-stay residents who received an antipsychotic medication 33.7%
16.5%
17.2 pts worse
16.7%
17 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 35.0% · Q2 32.5% · Q3 31.2% · Q4 36.8% · 4Q avg 33.7% · 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 30.8%
13.9%
16.9 pts worse
16.3%
14.5 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 30.9% · Q2 48.5% · Q3 18.8% · Q4 23.0% · 4Q avg 30.8% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased 31.3%
11.7%
19.6 pts worse
14.9%
16.4 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 34.0% · Q2 30.6% · Q3 31.4% · Q4 29.2% · 4Q avg 31.3% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder 4.1%
0.9%
3.2 pts worse
1.0%
3.1 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 7.9% · Q3 3.7% · Q4 4.7% · 4Q avg 4.1% · 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 0.0% · Q3 0.0% · Q4 1.8% · 4Q avg 0.5% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence 23.6%
20.4%
3.2 pts worse
19.8%
3.8 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 21.1% · Q2 30.9% · Q3 20.1% · Q4 22.8% · 4Q avg 23.6%
Percentage of long-stay residents with pressure ulcers 5.7%
5.6%
0.1 pts worse
5.1%
0.6 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 4.4% · Q3 5.5% · Q4 10.8% · 4Q avg 5.7% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 68.8%
82.8%
14 pts worse
81.7%
12.9 pts worse
Short Stay · 2024Q4-2025Q3 · 4Q avg 68.8%

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-09-10 · Fire 2025-09-10

22 health deficiencies

Top issue: Nursing and Physician Services (5 deficiencies)

1 fire-safety deficiencies

Top issue: Emergency Preparedness (1 deficiency)

Cycle 2 Health 2024-07-11 · Fire 2024-07-11

17 health deficiencies

Top issue: Nursing and Physician Services (5 deficiencies)

5 fire-safety deficiencies

Top issue: Services (2 deficiencies)

Cycle 3 Health 2023-07-17 · Fire 2023-07-17

8 health deficiencies

Top issue: Pharmacy Service (3 deficiencies)

5 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-09-10

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2025-10-13

F · Potential for more than minimal harm 2024-07-11

K100 · Construction Deficiencies

Fire Safety

Meet other general requirements.

Corrected 2024-10-14

F · Potential for more than minimal harm 2024-07-11

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-08-23

E · Potential for more than minimal harm 2024-07-11

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2024-08-17

E · Potential for more than minimal harm 2024-07-11

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2024-08-23

D · Potential for more than minimal harm 2024-07-11

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2024-08-23

F · Potential for more than minimal harm 2023-07-17

E26 · Emergency Preparedness Deficiencies

Fire Safety

Establish roles under a Waiver declared by secretary.

Corrected 2023-08-15

F · Potential for more than minimal harm 2023-07-17

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2023-08-15

F · Potential for more than minimal harm 2023-07-17

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-08-15

F · Potential for more than minimal harm 2023-07-17

K741 · Miscellaneous Deficiencies

Fire Safety

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Corrected 2023-08-15

E · Potential for more than minimal harm 2023-07-17

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 2023-08-15

Inspection history

Recent health citations

J · Immediate jeopardy 2025-10-08

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 2025-11-21

G · Actual harm 2025-09-10

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 2025-12-22

F · Potential for more than minimal harm 2025-09-10

F727 · Nursing and Physician Services Deficiencies

Health

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Corrected 2025-10-13

F · Potential for more than minimal harm 2025-09-10

F730 · Nursing and Physician Services Deficiencies

Health

Observe each nurse aide's job performance and give regular training.

Corrected 2025-10-13

F · Potential for more than minimal harm 2025-09-10

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 2025-10-13

F · Potential for more than minimal harm 2025-09-10

F867 · Administration Deficiencies

Health

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Corrected 2025-10-13

F · Potential for more than minimal harm 2025-09-10

F868 · Administration Deficiencies

Health

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Corrected 2025-10-13

F · Potential for more than minimal harm 2025-09-10

F947 · Nursing and Physician Services Deficiencies

Health

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Corrected 2025-10-13

E · Potential for more than minimal harm 2025-09-10

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2025-10-13

E · Potential for more than minimal harm 2025-09-10

F628 · Resident Rights Deficiencies

Health

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Corrected 2025-11-06

E · Potential for more than minimal harm 2025-09-10

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 2025-12-22

D · Potential for more than minimal harm 2025-09-10

F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Corrected 2025-11-06

D · Potential for more than minimal harm 2025-09-10

F645 · Resident Assessment and Care Planning Deficiencies

Health

PASARR screening for Mental disorders or Intellectual Disabilities

Corrected 2025-10-13

D · Potential for more than minimal harm 2025-09-10

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 2025-10-13

D · Potential for more than minimal harm 2025-09-10

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2025-10-13

D · Potential for more than minimal harm 2025-09-10

F711 · Nursing and Physician Services Deficiencies

Health

Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.

