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Mission Point Nursing & Physical Rehabilitation of

725 West Fuller, Big Rapids, MI 49307 · For profit - Corporation · 78 certified beds · (231) 796-2631 Medicare & Medicaid certified

Call the home — (231) 796-2631 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Aug 2024
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
  • lower-than-typical staff turnover (29% vs 45% nationally) — better care continuity
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1310 Woodward Ave · (231) 598-2356 · Call to confirm hours
Pharmacy
101 Maple St · (231) 796-7621 · Call to confirm hours
Grocery
112 S Michigan Ave · (231) 660-9000 · Call to confirm hours
Park
Trestle Bend Dr · (231) 592-4038 · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 4 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 4 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased4.5%10.8%15.4%better
Long-stay residents who lose too much weight3.8%5.4%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.8%0.9%better
Long-stay residents with a urinary tract infection0.5%1.5%2.0%better
Long-stay residents with depressive symptoms4.5%4.3%6.5%better
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury1.5%3.0%3.3%better
Long-stay residents whose ability to walk worsened4.4%12.0%16.1%better
Long-stay residents on antianxiety or hypnotic medication9.3%19.4%18.9%better
Long-stay residents given the seasonal flu vaccine72.3%95.0%95.3%worse
Long-stay residents with pressure ulcers2.4%5.1%4.7%better
Long-stay residents with worsening bladder/bowel control19.4%20.0%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table13.2%14.8%17.1%better
Short-stay residents who newly got an antipsychotic medication1.5%1.1%1.4%typical
Short-stay residents given the seasonal flu vaccine84.5%79.5%79.4%typical
Short-stay residents rehospitalized after admission27.6%24.0%22.6%worse
Short-stay residents with an outpatient ER visit11.4%11.7%12.0%typical

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

56.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 77 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

56.3%U.S. median 51.5%
Got home and stayed home
10.4%U.S. median 10.7%
Went back to hospital
66.7%U.S. median 56.6%
Met the expected recovery
0.35U.S. median 0.31
Therapy hours / resident / day
0.16hours / resident / day
Physical therapy
0.16hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 66.7% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 33 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.35 therapist hours per resident per day in 2026Q1 — more than 60% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 30% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF56.3%CMS range 46.2–68.851.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.4%CMS range 7.3–14.310.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge66.7%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge57.6%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge57.6%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified95.9%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge97.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.3%CMS range 4.2–12.17.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.861.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.79
RN hours/ resident / day
0.61
LPN hours/ resident / day
2.33
Aide hours/ resident / day
3.73
Total nurse hours/ resident / day
0.44
RN hoursweekends
29.0%
Total nursing turnover
18.2%
RN turnover

How full it usually is: this home is certified for 78 beds and averages 69.0 residents a day — about 88% occupied, or roughly 9 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.73 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.79 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.33 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.01 hrs/resident/day on weekends vs 4.02 on weekdays — 25% thinner on weekends — a notable drop. RN hours go from 0.93 to 0.44 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 29% is below the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

11
deficiencies at the latest standard inspection (2025-07-18)
9
at the previous standard inspection (2024-08-21)

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

25 citations, most serious first. The 10 most serious are shown; the remaining 15 are one tap away and print in full.

