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Mission Point Nursing & Physical Rehabilitation Ce

9146 Woodward Ave, Detroit, MI 48202 · For profit - Corporation · 129 certified beds · (313) 875-1263 Medicare & Medicaid certified

Call the home — (313) 875-1263 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited May 20261 actual-harm citation CMS recorded as corrected before the inspection ended (past non-compliance)
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
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
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection rating is low (2/5)

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.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 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 staffing and quality-measure ratings run 3 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, and staffing on its payroll (PBJ) submissions — 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
8282 Woodward Ave · (313) 874-3440 · Call to confirm hours
Pharmacy
10301 Woodward Ave · (313) 852-3651 · Call to confirm hours
Grocery
40 Clairmount St · (313) 872-0220 · Call to confirm hours
Park
74 Arden Park Blvd · Typically dawn to dusk
Place of worship
9000 Woodward Ave · (313) 872-2900

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

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 improved from 1 to 3 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 rating3★
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 increased5.4%10.8%15.4%better
Long-stay residents who lose too much weight7.0%5.4%5.4%worse
Long-stay residents with a catheter left in their bladder0.3%0.8%0.9%better
Long-stay residents with a urinary tract infection0.3%1.5%2.0%better
Long-stay residents with depressive symptoms5.3%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 injury0.6%3.0%3.3%better
Long-stay residents whose ability to walk worsened4.3%12.0%16.1%better
Long-stay residents on antianxiety or hypnotic medication12.3%19.4%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%95.0%95.3%typical
Long-stay residents with pressure ulcers3.7%5.1%4.7%better
Long-stay residents with worsening bladder/bowel control5.7%20.0%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table14.1%14.8%17.1%better
Short-stay residents who newly got an antipsychotic medication2.0%1.1%1.4%worse
Short-stay residents given the seasonal flu vaccine50.0%79.5%79.4%worse
Long-stay hospitalizations per 1,000 resident days1.251.841.67better
Long-stay outpatient ER visits per 1,000 resident days0.431.641.80better

§ 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.

0.28U.S. median 0.31
Therapy hours / resident / day
0.13hours / resident / day
Physical therapy
0.13hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.28 therapist hours per resident per day in 2026Q1 — more than 42% 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 SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot 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 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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.811.02Oct 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

0.53
RN hours/ resident / day
0.88
LPN hours/ resident / day
2.09
Aide hours/ resident / day
3.50
Total nurse hours/ resident / day
0.28
RN hoursweekends
41.3%
Total nursing turnover
11.1%
RN turnover

How full it usually is: this home is certified for 129 beds and averages 87.7 residents a day — about 68% occupied, or roughly 41 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 3.50 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.53 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.09 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 2.78 hrs/resident/day on weekends vs 3.79 on weekdays — 27% thinner on weekends — a notable drop. RN hours go from 0.63 to 0.28 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 41% is about the same as 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

3
deficiencies at the latest standard inspection (2026-05-15)
7
at the previous standard inspection (2025-03-05)

Deficiencies are fewer than at the previous inspection — improving. 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.

26 citations, most serious first. The 11 most serious are shown; the remaining 15 are one tap away and print in full.

  • Actual harm · Gcited before2024-08-01 · 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 MI00145699. Based on interview and record review the facility failed to ensure adequate assistance during a mechanical lift (Hoyer) transfer for one resident (R601) out of four residents reviewed for falls, resulting in a fracture of the right rib and hospitalization. Findings include: Review of an admission Record revealed, R601 originally admitted to the facility on [DATE] with pertinent diagnosis which included hemiplegia and hemiparesis following a cerebral infraction. R601 discharged on 7/1/24 due to a fall and returned to the facility on 7/5/24 with the diagnosis of Fracture of one rib, right side. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R601 had cognitive impairment with a Brief interview for Mental Status (BIMS) score of 8 out of 15 and had impairment on one side of the upper and lower extremities. Review of a nurse's progress note with a date of 7/1/24 at 4:13 p.m. revealed, Event occurred on 07/01/2024 11:30 AM. res was being lifted in hoyer…

