Cycle 1
Health 2025-02-05 · Fire 2025-02-05
16 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Holly, MI
Mission Point Nursing & Physical Rehabilitation Ce
2-star overall rating with 1-star inspections with $95,194 in total fines with 16 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
313 Sherwood Street, Holly, MI
(248) 708-3100
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
66
Certified beds
Average residents
62
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Mission Point Healthcare Services
Operator or chain grouping
Approved since
2017-06-01
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
0.60
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
1.02
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
1.82
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
1.63
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
0.62
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.71
CMS adjusted RN staffing hours
Adjusted total hours
4.06
CMS adjusted total nurse staffing hours
Case-mix index
1.16
Higher values indicate more complex resident acuity
RN turnover
36%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
55%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,812
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
25.61
Composite VBP score used to determine payment impact.
Payment multiplier
0.9839
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.67% · Performance 21.68% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
4.96
Baseline 6.50% · Performance 6.35% · Measure score 4.96 · Achievement 4.96 · Improvement 0.50
Total nurse turnover
5.28
Baseline 37.04% · Performance 42.10% · Measure score 5.28 · Achievement 5.28 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.45 hours · Performance 3.12 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.19% |
10.72%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 67 · Observed rate 13.43% · Lower 95% interval 7.41% |
| Discharge to community | 60.02% |
50.57%
9.5 pts better
|
No Different than the National Rate · Eligible stays 53 · Observed rate 54.72% · Lower 95% interval 45.35% |
| Medicare spending per beneficiary | 0.81 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 38 · Denominator 38 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 38 |
| Discharge self-care score | 40% |
53.69%
13.7 pts worse
|
Numerator 14 · Denominator 35 |
| Discharge mobility score | 62.86% |
50.94%
11.9 pts better
|
Numerator 22 · Denominator 35 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 38 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.35% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 32 · Observed rate 3.13% · Lower 95% interval 3.77% |
| Staff COVID-19 vaccination coverage | 1% |
8.2%
7.2 pts worse
|
Numerator 1 · Denominator 100 |
| Staff flu vaccination coverage | 21.67% |
42%
20.3 pts worse
|
Numerator 26 · Denominator 120 |
| Discharge function score | 65.71% |
56.45%
9.3 pts better
|
Numerator 23 · Denominator 35 |
| 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 26 · Denominator 26 |
| Resident COVID-19 vaccinations up to date | 52.38% |
25.2%
27.2 pts better
|
Numerator 11 · Denominator 21 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
1.7
0.1 pts worse
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.3 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.5
0.7 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.7 · Expected 1.4 · 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 | 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 | 4.7% |
3.1%
1.6 pts worse
|
3.3%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 3.8% · Q3 5.7% · Q4 5.3% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 16.7% |
4.1%
12.6 pts worse
|
11.4%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.2% · Q2 18.0% · Q3 17.6% · Q4 11.8% · 4Q avg 16.7% |
| 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 0.0% · Q2 0.0% · Q3 2.4% · Q4 11.1% · 4Q avg 3.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 36.2% |
19.6%
16.6 pts worse
|
19.6%
16.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 38.3% · Q2 37.5% · Q3 34.0% · Q4 34.8% · 4Q avg 36.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.1% |
16.5%
8.4 pts better
|
16.7%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 6.2% · Q3 9.4% · Q4 10.3% · 4Q avg 8.1% · 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 | 14.3% |
13.9%
0.4 pts worse
|
16.3%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 10.3% · Q3 23.6% · Q4 16.3% · 4Q avg 14.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.7% |
11.7%
2 pts better
|
14.9%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 4.5% · Q3 11.4% · Q4 13.6% · 4Q avg 9.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.9%
0.3 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.5% |
1.7%
0.2 pts better
|
1.7%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.0% · Q3 2.1% · Q4 1.8% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.8% |
20.4%
7.4 pts worse
|
19.8%
8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.6% · Q2 26.2% · Q3 25.1% · Q4 33.7% · 4Q avg 27.8% |
| Percentage of long-stay residents with pressure ulcers | 6.0% |
5.6%
0.4 pts worse
|
5.1%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 7.2% · Q3 2.1% · Q4 8.7% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.4% |
82.8%
15.6 pts better
|
81.7%
16.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.3% · Q2 96.6% · Q3 98.4% · Q4 100.0% · 4Q avg 98.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.2% |
11.5%
1.3 pts better
|
