8 health deficiencies
Top issue: Environmental (2 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Detroit, MI
3-star overall rating with 2-star inspections with 8 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
9146 Woodward Ave, Detroit, MI
(313) 875-1263
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
Beds
129
Certified beds
Average residents
84
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Mission Point Healthcare Services
Operator or chain grouping
Approved since
1988-05-13
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
RN hours / resident day
0.42
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.77
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
2.11
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
3.30
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
1.19
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
2.93
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.33
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.48
CMS adjusted RN staffing hours
Adjusted total hours
3.77
CMS adjusted total nurse staffing hours
Case-mix index
1.20
Higher values indicate more complex resident acuity
RN turnover
43%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Program rank
6,272
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
33.42
Composite VBP score used to determine payment impact.
Payment multiplier
0.9877
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
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
6.68
Baseline 41.07% · Performance 36.36% · Measure score 6.68 · Achievement 6.68 · Improvement 2.40
Adjusted total nurse staffing
0
Baseline 3.64 hours · Performance 2.71 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 23 · 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 19 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.81 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 3 · 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 11 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0.95% |
8.2%
7.2 pts worse
|
Numerator 1 · Denominator 105 |
| Staff flu vaccination coverage | 4.26% |
42%
37.7 pts worse
|
Numerator 6 · Denominator 141 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 2 · 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 Not Available · Newly certified or not enough cases to report. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
1.7
About the same
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 2.1 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
1.5
0.8 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.8 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.5% |
95.0%
0.5 pts better
|
93.4%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.2% · Q2 97.6% · Q3 95.3% · Q4 93.5% · 4Q avg 95.5% |
| 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 | 0.6% |
3.1%
2.5 pts better
|
3.3%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.1% |
4.1%
1 pts worse
|
11.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 5.6% · Q3 6.3% · Q4 5.7% · 4Q avg 5.1% |
| Percentage of long-stay residents who lose too much weight | 8.0% |
5.5%
2.5 pts worse
|
5.4%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 11.4% · Q3 5.0% · Q4 8.1% · 4Q avg 8.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.9% |
19.6%
6.7 pts better
|
19.6%
6.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.0% · Q2 12.3% · Q3 12.3% · Q4 16.2% · 4Q avg 12.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.2% |
16.5%
2.3 pts better
|
16.7%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.2% · Q2 12.0% · Q3 15.4% · Q4 16.1% · 4Q avg 14.2% · 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 | 3.1% |
13.9%
10.8 pts better
|
16.3%
13.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 6.4% · Q3 0.0% · Q4 2.7% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.5% |
11.7%
8.2 pts better
|
14.9%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 1.4% · Q3 5.3% · Q4 2.9% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
0.9%
0.2 pts better
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.3% · Q3 1.3% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.7%
1.7 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 5.5% |
20.4%
14.9 pts better
|
19.8%
14.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 2.4% · Q3 5.4% · Q4 6.8% · 4Q avg 5.5% |
| 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 3.9% · Q2 2.9% · Q3 4.1% · Q4 5.5% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 53.5% |
82.8%
29.3 pts worse
|
81.7%
28.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 50.0% · Q4 58.6% · 4Q avg 53.5% |
| 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 50.0% |
79.5%
29.5 pts worse
|
79.7%
29.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 50.0% |
Survey summary
Top issue: Environmental (2 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Quality of Life and Care (5 deficiencies)
20 fire-safety deficiencies
Top issue: Smoke (8 deficiencies)
Top issue: Resident Rights (6 deficiencies)
11 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Fire safety
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 2025-04-15
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-04-15
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-15
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-04-15
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-04-15
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-04-15
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-04-15
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-04-15
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 2025-04-15
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2025-04-15
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-04-15
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-04-15
Fire Safety
Ensure that sources of ignition are removed from patients receiving respiratory therapy.
Corrected 2025-04-15
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2024-04-01
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2024-04-01
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-04-01
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-04-05
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2024-03-25
Fire Safety
Construct fire resistant interior walls.
Corrected 2024-04-01
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-01
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-03-25
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-04-01
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2024-04-01
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-04-01
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-03-25
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-04-01
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-03-25
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-03-25
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-03-25
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-04-05
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-04-01
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2024-04-01
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-04-01
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-12-02
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-12-02
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-12-02
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-12-02
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2022-12-13
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 2022-12-02
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-12-13
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2022-12-02
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-12-02
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-12-02
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2022-12-02
Inspection history
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2026-02-02
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 2025-04-11
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-04-11
Health
Keep all essential equipment working safely.
Corrected 2025-04-11
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-04-11
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-04-11
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 2025-04-11
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2025-04-11
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-10-23
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-31
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 2024-03-10
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2024-03-10
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-03-10
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-03-10
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-03-10
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 2024-03-10
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-03-10
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-03-10
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-10
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 2024-03-10
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2023-04-10
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 2022-12-05
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2022-12-05
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2022-12-05
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2022-12-05
Health
Keep residents' personal and medical records private and confidential.
Corrected 2022-12-05
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2022-12-05
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-12-05
Penalties and ownership
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Organization
W-2 Managing Employee · Individual
Corporate Officer · Individual
Operational/Managerial Control · Organization
W-2 Managing Employee · Individual
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