Cycle 1
Health 2025-08-21 · Fire 2025-08-21
14 health deficiencies
Top issue: Resident Rights (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Clarkston, MI
Mission Point Nursing & Physical Rehabilitation Ce
1-star overall rating with 1-star inspections with $296,929 in total fines with 14 recent health deficiencies
4800 Clintonville Rd, Clarkston, MI
(248) 674-0903
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
71
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Mission Point Healthcare Services
Operator or chain grouping
Approved since
1987-02-03
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
0.74
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.69
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
2.01
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
3.44
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
1.43
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
3.00
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.56
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.77
CMS adjusted RN staffing hours
Adjusted total hours
3.59
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
9%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
42%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,985
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
14.41
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
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
2.88
Baseline 47.06% · Performance 51.90% · Measure score 2.88 · Achievement 2.88 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.05 hours · Performance 3.04 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.72% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 43 · Observed rate 13.95% · Lower 95% interval 7.04% |
| Discharge to community | 41.51% |
50.57%
9.1 pts worse
|
No Different than the National Rate · Eligible stays 54 · Observed rate 25.93% · Lower 95% interval 26.59% |
| Medicare spending per beneficiary | 1.04 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 97.14% |
95.27%
1.9 pts better
|
Numerator 34 · Denominator 35 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 35 |
| Discharge self-care score | 45.45% |
53.69%
8.2 pts worse
|
Numerator 10 · Denominator 22 |
| Discharge mobility score | 27.27% |
50.94%
23.7 pts worse
|
Numerator 6 · Denominator 22 |
| Pressure ulcers or injuries, new or worsened | 5.71% |
2.29%
3.4 pts worse
|
Numerator 2 · Denominator 35 · Adjusted rate 3.77% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 11 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 71 |
| Staff flu vaccination coverage | 0% |
42%
42 pts worse
|
Numerator 0 · Denominator 93 |
| Discharge function score | 40.91% |
56.45%
15.5 pts worse
|
Numerator 9 · Denominator 22 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 4.17% |
25.2%
21 pts worse
|
Numerator 1 · Denominator 24 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
95.0%
4.6 pts better
|
93.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.4% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.6% |
| 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 | 3.4% |
3.1%
0.3 pts worse
|
3.3%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 2.9% · Q3 3.1% · Q4 3.1% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.4% |
4.1%
3.7 pts better
|
11.4%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.7% · 4Q avg 0.4% |
| Percentage of long-stay residents who lose too much weight | 3.4% |
5.5%
2.1 pts better
|
5.4%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.0% · Q3 3.6% · Q4 8.5% · 4Q avg 3.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 43.0% |
19.6%
23.4 pts worse
|
19.6%
23.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.1% · Q2 44.3% · Q3 42.4% · Q4 48.3% · 4Q avg 43.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 29.2% |
16.5%
12.7 pts worse
|
16.7%
12.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.1% · Q2 35.1% · Q3 23.1% · Q4 27.5% · 4Q avg 29.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.8% |
0.1%
0.7 pts worse
|
0.1%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.5% · Q3 1.5% · Q4 0.0% · 4Q avg 0.8% |
| Percentage of long-stay residents whose ability to walk independently worsened | 10.6% |
13.9%
3.3 pts better
|
16.3%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.4% |
11.7%
6.3 pts better
|
14.9%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 3.6% · Q3 5.7% · Q4 5.3% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.9%
0.6 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.8% |
1.7%
0.9 pts better
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.5% · Q3 0.0% · Q4 1.6% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 12.6% |
20.4%
7.8 pts better
|
19.8%
7.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.3% · Q2 13.4% · Q3 8.2% · Q4 11.4% · 4Q avg 12.6% |
| Percentage of long-stay residents with pressure ulcers | 5.9% |
5.6%
0.3 pts worse
|
5.1%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 8.3% · Q3 5.5% · Q4 3.3% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.3% |
82.8%
12.5 pts better
|
81.7%
13.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 93.2% · Q3 92.3% · Q4 95.8% · 4Q avg 95.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.4% |
11.5%
6.9 pts worse
|
12.0%
6.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.4% · Observed 18.9% · Expected 11.5% · 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 · 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 | 84.1% |
79.5%
4.6 pts better
|
79.7%
4.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 84.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.7% |
24.2%
3.5 pts better
|
23.9%
3.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.7% · Observed 24.3% · Expected 28.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-11 · Fire 2024-09-11
18 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2023-11-01 · Fire 2023-11-01
38 health deficiencies
Top issue: Quality of Life and Care (13 deficiencies)
6 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-09-11
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-10-11
F · Potential for more than minimal harm
2024-09-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-11
E · Potential for more than minimal harm
2024-09-11
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 2024-10-11
E · Potential for more than minimal harm
2024-09-11
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-10-11
E · Potential for more than minimal harm
2024-09-11
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-10-11
E · Potential for more than minimal harm
2024-09-11
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-10-11
E · Potential for more than minimal harm
2024-09-11
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2024-10-11
E · Potential for more than minimal harm
2024-09-11
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-10-11
F · Potential for more than minimal harm
2023-11-01
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-11-28
F · Potential for more than minimal harm
2023-11-01
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-11-28
F · Potential for more than minimal harm
2023-11-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-12-21
E · Potential for more than minimal harm
2023-11-01
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 2023-11-28
E · Potential for more than minimal harm
2023-11-01
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 2023-11-28
E · Potential for more than minimal harm
2023-11-01
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-11-28
Inspection history
Recent health citations
G · Actual harm
2025-08-21
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 2025-09-09
F · Potential for more than minimal harm
2025-08-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-09
E · Potential for more than minimal harm
2025-08-21
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 2025-09-09
E · Potential for more than minimal harm
2025-08-21
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 2025-09-09
E · Potential for more than minimal harm
2025-08-21
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-09-09
E · Potential for more than minimal harm
