9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Bay City, MI
4-star overall rating with 3-star inspections with 9 recent health deficiencies
800 Mulholland Road, Bay City, MI
(989) 895-8539
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
51
Certified beds
Average residents
45
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Preferred Care
Operator or chain grouping
Approved since
1981-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
13 facilities
Chain averages 4 overall / 3 health / 3 staffing / 4 quality stars
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
RN hours / resident day
1.03
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.45
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
1.76
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
3.24
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
1.48
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
2.69
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.68
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
1.06
CMS adjusted RN staffing hours
Adjusted total hours
3.32
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
43%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Program rank
11,966
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
14.50
Composite VBP score used to determine payment impact.
Payment multiplier
0.9813
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0.20
Baseline 21.76% · Performance 21.43% · Measure score 0.20 · Achievement 0 · Improvement 0.20
Healthcare-associated infections
0
Baseline 6.90% · Performance 7.78% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
4.55
Baseline 31.58% · Performance 45.10% · Measure score 4.55 · Achievement 4.55 · Improvement 0
Adjusted total nurse staffing
1.05
Baseline 3.47 hours · Performance 3.38 hours · Measure score 1.05 · Achievement 1.05 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.98% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 82 · Observed rate 8.54% · Lower 95% interval 6.68% |
| Discharge to community | 52.54% |
50.57%
2 pts better
|
No Different than the National Rate · Eligible stays 87 · Observed rate 44.83% · Lower 95% interval 41.36% |
| Medicare spending per beneficiary | 1.09 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 52 · Denominator 52 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 52 |
| Discharge self-care score | 71.43% |
53.69%
17.7 pts better
|
Numerator 25 · Denominator 35 |
| Discharge mobility score | 48.57% |
50.94%
2.4 pts worse
|
Numerator 17 · Denominator 35 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 52 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.78% |
7.12%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 53 · Observed rate 9.43% · Lower 95% interval 4.44% |
| Staff COVID-19 vaccination coverage | 7.14% |
8.2%
1.1 pts worse
|
Numerator 7 · Denominator 98 |
| Staff flu vaccination coverage | 11.64% |
42%
30.4 pts worse
|
Numerator 17 · Denominator 146 |
| Discharge function score | 57.14% |
56.45%
0.7 pts better
|
Numerator 20 · Denominator 35 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 14 · 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 | 31.03% |
25.2%
5.8 pts better
|
Numerator 9 · Denominator 29 |
Quality measures
| 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 | 100.0% |
95.0%
5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.1%
3.1 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.6% |
4.1%
1.5 pts better
|
11.4%
8.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 7.1% · Q4 3.4% · 4Q avg 2.6% |
| Percentage of long-stay residents who lose too much weight | 4.0% |
5.5%
1.5 pts better
|
5.4%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 6.5% · Q3 3.1% · Q4 6.5% · 4Q avg 4.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.0% |
19.6%
6.4 pts worse
|
19.6%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 25.0% · Q3 28.1% · Q4 25.8% · 4Q avg 26.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.9% |
16.5%
9.6 pts better
|
16.7%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 7.7% · Q3 3.7% · Q4 8.7% · 4Q avg 6.9% · 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 | 10.9% |
13.9%
3 pts better
|
16.3%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.4% |
11.7%
0.7 pts worse
|
14.9%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 10.3% · Q3 16.1% · Q4 13.3% · 4Q avg 12.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.3% |
1.7%
0.6 pts worse
|
1.7%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 0.0% · Q3 0.0% · Q4 3.0% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.7% |
20.4%
2.7 pts better
|
19.8%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 23.9% · Q3 21.3% · Q4 15.3% · 4Q avg 17.7% |
| Percentage of long-stay residents with pressure ulcers | 4.1% |
5.6%
1.5 pts better
|
5.1%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.4% · Q3 9.6% · Q4 3.1% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.7% |
82.8%
14.9 pts better
|
81.7%
16 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.0% · Q2 100.0% · Q3 97.8% · Q4 94.9% · 4Q avg 97.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 0.0% |
11.5%
11.5 pts better
|
12.0%
12 pts better
|
Short Stay · 20240701-20250630 · Adjusted 0.0% · Observed 0.0% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.9% |
79.5%
15.4 pts better
|
79.7%
15.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.5% |
24.2%
2.3 pts worse
|
23.9%
2.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.5% · Observed 28.9% · Expected 26.0% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Quality of Life and Care (6 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
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 2025-07-24
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-07-24
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 2025-07-24
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-07-24
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-07-24
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-07-24
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-07-24
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 2025-07-24
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-07-24
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-08-11
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-08-11
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-08-11
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-08-11
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 2024-08-11
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-08-11
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2024-08-11
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-11
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-10-02
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-08-15
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 2023-08-15
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-08-15
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-15
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-08-15
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-08-15
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2023-08-15
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-08-15
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Mortgage Interest · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Nearby options
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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
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