  • Potential for harm · Ecited before2025-07-18 · tag F0842 — failed to keep accurate, complete medical records — pattern
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain complete and accurate medical records for 3 of 15 sampled residents (R3, R51, and R69). Findings include:Resident #51 (R51) A review of R51’s admission Record, dated 07/17/2025, revealed they were a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R51 had multiple diagnoses that included depression, bipolar disease, schizophrenia, and alcohol-induced disorder. R51’s admission Record also revealed they were their own responsible party (in charge of their own medical decisions). A review of R51’s Order Summary Report, dated 7/17/25, revealed R51 had physician orders for Benztropine Mesylate (a medication for Parkinson’s Disease and movement disorders from other diseases or side effects from antipsychotic medications) 0.5 milligrams (mg) twice a day and Bupropion (a medication for depression) 150 mg once a day. In addition, R51’s Order Summary Report revealed R51 was also prescribed Fluphenazine decanoate (an antipsychotic…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-18 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record reviews the facility failed to notify the responsible party of changes in conditions and treatment for one Resident (R5) of fifteen residents reviewed. Findings Resident #5 (R5) Review of the Electronic Medical Record (EMR) reflected R5 admitted to the facility 3/11/2018 with diagnoses that included: Traumatic Brain Dysfunction, Aphasia (inability or difficulty speaking), and Hemiplegia (weakness or paralysis on one side). Review of the Minimum Data Set (MDS) dated [DATE] reflected R5 was severely cognitively impaired. The EMR admission Record reflected Primary Contact (PC) K was the Guardian for R5. On 7/16/2025 at 11:16 AM a telephone interview was conducted with PC K who reported the facility had not always informed her of changes in status and care for R5. PC K reported several months ago she contacted the facility for an update on R5. PC K reported staff informed her R5 had been sick. PC K reported she contacted the facility a day or two later and was told by the facility R5…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-18 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure resident care plans were reviewed, revised, and implemented for 2 of 15 residents (Resident #40 and #5) reviewed for care plans. Findings: Resident #40 (R40) Review of an admission Record revealed R40 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: Muscular Dystrophy and dysphagia (difficulty swallowing). Review of R40’s “Antigravity Team Note” dated 6/12/25 revealed, “Date of Fall: 6/11/25Root Cause(s) of Fall: Rolled from bed…New Interventions: Floor mats added…” Review of R40’s fall “Care Plan” on 7/16/25 at 12:09 PM and on 7/17/25 at 11:02 AM revealed, “I am at an increased risk for falls r/t (related to) muscular dystrophy, muscle weakness, DM II (diabetes type 2), depression, anxiety, chronic pain, scoliosis, history of falls. Date Initiated: 11/23/2023.” There was no intervention for the placement of a floor mat. During an interview on 07/18/2025 at 8:30 AM, Staff…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-18 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow professional standards of nursing practice for 2 of 15 residents (Resident #40 and #55) reviewed for medication administration. Findings:Resident #40 (R40) Review of an admission Record revealed R40 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: Muscular Dystrophy and dysphagia (difficulty swallowing). The diagnosis of dysphagia was added to her diagnosis list on 12/1/23. Review of R40’s “Care Plan” revealed no entries that R40 could self-administer medications. Review of R40’s “Self-Administration of Medication Evaluation” revealed the assessment for self-administering medications was last completed on 8/10/23 (prior to the dysphagia diagnosis). Review of R40’s “SLP (Speech Language Pathology) Screen” dated 11/27/23 revealed R40 did not have the physical capacity to swallow without difficulty and had difficult/painful swallowing and would cough/choke with…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-07-18 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to 1.) ensure insulin was administered and monitored following the provider order and 2.) ensure abnormal blood sugar results were reported to the provider for 3 of 15 residents (Resident #40, #10, and #64) reviewed for insulin administration.Findings:Resident #40 (R40) Review of an admission Record revealed R40 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: Muscular Dystrophy Review of R40's Order Summary dated 5/3/25 revealed, HumaLOG KwikPen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Lispro) Inject 4 unit subcutaneously with meals for DM2 In addition to sliding scale insulin. Hold if BS <100 (blood sugar less than 100) or not eating.Review of R40's June Medication Administration Record and Blood Sugar Summary revealed that on 6/24/2025 at 08:06 AM R40's blood sugar was 93 and the 4 units of Humalog was administered. (The sliding scale insulin was not administered due to her blood…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-07-18 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure proper care of a Continuous Positive Airway Pressure (CPAP) device for one Resident (R15) of fifteen residents reviewed. Findings: Resident #15 (R15) Review of the medical record reflected R15 admitted to the facility 10/21/2019 with the pertinent diagnosis of Obstructive Sleep Apnea (a condition when breathing stops while sleeping due to a blockage of the windpipe). The medical record reflected that R15 used a CPAP device (the device that consisted of a pressure module that delivered breathable air under pressure via tubing from the device to a mask worn while sleeping to keep the windpipe open) to treat this condition. On 7/16/2025 at 10:09 AM an observation and interview were conducted with R15 in her room. It was observed that R15 had a CPAP device that was not in use and the mask was not stored in a bag. Review of the CPAP filter revealed it was moderately soiled. R15 reported that staff had not cleaned her CPAP in a long time. On 7/17/2025 at 10:53 AM during an observation and interview with R15…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-18 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure controlled medications were properly dispensed and documented for 3 of 