    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 · Fcited before2026-05-15 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with 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 maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include:On 05/12/2026 beginning at 8:43 AM a kitchen tour was conducted with [NAME] B.On 05/12/2026 at 8:55 AM observed blue metal storage racks in the walk in cooler with worn paint exposing the rusted metal surfaces of the rack. On 05/13/2026 at 8:50 AM observed blue metal storage racks in the walk in cooler with worn paint exposing the rusted metal surfaces of the rack. In an interview at this time with Dietary Manager (DM) A when asked about cleaning of racks, DM A indicated the storage racks are cleaned weekly and they are slightly rusted.According to the 2022 Food Code, section 4-101.19 Nonfood-Contact Surfaces, NonFOOD-CONTACT SURFACES of EQUIPMENT that are exposed to splash, spillage, or other FOOD soiling or that require frequent cleaning shall be constructed of a CORROSION-RESISTANT, nonabsorbent, and SMOOTH material.On 05/12/2026 at…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2026-05-15 · tag F0814 — failed to dispose of garbage properly — widespread
    Dispose of garbage and refuse properly.
    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 properly dispose of waste and maintain the dumpster area to mitigate the presence of pests, potentially affecting all residents in the facility. Findings include:On 05/12/2026 at 9:40 AM observed two outdoor waste receptacles adjacent to each other with their lids in the open position. One receptacle had multiple trash bags overflowing from the bin and resting on top of the lid. Birds were observed landing on the mound of trash and flying away. The second receptacle was also observed with its lids in the open position and trash piled over the rim of the receptacle. Further observation of the area found various scattered debris around and behind the receptacles including water bottles, plastic bags, gloves, a mask, utensils, cardboard, a folding table and tires. An interview at this time with Dietary Manager (DM) A found they were unsure the frequency of pickup. When asked if the lids are usually open, DM A indicated they are not usually open.On 05/12/2026 at 3:01 PM an interview with Maintenance Director (MD)…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2026-05-15 · tag F0880 — failed to prevent and control infections — widespread
    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 have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in waterborne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among all residents in the facility. Findings Include:On 05/12/2026 at 10:29 AM observed a nonfunction hot water faucet on the hand sink in the second floor activities room. On 05/12/2026 at 1:29 PM observed a hopper with no water in the bowl indicating low use in the second floor long hall storage room. Further observation found the hopper inoperable, and the spray hose head removed from the hopper.On 05/12/2026 at 1:38 PM observed the hot water handle missing from the janitor sink in the second floor short hall janitor closet. On 05/12/2026 at 2:06 PM an interview with Maintenance Director (MD) D was conducted regarding water management.…

    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 · D2026-05-15 · 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 This citation pertains to intake 3001301.Based on interview and record review, the facility failed to ensure staff reported the results of an investigation to the State Agency within five working days of an incident for two of four residents (R15 and R56) reviewed for abuse.Findings include: On 04/21/2026, a Facility Reported Incident of a resident-to-resident abuse allegation was reported to the State Agency. The investigation report was received on 04/30/2026. A review of the facility's abuse investigation summary dated 04/30/2026 documented in part the following: R56 hit R15 on the left side of the face/head area; unprovoked. No injury reported. R56 was sent to the hospital for a psychiatric evaluation. During an interview on 05/15/2026 at 10:55 AM, the Nursing Home Administrator (NHA) was identified as the facility's abuse coordinator. The NHA said he submitted the Facility Reported Incident report and the investigation summary to the State Agency. The NHA was queried regarding the delayed submission of 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 · Dcited before2026-03-27 · 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 Based on observation, interview, and record review, the facility failed to provide appropriate positioning assistance and safety interventions during incontinence care for one resident (R103) out of three residents reviewed for accidents, resulting in a fall. Findings include: On 3/26/26 at 11:30 AM, R103 was observed awake and lying in a bariatric bed (a specialized, heavy-duty bed designed to safely support plus size or obese people). R103 said they cannot walk or stand but can move about the bed. R103 said they fell out of bed a few days ago during incontinence care. R103 said staff clean them up one side at a time. Staff will have them cross one leg over the other and turn. R103 stated, I didn't know how close I was to the edge of the bed and when I flung my leg over, I slid out of the bed onto the floor. R103 said there was one person changing them at the time. Staff used a mechanical lift plus three people to get them back into bed. A review of the clinical record for R103 documented an initial admission…

