Cycle 1
Health 2024-12-10 · Fire 2024-12-10
17 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (6 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cedar Springs, MI
Mission Point Nursing & Physical Rehabilitation Ce
3-star overall rating with 2-star inspections with abuse icon flag with $45,438 in total fines with 17 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
400 Jeffrey, Cedar Springs, MI
(616) 696-0170
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
77
Certified beds
Average residents
70
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Mission Point Healthcare Services
Operator or chain grouping
Approved since
1976-04-26
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
22 facilities
Chain averages 3 overall / 2 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
Hours and turnover
RN hours / resident day
0.79
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.59
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
2.30
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
3.68
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
1.38
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
3.16
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.48
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
0.75
CMS adjusted RN staffing hours
Adjusted total hours
3.46
CMS adjusted total nurse staffing hours
Case-mix index
1.46
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
25%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,633
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.49
Composite VBP score used to determine payment impact.
Payment multiplier
0.9891
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.16
Baseline 20.25% · Performance 19.51% · Measure score 4.16 · Achievement 4.16 · Improvement 1.81
Healthcare-associated infections
1.98
Baseline 7.24% · Performance 7.24% · Measure score 1.98 · Achievement 1.98 · Improvement 0
Total nurse turnover
7.30
Performance 33.85% · Measure score 7.30 · Achievement 7.30 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0.76
Baseline 3.25 hours · Performance 3.29 hours · Measure score 0.76 · Achievement 0.76 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.13% |
10.72%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 83 · Observed rate 12.05% · Lower 95% interval 7.5% |
| Discharge to community | 56.38% |
50.57%
5.8 pts better
|
No Different than the National Rate · Eligible stays 71 · Observed rate 52.11% · Lower 95% interval 45.91% |
| Medicare spending per beneficiary | 0.74 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 48 · Denominator 48 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 48 |
| Discharge self-care score | 43.75% |
53.69%
9.9 pts worse
|
Numerator 14 · Denominator 32 |
| Discharge mobility score | 46.88% |
50.94%
4.1 pts worse
|
Numerator 15 · Denominator 32 |
| Pressure ulcers or injuries, new or worsened | 2.08% |
2.29%
0.2 pts better
|
Numerator 1 · Denominator 48 · Adjusted rate 1.65% |
| Healthcare-associated infections requiring hospitalization | 7.24% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 35 · Observed rate 5.71% · Lower 95% interval 3.38% |
| Staff COVID-19 vaccination coverage | 2.35% |
8.2%
5.8 pts worse
|
Numerator 2 · Denominator 85 |
| Staff flu vaccination coverage | 4.76% |
42%
37.2 pts worse
|
Numerator 4 · Denominator 84 |
| Discharge function score | 56.25% |
56.45%
0.2 pts worse
|
Numerator 18 · Denominator 32 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 4 · 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 | 47.62% |
25.2%
22.4 pts better
|
Numerator 10 · 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 0.4 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.4 |
1.5
1.1 pts better
|
1.8
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.4 · Expected 1.6 · 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 | 96.9% |
95.0%
1.9 pts better
|
95.5%
1.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.9% |
| 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 1.7% · Q2 1.8% · Q3 1.9% · Q4 1.9% · 4Q avg 1.8% · Used in QM five-star |
| 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 · Q1 1.8% · Q2 9.8% · Q3 2.0% · Q4 0.0% · 4Q avg 3.4% |
| Percentage of long-stay residents who lose too much weight | 2.2% |
5.5%
3.3 pts better
|
5.4%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 4.2% · Q3 0.0% · Q4 2.2% · 4Q avg 2.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.8% |
19.6%
2.8 pts better
|
19.6%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.2% · Q2 20.8% · Q3 19.0% · Q4 17.8% · 4Q avg 16.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.1% |
16.5%
5.4 pts better
|
16.7%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.9% · Q2 12.1% · Q3 9.1% · Q4 3.1% · 4Q avg 11.1% · 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 | 9.1% |
13.9%
4.8 pts better
|
16.3%
7.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.3% |
11.7%
8.4 pts better
|
14.9%
11.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 4.2% · Q3 0.0% · Q4 0.0% · 4Q avg 3.3% · 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 | 4.0% |
1.7%
2.3 pts worse
|
1.7%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 3.5% · Q3 5.8% · Q4 1.9% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.6% |
20.4%
2.8 pts better
|
19.8%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 22.9% · Q2 22.7% · Q3 14.3% · Q4 9.3% · 4Q avg 17.6% |
| Percentage of long-stay residents with pressure ulcers | 4.3% |
5.6%
1.3 pts better
|
5.1%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 4.4% · Q3 3.7% · Q4 5.1% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.1% |
82.8%
14.3 pts better
|
81.7%
15.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.1% · Q2 97.4% · Q3 97.6% · Q4 96.4% · 4Q avg 97.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 26.9% |
11.5%
15.4 pts worse
|
12.0%
14.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.9% · Observed 25.8% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.4% |
1.3%
2.1 pts worse
|
1.6%
1.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 3.1% · Q3 5.2% · Q4 3.6% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.8% |
79.5%
16.3 pts better
|
79.7%
16.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.8% |
24.2%
2.4 pts better
|
23.9%
2.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.8% · Observed 19.4% · Expected 21.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-18 · Fire 2023-10-18
4 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-11-03 · Fire 2022-11-03
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
10 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-10
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-01-03
E · Potential for more than minimal harm
2024-12-10
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-01-03
E · Potential for more than minimal harm
2024-12-10
K522 · Services Deficiencies
Fire Safety
Have an externally vented heating system.