15 residents (Residents #2, #4, and #25) reviewed for controlled medication administration. Findings:Resident #2 (R2) Review of an admission Record revealed R2 was an [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: osteoporosis. Review of R2's Order Summary dated 5/26/25 revealed, tramadol HCl Oral Tablet 50 MG Give 1 tablet by mouth two times a day for PAIN.Review of R2's Controlled Substance Proof-Of-Use Record revealed that on 7/1/25, 7/2/25, 7/3/25, and 7/14/25 the evening doses of tramadol were documented as dispensed.Review of R2's July Medication Administration Record revealed that on 7/1/25, 7/2/25, 7/3/25, and 7/14/25 the evening doses of tramadol were documented as not administered. Review of R2's Controlled Substance Proof-Of-Use Record revealed that on 7/4/25 there were no doses of tramadol documented as…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-18 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5% for 2 of 6 residents (R52 and R60) observed during the medication administration task, resulting in a medication error rate of 6.66% (2 errors of 30 medications administered).Findings include:R52A review of R52's admission Record, dated 7/18/25, revealed they were a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R52's admission Record revealed multiple diagnoses that included Vitamin D deficiency.During an observation on 7/16/25 at 8:25 AM, Licensed Practical Nurse (LPN) E administered eleven medications to R52, including Vitamin D3 (cholecalciferol) 50 mcg (micrograms) (2000 International Units (IU)).A review of R52's Medication Administration Record (MAR), dated 7/1/25 to 7/18/25, revealed LPN E should have administered cholecalciferol 1000 units on 7/16/25, not cholecalciferol 2000 units.During an interview on 7/16/25 at 12:18 PM, the Director of Nursing (DON) was…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-07-18 · tag F0761 — failed to label and store drugs safely — isolated
    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.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to properly label medications in 1 of 2 medication carts (Northeast/ Northwest Split Medication Cart) observed for medication storage.Findings include: During an observation on 07/16/2025 at 8:35 AM, the Northeast/Northwest Split Medication Cart was inspected with Licensed Practical Nurse (LPN) E. The following observations were made: - Incruse Ellipta 62.5 mcg/act discus box labeled with R52's name. However, the discus in the box was not labeled with R52's name and/or any other resident identifying information. - Fluticasone propionate 50 mcg/act nasal spray box labeled with R52's name. However, the nasal spray was not labeled with R52's name and/or any other resident identifying information. During an interview on 07/16/2025 following the inspection of the Northeast/Northwest Split Medication Cart at 8:35 AM, LPN E stated, They (the discus and nasal spray) should be labeled [with the resident's name] so we know if they are in the right box. LPN E also stated the discus, and nasal spray should be labeled with the resident's…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-18 · tag F0921 — failed to keep a safe, functional, sanitary building — isolated
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #1239234:Based on observation, interview, and record review, the facility failed to ensure a clean environment for 2 residents (R7 and R17) reviewed for environmental concerns. Findings include: On 7/11/2025 the Long-Term Care Ombudsman reported that the facility was odoriferous (unpleasant smell) during recent visits. On 7/15/2025 at 11:04 AM a strong smell of urine was noted at and around the Nurse's Station at the South East/West Hall becoming more pronounced down the hall past room [ROOM NUMBER] and continued to room [ROOM NUMBER] before subsiding but still notable. Due to the strong prevalence of the odor in the area the source could not immediately be isolated. Resident #7 (R7) Review of the medical record reflected R7 admitted to the facility 5/3/2024 with pertinent diagnoses that included Need for Assistance with Personal Care. Review of the Minimum Data Set (MDS) dated [DATE] reflected R7 was occasionally incontinent of urine and was not on a toileting program. The Care…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Environmental Deficiencies · Deficient, Provider has date of correction
Show the remaining 15 citations
  • Potential for harm · D2025-07-18 · tag F0947 — failed to train nurse aides adequately — isolated
    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews.Findings:Review of the Facility Assessment dated 8/6/24 revealed, .INFORMATION ABOUT OUR STAFF TRAINING/EDUCATION AND COMPETENCIES-Our facility's training program includes an orientation process and ongoing training for all new and existing staff including managers, nursing and other direct care staff, individuals providing services under contractual arrangement, and volunteers consistent with their expected roles. We complete an education needs assessment and develop a curriculum and training plan based on staff need (sic) and resident characteristics.Review of Certified Nursing Assistant (CNA) I's employee file revealed she was hired on 12/18/2023. There were no performance evaluations completed since CNA I's date of hire. Review of CNA I's computerized education/continuing competencies hours revealed:*On 12/30/23, Employee Safety Orientation was completed for 1…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-21 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide an appropriate size drinking cup to 1 resident (R16) of 1 Resident reviewed for reasonable accommodation of needs. Findings include: Review of R16's face sheet dated 8/19/24 revealed she was an [AGE] year-old female admitted to the facility on [DATE] she had diagnoses that included: Dementia, anxiety disorder, weakness and aphasia (difficulty in communication). R16 was not her own responsible party. R16 was observed in her room on 8/20/24 at 11:45 AM, R16 had a large plastic mug with a straw in it on her bedside table. R16's family member said they have talked to staff several times and reported at her care conferences that R16 does not have the strength to lift a mug that big. R16's family member reports for a week or two after voicing the concern the facility will provide a Styrofoam cup of water. R16's family member said she visits almost daily but will be taking a vacation soon and was worried R16 may get dehydrated as