    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 · D2026-03-27 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure resident's medical record accurately documented the administration of prescribed medications (magnesium oxide, metoprolol tartrate, and Seroquel) for one resident (R101). Findings include: A review of the clinical record for R101 documented an admission date of 9/27/25 and discharge date of 3/7/26. R101's diagnoses included acute respiratory failure with hypoxia, hypertension, and bipolar disorder. A Minimum Data Set assessment dated [DATE] documented severe cognitive impairment. Discharge note of 3/7/26 at 3:33 PM (author Licensed Practical Nurse [LPN] C) documented in part the following: Resident was transferred to local hospital. Reason(s) for Transfer: Behavioral symptoms (e.g. agitation, psychosis). Resident/Responsible party were notified of the reason for transfer. Nursing progress note of 3/7/26 at 3:38 PM (author LPN C) documented in part the following: Writer notified by EMT's (emergency medical technicians) that they were here from a…

    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 · Ecited before2025-12-22 · tag F0921 — failed to keep a safe, functional, sanitary building — pattern
    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

    This citation pertains to Intake #2617411. Based on observation, interview, and record review, the facility failed to effectively clean and maintain two common resident bathrooms, resulting in unsanitary and unsafe conditions and the potential for dissatisfaction of the residents' living area. Findings include:It was reported to the State Agency that resident bathrooms were not properly maintained. On 12/22/25 at 8:30 AM, observations of the first-floor common bathrooms were conducted with Certified Nurse Aide (CNA) D. The following items were noted: Back hall bathroom: A small wash basin containing used soiled towels was observed on the floor. The towels appeared to be dry. Four irregular streaks of solid brown matter were observed on the wall above and to the right of the wash basin on the floor. CNA D indicated resident showers had not yet been given on the day shift. CNA D added that CNAs were to remove soiled towels after use. Front hall bathroom: The soap dispenser near the handwashing sink was empty. A disposable razor was observed on the shelf above the handwashing sink. CNA…

    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
  • Potential for harm · Fcited before2025-03-05 · tag F0727 — failed to provide required RN coverage — widespread
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) was on duty for eight consecutive hours a day, seven days a week; resulting in the potential for inadequate coordination of emergent or routine care that could cause negative outcomes. This deficient practice had the potential to affect all 84 residents in the facility. Findings include: On 3/5/25 at 11:13 AM review of the nurses' schedule for the months of July, August and September 2024 with staffing coordinator K, revealed there was no Registered Nurse (RN) coverage on the following dates: -September 2nd, 2024 -September 8th, 2024 Staffing coordinator K acknowledged the facility had difficulty finding RN coverage for weekends. O3/5/25 at 12:14 PM the Director of Nursing (DON) was interviewed and said there have been times when a RN was not available, and the expectation is that there is 8-hour RN coverage 7 days per week. The DON agreed the resident population consisted of residents with tube feedings, intravenous medications and the facility had previous residents with tracheostomies that…

    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 · Fcited before2025-03-05 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with 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: 1. Properly clean surfaces in the kitchen that were visibly soiled; 2. Properly seal food in the freezer; 3. Ensure pans were cleaned and air dried before stacking; 4. Properly maintain resident refrigerator; and 5. Ensure reusable resident meal service ware was properly sanitized. These deficient practices had the potential to affect all residents who consumed food from the kitchen, resulting in the increased potential for food borne illness. Findings include: During the initial tour of the kitchen on 3/3/25 at 8:28 AM with Dietary Manager, (DM) G, the following was observed: 1. The inside of the ice scoop container was soiled with food debris and contained in a plastic sandwich bag. 2. The sides and bottom vents on the vegetable reach-in freezer and supplement reach-in freezer were soiled and stained with food debris. 3. The meat freezer contained an opened box of turkey sausage that was not adequately sealed exposing the contents to the freezer air. 4. A wet 1/2 pan and full-size pan soiled with food…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-03-05 · tag F0908 — failed to keep essential equipment working — widespread
    Keep all essential equipment working safely.
    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 equipment used in food service operation was maintained in a safe and sanitary operating condition, resulting in the coffee machine and walk-in cooler not being protected against contamination from sewage or other sources of contamination. Findings include: On 3/3/25 at 8:28 AM, during the initial tour of the kitchen with Dietary Manager (DM) G, the following was observed: - The drain line from the coffee machine was partially positioned on a metal plate which resulted in a direct connection between the coffee machine drain line and the floor drain. - The drain line from the walk-in cooler was observed to not have an unobstructed vertical space between the end of the walk-in cooler drain line and the floor drain. When queried about an air gap for the coffee machine and walk-in cooler, DM G stated, There should have been an air gap. On 3/5/25 at 11:47 AM, the Nursing Home Administrator (NHA) said the coffee machine drainpipe needed to be moved over a couple of inches and the walk-in cooler drain was not…