Corrected 2025-01-03
E · Potential for more than minimal harm
2024-12-10
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2025-01-03
F · Potential for more than minimal harm
2022-11-03
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-12-16
F · Potential for more than minimal harm
2022-11-03
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2022-12-16
F · Potential for more than minimal harm
2022-11-03
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-12-16
F · Potential for more than minimal harm
2022-11-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-12-16
F · Potential for more than minimal harm
2022-11-03
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-12-16
F · Potential for more than minimal harm
2022-11-03
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2022-12-16
F · Potential for more than minimal harm
2022-11-03
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-12-16
F · Potential for more than minimal harm
2022-11-03
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-12-16
E · Potential for more than minimal harm
2022-11-03
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 2022-12-16
E · Potential for more than minimal harm
2022-11-03
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-12-16
Inspection history
Recent health citations
G · Actual harm
2025-03-05
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-03-24
G · Actual harm
2025-03-05
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 2025-03-24
D · Potential for more than minimal harm
2025-03-05
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 2025-03-24
D · Potential for more than minimal harm
2025-03-05
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-03-31
D · Potential for more than minimal harm
2025-03-05
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-03-31
D · Potential for more than minimal harm
2025-03-05
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-03-24
D · Potential for more than minimal harm
2025-03-05
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-04-08
D · Potential for more than minimal harm
2025-03-05
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-03-24
G · Actual harm
2024-12-10
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-01-03
F · Potential for more than minimal harm
2024-12-10
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 2025-01-03
E · Potential for more than minimal harm
2024-12-10
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-01-03
E · Potential for more than minimal harm
2024-12-10
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2025-01-03
D · Potential for more than minimal harm
2024-12-10
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 2025-01-03
D · Potential for more than minimal harm
2024-12-10
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 2025-01-03
D · Potential for more than minimal harm
2024-12-10
F688 · Quality of Life and Care Deficiencies
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 2025-01-03
D · Potential for more than minimal harm
2024-12-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-03
D · Potential for more than minimal harm
2024-12-10
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-01-03
D · Potential for more than minimal harm
2024-08-22
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-09-17
D · Potential for more than minimal harm
2024-08-22
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-09-17
D · Potential for more than minimal harm
2024-08-22
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-09-17
D · Potential for more than minimal harm
2024-01-03
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 2024-01-22
D · Potential for more than minimal harm
2023-10-18
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-11-03
G · Actual harm
2022-11-03
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 2022-12-05
E · Potential for more than minimal harm
2022-11-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-12-05
D · Potential for more than minimal harm
2022-11-03
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2022-12-05
D · Potential for more than minimal harm
2022-11-03
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 2022-12-05
D · Potential for more than minimal harm
2022-11-03
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 2022-12-05
D · Potential for more than minimal harm
2022-11-03
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-12-05
Penalties and ownership
What sits behind the stars
$45,438
2025-03-05
Fine
Fine · fine $45,438
Fine
$0
2025-03-05
Payment Denial
Payment Denial · denial start 2025-03-27 · 12 days
12 day denial
Ownership
Mali, Hari
5% Or Greater Indirect Ownership Interest · Individual
Mission Point Grand Rapids Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Cleveringa, Yuliya
W-2 Managing Employee · Individual
Mali, Hari
Operational/Managerial Control · Individual
Mission Point Management Services LLC
Operational/Managerial Control · Organization
Sosnowski, Welarchie
W-2 Managing Employee · Individual
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