the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-21 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to investigate and report an allegation of misappropriation to the state survey agency for 1 of 3 residents (R20) reviewed for abuse and misappropriation, resulting in the potential for abuse and misappropriation to go undetected, underreported, and not investigated. Findings include: A review of R20's admission Record, dated 8/20/24, revealed R20 was an [AGE] year-old resident admitted to the facility on [DATE]. In addition, R20's admission Record revealed multiple diagnoses that included dementia and depression. A review of R20's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 5/15/24, revealed R20 had a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 15 which revealed R20 was cognitively intact. During an interview on 08/19/24 at 10:45 AM, R20 stated her cell phone came up missing about three months ago (two weeks after she was admitted ). She stated the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-21 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide care for 1 (Resident #8) of 2 residents reviewed for Activities of Daily Living (ADL) care. Findings include: Resident #8 (R8) Review of a Face Sheet revealed R8 originally admitted to the facility on [DATE] with pertinent diagnoses of multiple sclerosis, cognitive communication deficit (not interviewable), and contractures. In an interview on 8/19/24 at 2:20 PM, the Guardian of R8 reported he was not being provided with oral care often and the staff are not using the [Brand name of oral moisturizer] gel she provided them with to keep his mouth moist. The Guardian reported she visits every other day and will observe his mouth with caked, dried on secretions that could be avoided if he had routine care with the gel. The Guardian also had concerns R8 was in bed most of the day and not up in his electric wheelchair. R8 enjoys being up in his wheelchair and she had expressed her concerns with the staff. During an observation and an…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-21 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide meaningful activities for 2 Residents (R7 and R16) of 2 residents sampled. Findings included: R7 Review of R7's face sheet dated 8/20/24 revealed she was an [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: Dementia, Alzheimer's Disease, major depressive disorder, anxiety disorder and difficulty in walking. R7 was not her own responsible party. R7 was observed sleeping on 8/19/24 at 11:05 AM. R7 was observed sleeping on 8/20/24 at 1:15 PM. During an interview with Certified Nurse Aides (CNA) O and CNA P on 8/20/24 at 1:17 PM, they explained R7 normally sleeps all day, she rarely eats breakfast or lunch. They do attempt to wake her up for breakfast and lunch, but she rarely eats. They were aware she generally wakes up a 5:00 PM. They did not know what her activity or food preferences were as they rarely see her awake long enough to do these activities. During an interview with the Activity…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-21 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    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.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to apply hand splints for 1 (Resident #8) of 1 resident reviewed for contractures. Findings include: Resident #8 (R8) Review of a Face Sheet revealed R8 originally admitted to the facility on [DATE] with pertinent diagnoses of multiple sclerosis, cognitive communication deficit, and contractures. In an interview on 8/19/24 at 2:20 PM, the Guardian of R8 reported he was not wearing his braces/splints on both hands anymore and when he did wear them, the staff was not applying them correctly and the straps would rub his knuckles really hard. During an observation and an interview on 8/19/24 at 2:42 PM, Certified Nursing Assistant (CNA) I repositioned R8 who was laying in bed hugging a couple of pillows. CNA I reported he gets skin breakdown on the inside of his elbows and the pillows help prevent that. He did not have any splints on his contracted hands. When queried about splints for his hand contractures, CNA I reported his splints are in the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-21 · tag F0761 — failed to label and store drugs safely — isolated
    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.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure expired medications were not in 1 of 2 medication carts inspected (Northwest Medication Cart) and failed to secure 1 of 4 medication carts (Southwest Medication cart). Findings include: During an inspection of the Northwest Medication Cart with Licensed Practical Nurse (LPN) A and the Director of Nursing (DON) on 8/19/24 at 5:15 PM, the following observations were made: - An opened 8 fluid ounce bottle of Senna Syrup (a laxative) was observed to have an expiration date of 1/24. - An opened bottle of a multivitamin was observed to have an expiration date of 3/24. - LPN A and the DON verified these findings. During an observation on 8/21/24 at 8:25 AM, the Southwest Medication Cart was observed in the hallway, unlocked, and unattended. There were not any staff within sight of the medication cart. During an interview on 8/21/24 at 8:30 AM, Registered Nurse (RN) E (the nurse assigned to the Southwest Medication Cart) stated she did not see an issue with leaving the medication cart unlocked because I was…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-21 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to safeguard the confidentiality of medical records for 2 of 60 facility residents [R34 and R46), resulting in the potential for unauthorized access to resident medical records and the potential for the loss of resident privacy and confidentiality of their personal health information. Findings include: R46 During an observation on 08/21/24 at 8:25 AM, the computer screen on top of the Southwest Medication Cart was observed open to R46's electronic Medication Administration Record, (e-MAR). R46's personal and health identifying information (i.e., picture, name, room number, physician's name, allergies, recent vital signs, code status, special instructions for medication administration) and medications were visible to anyone walking by the medication cart. No staff were visible within sight of the medication cart. During an interview on 8/21/24 at 8:30 AM, Registered Nurse (RN) E (the nurse assigned to the Southwest Medication Cart) stated she did not see an issue with leaving the computer screen open to R46's…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-21 · tag F0849 — isolated
    Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide collaborative hospice care for 2 Residents (R4 and R7) of 2 residents reviewed for hospice care. Findings included: Review of R4's face sheet dated 8/21/24 revealed, she was a [AGE] year-old female that admitted to the facility on [DATE] and had diagnoses that included: Parkinson's disease and adult failure to thrive. She was not her own responsible party. R4 was observed on 8/21/24 at 8:49 PM sitting on the edge of her bed with her head down on the mattress on her right side. R4 had vomited on her shirt and her bed. Registered Nurse (RN) E, Certified Nurse Aides (CNA) Q and (CNA) R came in to provide care. They were all aware R4 was in hospice care. None of them were aware of the last time the hospice staff were in to provide service and had no idea of when hospice was scheduled to see R4 again. RN E said at one point hospice kept their schedules in a book at the nursing station. RN E looked at all the books at the nursing…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-21 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to clean a glucometer per the manufacturer's instructions for 2 of 2 residents (R28 and R37) reviewed for blood glucose testing, resulting in the potential for the spread of infection and disease. Findings include: R37 A review of R37's admission Record, dated 8/21/24, revealed R37 was a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R37's admission Record revealed multiple diagnoses that included diabetes. During an observation on 8/19/24 at 4:50 PM, Licensed Practical Nurse (LPN) A was observed cleaning the glucometer machine with a 70% isopropyl alcohol prep pad after checking R37's blood sugar level. LPN A cleaned the machine by quickly swiping it with the alcohol pad. LPN A stated an alcohol prep pad can be used to properly clean and sanitize their glucometer machines. R28 A review of R28's admission Record, dated 8/21/24, revealed R28 was a [AGE] year-old resident admitted to the facility on [DATE] and…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-27 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This Citation pertains to Intake Number MI00143327. Based on observation, interview, and record review the facility failed to ensure the safety of one facility resident (Resident #6) who did not have full decision-making capabilities which resulted in the potential for elopement from the facility for the resident and all cognitively impaired residents. Findings include: Resident #6 (R6): Review of the medical record reflected R6 admitted to the facility 12/13/23 with diagnoses that included: Encephalopathy (the brain is affected by some agent or condition such as a viral infection or toxin in the blood), Cystitis (infection of the bladder) and acute kidney failure. Review the Minimum Data Set (MDS) dated [DATE] reflected a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicted R6 was mildly cognitively impaired. The medical record reflected R6 had a guardian. Review of the Facility Reported Incident (FRI) dated 3/8/24 revealed on 3/1/24 at approximately 11:45 AM staff allowed R6 to exit…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Potential for harm · Dcited before2023-08-10 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility to failed to ensure resident needs were met in a timely manner for 2 residents (Resident #28 and #314), reviewed for accommodation of needs, resulting in the potential for residents to not meet their highest practicable level of well-being. Findings include: Resident #28 (R28) Review of an admission Record revealed R28 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: muscle weakness, difficulty in walking, and history of falling. Review of a Minimum Data Set (MDS) assessment for R28, with a reference date of 7/13/23 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated R28 was cognitively intact. Review of the Functional Status revealed that R28 required extensive 2 person assist for bed mobility, toileting, and transferring. Review of R28's Care Plan revealed R28 required the use of a sit to stand machine for…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-10 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide quality care for 1 resident (Resident #314), resulting in the loss of the resident's prescribed eye drops and subsequent failure to administer the eye drops per physician orders. Findings: Resident #314 (R314) Review of an admission Record revealed R314 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses of a fractured right wrist that was supported by a cast, glaucoma, muscle weakness, history of falls, and need for assistance with personal care. During an interview on 08/08/23 at 10:20 AM, R314 indicated the following: (a) a few nights ago the nurse brought in eye drops that were prescribed and used for glaucoma and left the bottle of eye drops on the bedside table, (b) when the next staff person came to the room, R314 asked that staff person to make sure the eye drops got back to the medication cart, (c) R314 observed the staff person (R314 did not remember the name of the staff person) put…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-10 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure oxygen tubing and equipment were properly maintained in accordance with the facility policy and procedure for two facility Residents (Resident #56 (R56) and R34) resulting in the potential for respiratory infection for all facility residents that require the use oxygen devices. Findings: Review of the medical record reflected that R56 admitted to the facility 7/6/23 with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD) and Acute and Chronic Respiratory Failure. Review of the Doctors Orders for R56 reflected orders for oxygen therapy, the use of a BIPAP device, and nebulizer treatments as needed. On 8/8/23 at 10:49 AM in the room of R56 a BIPAP mask was observed uncovered hanging on a hook on the wall. A nebulizer machine was on the top of a dresser at the foot of the bed. Uncovered oxygen tubing was coiled on the top of the machine with an uncovered inhalation device attached. On 8/9/23 at 12:00 PM in the room…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2024-03-27 · tag F0680 — pattern
    Ensure the activities program is directed by a qualified professional.
    What the surveyor found here — the official record, unedited, may be distressing