    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 · D2025-03-05 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    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 a urinary catheter drainage bag was maintained in a dignified manner for one resident (R4) of two resident reviewed for catheters, resulting in the potential for feelings of diminished self-worth using the reasonable person concept. Findings include: On 03/03/25 at 10:10 AM, R4 was observed in bed, laying slightly towards the left side with their eyes open. R4's right arm appeared contracted, with the arm toward their chest and fingers curled towards their palm. The drainage bag was exposed and revealed cloudy, amber colored urine. The catheter bag was not contained in a dignity bag and/or with a dignity covering. R4 was confused and was able to answer basic questions. On 03/03/25 at 2:28 PM, R4 was observed in bed on their right side. The urinary catheter drainage bag remained in the same place without a dignity bag/cover in place. A review of R4's Electronic Medical Record (EMR) revealed an admission of 09/11/2020 with the diagnosis of Schizophrenia, Contracture of Right Elbow, Muscle Wasting,…

    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 before2025-03-05 · 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 ensure the provision of hygiene and daily care for two residents, (R4 and R8) of two residents reviewed for assistance with Activities of Daily Living (ADL's), resulting in R4 not receiving timely fingernail care and R8 not receiving adequate facial hair care. Findings include: R4 On 03/03/25 at 10:10 AM, R4 was observed in bed, laying slightly towards the left side with their eyes open. R4 was confused and was able to answer only basic questions. R4's right arm appeared contracted, with their arm toward their chest and fingers curled into a fist. R4's nail on their first finger of their right hand was long and jagged. R4's other nails on their right hand curled into a fist. When asked if they could open their right hand, R4 replied, No. Observation of the R4's left hand and fingernails revealed the fingernails were long and jagged. A review of R4's Electronic Medical Record (EMR) revealed an admission of 09/11/2020 with the diagnosis of…

    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 · D2025-03-05 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    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 a physician responded to pharmacy recommendations in a timely manner for one resident (R52), out of five residents reviewed for unnecessary medications. Findings include: A review of the clinical record for R52 documented an admission date of 7/5/24 with diagnoses that included heart failure, Parkinson's Disease, psychotic disorder with hallucinations, post-traumatic stress disorder, and adjustment disorder with mixed anxiety and depressed mood. A Minimum Data Set, dated [DATE] documented severe cognitive impairment and administration of antipsychotic and antianxiety medications. Physician's current orders for R52 documented to administer Xanax tablet 0.25 mg by mouth every 12 hours as needed for anxiety with a start date of 2/25/2025. Review of R52's pharmacy consultations identified irregularities on 8/7/24, 9/13/24, and 10/11/24 which all indicated, Recommend discontinuing PRN (as needed) use of Xanax for this Resident, OR reorder for a…