2025-08-21
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2025-09-09
E · Potential for more than minimal harm
2025-08-21
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 2025-09-09
D · Potential for more than minimal harm
2025-08-21
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2025-09-09
D · Potential for more than minimal harm
2025-08-21
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-09-09
D · Potential for more than minimal harm
2025-08-21
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-09-09
D · Potential for more than minimal harm
2025-08-21
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 2025-09-09
D · Potential for more than minimal harm
2025-08-21
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 2025-09-09
D · Potential for more than minimal harm
2025-08-21
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-09-09
G · Actual harm
2025-05-22
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-01-07
F · Potential for more than minimal harm
2024-09-11
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 2024-10-11
D · Potential for more than minimal harm
2024-09-11
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-10-11
D · Potential for more than minimal harm
2024-09-11
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-10-11
D · Potential for more than minimal harm
2024-09-11
F693 · Quality of Life and Care Deficiencies
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 2024-10-11
D · Potential for more than minimal harm
2024-09-11
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-10-11
D · Potential for more than minimal harm
2024-09-11
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-10-11
D · Potential for more than minimal harm
2024-09-11
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 2024-10-11
D · Potential for more than minimal harm
2024-09-11
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 2024-10-11
D · Potential for more than minimal harm
2024-09-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-11
D · Potential for more than minimal harm
2024-09-11
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-10-11
D · Potential for more than minimal harm
2024-06-25
F635 · Resident Assessment and Care Planning Deficiencies
Health
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Corrected 2024-07-19
D · Potential for more than minimal harm
2024-04-24
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-05-14
D · Potential for more than minimal harm
2024-04-24
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 2024-05-14
D · Potential for more than minimal harm
2024-04-24
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 2024-05-14
D · Potential for more than minimal harm
2024-04-24
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 2024-05-14
G · Actual harm
2024-04-04
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-04-30
F · Potential for more than minimal harm
2024-04-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-30
D · Potential for more than minimal harm
2024-04-04
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 2024-04-30
D · Potential for more than minimal harm
2024-02-20
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 2024-03-08
D · Potential for more than minimal harm
2024-01-03
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 2024-01-13
G · Actual harm
2023-11-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-28
G · Actual harm
2023-11-01
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 2023-11-24
F · Potential for more than minimal harm
2023-11-01
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 2023-11-24
F · Potential for more than minimal harm
2023-11-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-24
E · Potential for more than minimal harm
2023-11-01
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 2023-11-24
E · Potential for more than minimal harm
2023-11-01
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 2023-11-28
E · Potential for more than minimal harm
2023-11-01
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 2023-11-24
D · Potential for more than minimal harm
2023-11-01
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-11-24
D · Potential for more than minimal harm
2023-11-01
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-11-24
D · Potential for more than minimal harm
2023-11-01
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 2023-11-24
D · Potential for more than minimal harm
2023-11-01
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 2023-11-24
D · Potential for more than minimal harm
2023-11-01
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 2023-11-28
D · Potential for more than minimal harm
2023-11-01
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-11-28
D · Potential for more than minimal harm
2023-11-01
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 2023-11-24
D · Potential for more than minimal harm
2023-11-01
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 2023-11-24
D · Potential for more than minimal harm
2023-11-01
F693 · Quality of Life and Care Deficiencies
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 2023-11-24
D · Potential for more than minimal harm
2023-11-01
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-11-24
D · Potential for more than minimal harm
2023-11-01
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 2023-11-28
D · Potential for more than minimal harm
2023-11-01
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-11-28
D · Potential for more than minimal harm
2023-11-01
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-11-24
F · Potential for more than minimal harm
2023-08-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-11
D · Potential for more than minimal harm
2023-08-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-09-11
D · Potential for more than minimal harm
2023-08-17
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 2023-09-11
J · Immediate jeopardy
2023-07-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-15
D · Potential for more than minimal harm
2023-05-23
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2023-06-12
G · Actual harm
2023-03-01
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-03-28
G · Actual harm
2023-03-01
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-03-28
G · Actual harm
2023-03-01
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-03-28
F · Potential for more than minimal harm
2023-03-01
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 2023-03-28
F · Potential for more than minimal harm
2023-03-01
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2023-03-28
E · Potential for more than minimal harm
2023-03-01
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-04-19
D · Potential for more than minimal harm
2023-03-01
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2023-03-28
D · Potential for more than minimal harm
2023-03-01
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 2023-03-28
D · Potential for more than minimal harm
2023-03-01
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2023-03-28
D · Potential for more than minimal harm
2023-03-01
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 2023-03-28
D · Potential for more than minimal harm
2023-03-01
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2023-03-28
Penalties and ownership
What sits behind the stars
$52,281
2024-04-04
Fine
Fine · fine $52,281
Fine
$0
2024-04-04
Payment Denial
Payment Denial · denial start 2024-05-02 · 12 days
12 day denial
$127,399
2023-11-01
Fine
Fine · fine $127,399
Fine
$0
2023-11-01
Payment Denial
Payment Denial · denial start 2023-11-30 · 44 days
44 day denial
$117,249
2023-07-21
Fine
Fine · fine $117,249
Fine
$0
2023-07-21
Payment Denial
Payment Denial · denial start 2023-08-16 · 26 days
26 day denial
Ownership
Mali, Hari
5% Or Greater Indirect Ownership Interest · Individual
Mission Point Metro Holding LLC
5% Or Greater Direct Ownership Interest · Organization
Hodge, Sherry
W-2 Managing Employee · Individual
Mali, Hari
Corporate Officer · Individual
Rouse, Tammy
W-2 Managing Employee · Individual
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