    This Citation pertains to Intake MI00142054 Based on interview and record review the facility failed to ensure that staff had the necessary training and qualifications to hold the position of Activities Director. Findings: Review of the facility employee list identified the person in the position of Activity Director. (AD). During an interview conducted on 3/27/24 at 4:04 PM, Activities Director (AD) C reported she has held the position since May 05, 2023. AD C reported she does not currently hold any of the certifications, licenses, nor has met the regulatory requirements for the position of Activities Director. As of survey exit no additional information was provided.

    Quality of Life and Care Deficiencies · Deficient, Provider has plan of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to MISSION POINT HEALTHCARE SERVICES — 14 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 4 of 52.8+1.2 vs chain
Health inspection 3 of 52.3+0.7 vs chain
Staffing 4 of 53.9+0.1 vs chain
Quality measures 5 of 54.1+0.9 vs chain
The other 13 homes this chain runs (chain average 2.8★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
MISSION POINT GRAND RAPIDS HOLDINGS LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 02/14/2000
MITCHELL FAMILY III IRREVOCABLE GST TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF21%since 04/14/2023
MALI, HARIIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/14/2023
MITCHELL, MARKIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/14/2023
GRAY, PATRICIAIndividualW-2 MANAGING EMPLOYEEsince 02/14/2020
WILLIAMS, ERICAIndividualW-2 MANAGING EMPLOYEEsince 02/14/2020
MISSION POINT MANAGEMENT SERVICES LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 02/14/2020
HIGHAM, JENNIFERIndividualTRUSTEE OF THE SNFsince 04/14/2023
OEGEMA, JAMESIndividualTRUSTEE OF THE SNFsince 04/14/2023
MP BIG RAPIDS PROPERTY HOLDING LLCOrganizationADP OF THE SNFsince 04/14/2023
KOSTECKI, JASONIndividualADP OF THE SNFsince 04/22/2024
SOLAREWICZ, MACIEJIndividualADP OF THE SNFsince 11/20/2025

CMS files one row per role, so the 17 rows in the source record cover these 12 parties — each is shown once here with every role it holds. Nothing is omitted.

4 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$6.7M
Net patient revenuemost recent cost report
-50.0%
Operating marginrevenue minus expenses
$1.6M
Related-party expense16% of expenses
Who pays — share of resident-days
Medicaid 59%Medicare 7%Other / private 34%

This home reported $1.6M paid to related parties — landlords or management companies under common ownership — equal to about 16% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$429per resident / day
operating cost
$13,050per month
≈ monthly operating cost
$286per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in MI

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Michigan Medicaid page.

Typical monthly cost in Michigan
$11,254/mo
Nursing home (semi-private)
$11,969/mo
Nursing home (private)
$5,818/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 235312. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-18, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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