    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 · D2025-03-05 · tag F0806 — failed to honor food preferences — isolated
    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
    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 food items listed as always available were on hand to ensure resident food preferences were honored for one resident (R6). Findings include: During an interview on 3/3/25 at 10:50 AM, R6 was observed awake and lying in his bed. When queried if he was getting enough food to eat, R6 indicated he was not. When queried if he was offered an alternative menu item, R6 indicated that the menu items were not always available. A sheet of paper titled, Always Available Menu was attached to the bulletin board in R6's room. When queried if these menu items were always available, R6 indicated no. During an observation and interview on 3/3/25 at 11:30 AM with Dietary Manager (DM) G, the following items listed on the always available menu posted in R6's room were not in stock in the kitchen: sliced turkey lunch meat and cottage cheese. DM G acknowledged that always available menu items should always be available. During an interview on 3/4/25 at…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-03 · 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 timely personal care for one of (R15) four residents reviewed for ADL's resulting in untimely assistance with bathing, dressing, and transferring to their wheelchair and the resident verbalizing feelings of frustration and anger. Findings include: On 10/2/24 at 08:56am, R15's call light was on, and the resident was observed lying on their back, sheet and blanket was not covering the right side of R15's body, wearing a soiled brief and a faded black t-shirt with food stains across the front of the shirt. There was an odor of stool. R15 lips were dry with skin peeling. In addition, the resident face had dried food within their beard. R15 indicated they needed to be cleaned up due to an accident in their brief. On 10/2/24 at 09:40am, an unknown certified nurse aide (CNA) was observed with R15 changing their brief. During this time of care, staff did not perform bathing nor dressing the resident. R15 stated that they were waiting 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-02-01 · tag F0727 — failed to provide required RN coverage — widespread
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — an excerpt from the official record, may be distressing

    This citation pertains to Intakes MI00141917. Based on interview and record review, the facility failed to consistently utilize the services of a Registered Nurse (RN) for eight consecutive hours per day (24-hour period), seven days a week, resulting in the potential for inadequate coordination of emergent or routine care that could cause negative outcomes, affecting the 89 residents who resided in the facility. Findings include: A complainant reported to the State Agency concerns with nursing staffing levels. On 2/1/24 at approximately 1:00 PM, an interview was conducted with Staffing Coordinator (SC) E who was responsible for scheduling nursing staff for the facility. A review of nursing schedules during the periods of 11/15/23 to 11/30/23 and 1/2/24 to 1/15/24 revealed there was no RN coverage per day (24-hour period) for the following dates: 11/15/23, 11/17/23, 11/20/23, 11/23/23, 11/24/23, 11/25/23, 11/26/23, 11/28/23, 11/29/23, 11/30/23, 1/2/24, 1/4/24, 1/7/24, and 1/12/24. On 2/1/24 at 2:34 PM, the Director of Nursing (DON) said the building should be staffed with eight hours…

    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 · F2024-02-01 · tag F0868 — widespread
    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to ensure that the Medical Director (MD) attended the Quality Assurance and Performance Improvement (QAPI-program aimed on improving processes involved in health care delivery and resident quality of life) meetings quarterly, resulting in the potential for impaired resolution of identified issues or decreased quality of care with the potential to affect all 89 residents that reside in the facility. Findings include: During an interview and record review on 2/01/24 at 1:58 PM, the QAPI program was reviewed with the Nursing Home Administrator (NHA). The NHA revealed that QAPI team members met monthly and included managers and interdisciplinary team members. When queried if the medical director attends the required quarterly QAPI meeting the NHA stated, The medical director did not participate in any of the 2023 QAPI committees or any meetings for 2024 nor did his representative. Record review of the provided 12 QAPI attendance records dated January 2023 through September 2023, and 3 undated sign in sheets next to the Medical…

    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 · Fcited before2024-02-01 · tag F0921 — failed to keep a safe, functional, sanitary building — widespread
    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 Based on observation and interview the facility failed to provide a safe, functional, sanitary, and comfortable environment for the facilities census of 89 residents and its staff resulting in an increased chance of harm and the spread of harmful pathogens. Findings include: On 1/31/24 between 11:02 AM and 11:25 AM, during a tour of the laundry room and its support spaces the following observations were made: An accumulation of dust and debris was observed on top and on the sides of both washing machines, underneath and behind both dryers, on the blades and grill of the wall mounted fan, on the furnace vent grates and its filters, and within the floor grates next to the washing machines. Multiple soiled towels were observed on top of the washing machines. The overhead light fixture above the dryers was observed with its light bulbs missing. Floor tiles/ a flooring material was observed deteriorated and missing in multiple areas throughout the laundry room. One of two washing machines was observed in a…

