Cycle 1
Health 2025-02-11 · Fire 2025-02-11
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
5 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Roscommon, MI
Mission Point Nursing & Physical Rehabilitation of
4-star overall rating with 4-star inspections with 6 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
1290 East Michigan Highway, Roscommon, MI
(989) 275-8936
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
39
Certified beds
Average residents
37
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Mission Point Healthcare Services
Operator or chain grouping
Approved since
1991-11-25
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
1.03
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.78
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
1.89
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
3.70
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
1.81
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
2.95
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
0.12
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
1.02
CMS adjusted RN staffing hours
Adjusted total hours
3.66
CMS adjusted total nurse staffing hours
Case-mix index
1.38
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
33%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,552
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29.45
Composite VBP score used to determine payment impact.
Payment multiplier
0.9855
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Performance 22.57% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
1.04
Baseline 6.03% · Performance 7.52% · Measure score 1.04 · Achievement 1.04 · Improvement 0
Total nurse turnover
9.06
Performance 26.67% · Measure score 9.06 · Achievement 9.06 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
1.69
Baseline 4.19 hours · Performance 3.56 hours · Measure score 1.69 · Achievement 1.69 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.36% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 47 · Observed rate 14.89% · Lower 95% interval 7.88% |
| Discharge to community | 51.88% |
50.57%
1.3 pts better
|
No Different than the National Rate · Eligible stays 40 · Observed rate 47.5% · Lower 95% interval 38.81% |
| Medicare spending per beneficiary | 1.12 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 30 · Denominator 30 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 30 |
| Discharge self-care score | 54.55% |
53.69%
0.9 pts better
|
Numerator 12 · Denominator 22 |
| Discharge mobility score | 68.18% |
50.94%
17.2 pts better
|
Numerator 15 · Denominator 22 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 30 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.53% |
7.12%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 30 · Observed rate 10% · Lower 95% interval 4.08% |
| Staff COVID-19 vaccination coverage | 17.02% |
8.2%
8.8 pts better
|
Numerator 8 · Denominator 47 |
| Staff flu vaccination coverage | 54% |
42%
12 pts better
|
Numerator 27 · Denominator 50 |
| Discharge function score | 63.64% |
56.45%
7.2 pts better
|
Numerator 14 · Denominator 22 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
95.0%
5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.0%
5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.8% |
3.1%
1.3 pts better
|
3.3%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 3.6% · Q3 0.0% · Q4 0.0% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
4.1%
4.1 pts better
|
11.4%
11.4 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 who lose too much weight | 4.4% |
5.5%
1.1 pts better
|
5.4%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 5.0% · Q3 4.2% · Q4 3.4% · 4Q avg 4.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.8% |
19.6%
9.8 pts better
|
19.6%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 9.5% · Q3 12.5% · Q4 13.8% · 4Q avg 9.8% |
| 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 · Q3 4.5% · Q4 10.7% · 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 | 14.7% |
13.9%
0.8 pts worse
|
16.3%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 14.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.5% |
11.7%
1.2 pts better
|
14.9%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 20.0% · Q3 13.6% · Q4 3.7% · 4Q avg 10.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.7% |
1.7%
1 pts worse
|
1.7%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 3.7% · Q3 0.0% · Q4 3.1% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.9% |
20.4%
0.5 pts worse
|
19.8%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.2% · Q2 28.4% · Q3 15.2% · Q4 7.4% · 4Q avg 20.9% |
| Percentage of long-stay residents with pressure ulcers | 13.1% |
5.6%
7.5 pts worse
|
5.1%
8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 20.3% · Q3 12.9% · Q4 13.3% · 4Q avg 13.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.8% |
82.8%
15 pts better
|
81.7%
16.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.7% · Q2 97.0% · Q3 98.1% · Q4 100.0% · 4Q avg 97.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 23.2% |
11.5%
11.7 pts worse
|
12.0%
11.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 23.2% · Observed 18.2% · Expected 8.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.0% |
79.5%
17.5 pts better
|
79.7%
17.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 45.7% |
24.2%
21.5 pts worse
|
23.9%
21.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 45.7% · Observed 39.4% · Expected 20.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-13 · Fire 2024-03-13
5 health deficiencies
Top issue: Infection Control (1 deficiency)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2023-04-07 · Fire 2023-04-07
2 health deficiencies
Top issue: Infection Control (1 deficiency)
7 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-11
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2025-03-13
F · Potential for more than minimal harm
2025-02-11
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-03-13
E · Potential for more than minimal harm
2025-02-11
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2025-03-13
E · Potential for more than minimal harm
2025-02-11
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-03-13
D · Potential for more than minimal harm
2025-02-11
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2025-03-13
F · Potential for more than minimal harm
2024-03-13
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2024-04-08
F · Potential for more than minimal harm
2024-03-13
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-04-08
F · Potential for more than minimal harm
2024-03-13
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-04-08
F · Potential for more than minimal harm
2024-03-13
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-04-08
F · Potential for more than minimal harm
2024-03-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-12
E · Potential for more than minimal harm
2024-03-13
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 2024-04-08
E · Potential for more than minimal harm
2024-03-13
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-04-08
F · Potential for more than minimal harm
2023-04-07
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-05-03
F · Potential for more than minimal harm
2023-04-07
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-05-03
F · Potential for more than minimal harm
2023-04-07
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-05-03
F · Potential for more than minimal harm
2023-04-07
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-05-03
E · Potential for more than minimal harm
2023-04-07
K223 · Egress Deficiencies
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 2023-05-03
E · Potential for more than minimal harm
2023-04-07
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 2023-05-03
E · Potential for more than minimal harm
2023-04-07
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-05-03
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-03-12
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 2025-03-31
D · Potential for more than minimal harm
2025-03-12
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 2025-03-31
E · Potential for more than minimal harm
2025-02-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-13
D · Potential for more than minimal harm
2025-02-11
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 2025-03-13
D · Potential for more than minimal harm
2025-02-11
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 2025-03-13
D · Potential for more than minimal harm
2025-02-11
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2025-03-13
F · Potential for more than minimal harm
2024-03-13
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 2024-04-08
E · Potential for more than minimal harm
2024-03-13
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-04-08
E · Potential for more than minimal harm
2024-03-13
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 2024-04-08
D · Potential for more than minimal harm
2024-03-13
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-04-08
D · Potential for more than minimal harm
2024-03-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-08
F · Potential for more than minimal harm
2023-04-07
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 2023-05-03
C · Minimal harm
2023-04-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-05-03
Penalties and ownership
What sits behind the stars
Ownership
Mali, Hari
5% Or Greater Indirect Ownership Interest · Individual
Mission Point Northern Michigan Holding LLC
5% Or Greater Direct Ownership Interest · Organization
Flores, Dawn
W-2 Managing Employee · Individual
Mali, Hari
Corporate Officer · Individual
Mission Point Management Services LLC
Operational/Managerial Control · Organization
Wilt, Roberta
W-2 Managing Employee · Individual
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#2
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4-star overall rating with 3-star inspections with $27,600 in total fines with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
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5-star overall rating with 5-star inspections with 1 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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