12.0%
1.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.2% · Observed 11.4% · Expected 12.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
1.3%
0.1 pts worse
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 0.0% · Q3 0.0% · Q4 2.8% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.0% |
79.5%
10.5 pts better
|
79.7%
10.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.5% |
24.2%
4.3 pts worse
|
23.9%
4.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.5% · Observed 31.8% · Expected 26.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-23 · Fire 2024-01-23
18 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
13 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Cycle 3
Health 2023-02-09 · Fire 2023-02-09
18 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-05
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-02-28
F · Potential for more than minimal harm
2025-02-05
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-02-28
F · Potential for more than minimal harm
2025-02-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-28
F · Potential for more than minimal harm
2025-02-05
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-02-28
F · Potential for more than minimal harm
2025-02-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-02-28
E · Potential for more than minimal harm
2025-02-05
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-02-28
E · Potential for more than minimal harm
2025-02-05
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-02-28
E · Potential for more than minimal harm
2025-02-05
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-02-05
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-02-28
F · Potential for more than minimal harm
2024-01-23
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-02-19
F · Potential for more than minimal harm
2024-01-23
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-02-19
F · Potential for more than minimal harm
2024-01-23
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-02-19
F · Potential for more than minimal harm
2024-01-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-21
F · Potential for more than minimal harm
2024-01-23
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-02-19
F · Potential for more than minimal harm
2024-01-23
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-02-19
F · Potential for more than minimal harm
2024-01-23
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 2024-02-19
F · Potential for more than minimal harm
2024-01-23
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-02-19
E · Potential for more than minimal harm
2024-01-23
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-02-19
E · Potential for more than minimal harm
2024-01-23
K522 · Services Deficiencies
Fire Safety
Have an externally vented heating system.
Corrected 2024-02-19
E · Potential for more than minimal harm
2024-01-23
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-02-19
E · Potential for more than minimal harm
2024-01-23
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-02-19
D · Potential for more than minimal harm
2024-01-23
K925 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that sources of ignition are removed from patients receiving respiratory therapy.
Corrected 2024-02-19
F · Potential for more than minimal harm
2023-02-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-07
F · Potential for more than minimal harm
2023-02-09
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-03-07
F · Potential for more than minimal harm
2023-02-09
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-03-07
E · Potential for more than minimal harm
2023-02-09
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-03-07
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-08-14
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 2025-09-03
D · Potential for more than minimal harm
2025-08-14
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 2025-08-07
D · Potential for more than minimal harm
2025-08-14
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-09-03
D · Potential for more than minimal harm
2025-08-14
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 2025-09-03
D · Potential for more than minimal harm
2025-08-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-09-03
D · Potential for more than minimal harm
2025-08-14
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 2025-09-03
D · Potential for more than minimal harm
2025-08-14
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-09-03
F · Potential for more than minimal harm
2025-07-08
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-09-03
E · Potential for more than minimal harm
2025-07-08
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 2025-09-03
F · Potential for more than minimal harm
2025-02-05
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 2025-02-28
E · Potential for more than minimal harm
2025-02-05
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 2025-02-28
E · Potential for more than minimal harm
2025-02-05
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-02-28
E · Potential for more than minimal harm
2025-02-05
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 2025-02-28
D · Potential for more than minimal harm
2025-02-05
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-02-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-02-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-28
F · Potential for more than minimal harm
2024-07-15
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 2024-08-03