Corrected 2025-12-22

D · Potential for more than minimal harm 2025-09-10

F712 · Nursing and Physician Services Deficiencies

Health

Ensure that the resident and his/her doctor meet face-to-face at all required visits.

Corrected 2025-10-13

D · Potential for more than minimal harm 2025-09-10

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2025-10-13

D · Potential for more than minimal harm 2025-09-10

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2025-10-13

G · Actual harm 2025-05-07

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-08-08

G · Actual harm 2025-05-07

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 2025-06-05

D · Potential for more than minimal harm 2025-05-07

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2025-06-05

F · Potential for more than minimal harm 2024-07-11

F725 · Nursing and Physician Services Deficiencies

Health

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Corrected 2024-08-10

F · Potential for more than minimal harm 2024-07-11

F726 · Nursing and Physician Services Deficiencies

Health

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Corrected 2024-08-10

F · Potential for more than minimal harm 2024-07-11

F730 · Nursing and Physician Services Deficiencies

Health

Observe each nurse aide's job performance and give regular training.

Corrected 2024-08-10

F · Potential for more than minimal harm 2024-07-11

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 2024-08-10

F · Potential for more than minimal harm 2024-07-11

F868 · Administration Deficiencies

Health

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Corrected 2024-08-10

F · Potential for more than minimal harm 2024-07-11

F947 · Nursing and Physician Services Deficiencies

Health

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Corrected 2024-08-10

F · Potential for more than minimal harm 2024-07-11

F949 · Administration Deficiencies

Health

Provide behavior health training consistent with the requirements and as determined by a facility assessment.

Corrected 2024-08-10

E · Potential for more than minimal harm 2024-07-11

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 2024-08-10

E · Potential for more than minimal harm 2024-07-11

F711 · Nursing and Physician Services Deficiencies

Health

Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.

Corrected 2024-08-10

E · Potential for more than minimal harm 2024-07-11

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 2024-08-10

D · Potential for more than minimal harm 2024-07-11

F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Corrected 2024-08-10

D · Potential for more than minimal harm 2024-07-11

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-08-10

D · Potential for more than minimal harm 2024-07-11

F745 · Quality of Life and Care Deficiencies

Health

Provide medically-related social services to help each resident achieve the highest possible quality of life.

Corrected 2024-08-10

D · Potential for more than minimal harm 2024-07-11

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2024-08-10

D · Potential for more than minimal harm 2024-07-11

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 2024-08-10

C · Minimal harm 2024-07-11

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-08-10

D · Potential for more than minimal harm 2024-04-22

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 2024-05-17

E · Potential for more than minimal harm 2023-07-17

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 2023-08-15

D · Potential for more than minimal harm 2023-07-17

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2023-08-15

D · Potential for more than minimal harm 2023-07-17

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 2023-08-15

D · Potential for more than minimal harm 2023-07-17

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2023-08-15

D · Potential for more than minimal harm 2023-07-17

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2023-08-15

D · Potential for more than minimal harm 2023-07-17

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2023-08-15

F · Potential for more than minimal harm 2023-06-09

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-07-10

D · Potential for more than minimal harm 2023-06-09

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2023-07-10

Penalties and ownership

What sits behind the stars

$0 2025-09-10

Payment Denial

Payment Denial · denial start 2025-10-08 · 75 days

75 day denial

$39,897 2025-05-07

Fine

Fine · fine $39,897

Fine

$0 2025-05-07

Payment Denial

Payment Denial · denial start 2025-06-06 · 63 days

63 day denial

Ownership

Baraga County Memorial Hospital

5% Or Greater Direct Ownership Interest · Organization

100% 1 facilities 1995-09-06
Baraga County Memorial Hospital

5% Or Greater Mortgage Interest · Organization

0% 1 facilities 2010-01-18
Carlson, Sharon

W-2 Managing Employee · Individual

0% 2 facilities 2016-12-20
Coffey, Willard

Corporate Director · Individual

0% 1 facilities 1995-10-10
Koivu, Robert

Corporate Officer · Individual

0% 1 facilities 2016-12-20
Lapointe, Carole

Corporate Director · Individual

0% 1 facilities 2011-01-01
Rosenberger, Roberta

Corporate Director · Individual

0% 2 facilities 2023-03-01
Younggren, Shirley

Corporate Officer · Individual

0% 1 facilities 2016-12-20

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