D · Potential for more than minimal harm
2024-07-15
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 2024-08-03
D · Potential for more than minimal harm
2024-06-04
F622 · Resident Rights Deficiencies
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 2024-06-18
F · Potential for more than minimal harm
2024-01-23
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 2024-02-19
F · Potential for more than minimal harm
2024-01-23
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 2024-02-19
E · Potential for more than minimal harm
2024-01-23
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 2024-02-19
E · Potential for more than minimal harm
2024-01-23
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-04-02
E · Potential for more than minimal harm
2024-01-23
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 2024-02-19
D · Potential for more than minimal harm
2024-01-23
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 2023-12-18
D · Potential for more than minimal harm
2024-01-23
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 2024-02-19
D · Potential for more than minimal harm
2024-01-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-19
D · Potential for more than minimal harm
2024-01-23
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 2024-02-19
D · Potential for more than minimal harm
2024-01-23
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 2024-02-19
D · Potential for more than minimal harm
2024-01-23
F691 · Quality of Life and Care Deficiencies
Health
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Corrected 2024-02-19
D · Potential for more than minimal harm
2024-01-23
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-04-02
D · Potential for more than minimal harm
2024-01-23
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2024-02-19
D · Potential for more than minimal harm
2024-01-23
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2024-02-19
D · Potential for more than minimal harm
2024-01-23
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-02-19
E · Potential for more than minimal harm
2024-01-18
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-02-05
D · Potential for more than minimal harm
2023-09-19
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-09-06
D · Potential for more than minimal harm
2023-09-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-03
D · Potential for more than minimal harm
2023-09-19
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 2023-10-03
G · Actual harm
2023-08-02
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 2023-08-22
F · Potential for more than minimal harm
2023-08-02
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 2023-08-22
D · Potential for more than minimal harm
2023-08-02
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 2023-08-22
D · Potential for more than minimal harm
2023-03-22
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 2023-04-28
E · Potential for more than minimal harm
2023-02-09
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2023-03-07
E · Potential for more than minimal harm
2023-02-09
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 2023-03-07
E · Potential for more than minimal harm
2023-02-09
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 2023-03-07
E · Potential for more than minimal harm
2023-02-09
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 2023-03-07
D · Potential for more than minimal harm
2023-02-09
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 2023-03-07
D · Potential for more than minimal harm
2023-02-09
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-03-07
D · Potential for more than minimal harm
2023-02-09
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 2023-03-07
D · Potential for more than minimal harm
2023-02-09
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-03-07
D · Potential for more than minimal harm
2023-02-09
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-03-07
D · Potential for more than minimal harm
2023-02-09
F888 · Infection Control Deficiencies
Health
Ensure staff are vaccinated for COVID-19
Corrected 2023-03-07
Penalties and ownership
What sits behind the stars
$63,528
2025-03-28
Fine
Fine · fine $63,528
Fine
$0
2025-03-28
Payment Denial
Payment Denial · denial start 2025-04-26 · 4 days
4 day denial
$15,833
2023-08-02
Fine
Fine · fine $15,833
Fine
$15,833
2023-08-02
Fine
Fine · fine $15,833
Fine
Ownership
Hrm Holly Holding, LLC
5% Or Greater Direct Ownership Interest · Organization
Mpms Holly Acquisition LLC
5% Or Greater Direct Ownership Interest · Organization
Capital Funding Group, Inc.
5% Or Greater Mortgage Interest · Organization
Conley, Tanya
Operational/Managerial Control · Individual
Mali, Hari
Corporate Officer · Individual
Mcleod, Leigh
Operational/Managerial Control · Individual
New Center Management Services, LLC
Operational/Managerial Control · Organization
Rojas, Bernardo
Operational/Managerial Control · Individual
Nearby options
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WellBridge of Fenton
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3-star overall rating with 3-star inspections with $49,030 in total fines with 10 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Fenton Healthcare
Fenton, MI
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
WellBridge of Grand Blanc
Grand Blanc, MI
3-star overall rating with 2-star inspections with $33,647 in total fines with 14 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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