    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
  • Potential for harm · Ecited before2024-02-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    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

    Based on observation, interview, and record review the facility failed to ensure an oxygen cylinder was stored properly Findings include: On 1/31/24 at 1:06 p.m. an observation of the medication room located on the second floor of the facility revealed an oxygen cylinder without a stand propped against the wall in the corner next to two fire extinguishers and a metal rack. Near the top of the oxygen cylinder regulator, the red needle was on 0 in the REFILL area (within or just outside of the red area, the cylinder is close to empty). This indicated the cylinder was not empty of oxygen. On 2/1/24 at 2:02 p.m. Unit Manager J was interviewed regarding the oxygen cylinder inappropriately stored in the medication room. Unit Manager J directed a staff person to remove the cylinder while stating, I didn't know this was in here. This should not be in here. On 2/1/24 at 3:11 p.m. the Director of Nursing was interviewed. The DON said the Central Supply staff person was responsible for removing oxygen equipment out of the medication rooms and ensure they are stored and placed safely. Review of…

    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 · E2024-02-01 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    This citation pertains to Intakes MI00141917. Based on observation, interview, and record review, the facility failed to ensure meals were served at palatable temperatures for residents served from a first-floor meal cart and specifically R7 from the third floor, resulting in dissatisfaction with the meal experience. A complainant reported to the State Agency that the facility failed to serve palatable food. During an observation and interview on 1/30/24 at 12:57 PM, the last tray on a first-floor meal cart was obtained and used as a test tray. License Practical Nurse (LPN) D was present during the testing of food temperatures on the lunch tray. The following temperatures were obtained using a metal stem thermometer: - BBQ chicken: 103ºF (Fahrenheit) - Mixed vegetables: 96ºF - Rice: 98ºF LPN D physically touched the mixed vegetables and rice and stated the food was not warm enough that you would enjoy eating it. During an interview on 1/31/24 at 2:57 PM, Dietary Director (DD) B said the temperature of hot food when it reaches the floor should be 140 degrees. During an interview on…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-02-01 · tag F0809 — failed to serve meals on a reasonable schedule — pattern
    Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
    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 meals were delivered in a timely manner and in accordance with the scheduled mealtimes for the residents observed during dining observations, resulting in resident dissatisfaction. Findings include: A review of a facility document titled, Resident Meal Service Times, dated 11/17/23, revealed that meal trays were to be delivered to the first-floor residents for breakfast and lunch at 7:50 AM and 11:45 AM respectively. This document further indicated to Please allow + or - 10 minutes between meal delivery times. During an observation on 1/30/24 at 8:26 AM, breakfast had not been served to the residents residing on the first floor. On 1/30/24 at 9:20 AM, Resident #60 (R60) was observed alert, fully oriented, and in his room. R60 indicated he had not been served breakfast yet and stated, I'm hungry. Breakfast meal trays were delivered to the first floor at 9:16 AM. R60 received his breakfast at 9:24 AM. During an observation on 1/30/24, lunch meal trays were delivered to the first floor at 12:52 PM. During…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-01 · 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 ensure an accommodating call light was provided for one resident (R4) of one resident reviewed for accommodation of needs, resulting in R4's inability to use the call light and the potential for unmet care needs. Findings include: On 1/30/2024 at 10:28 a.m., R4 was observed lying in bed alert and able to be interviewed. Observed R4 left eye closed and no call light in reach. R4 call light was on the floor behind the bed. R4 bilateral hand was observed in a fist like position which appeared to be contracted and unable to extend when asked to so. During an interview regarding the capability of using a call light, R4 reported being unable to push the button on the call light. R4 stated, My eye has been burning for a couple of days and would have let someone know that it is still burning if she was able to use the call light. R4 added that no staff asked her about her eye on 1/30/24. On 1/30/2024 at 10:33 a.m., Certified Nursing Assistance…

    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 before2024-02-01 · 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 nail care and oral care for one resident (R4) out of four residents reviewed for Activities of Daily Living (ADLs), resulting in unmet ADLs needs. On 1/30/2024at 11:05 a.m., R4 was observed lying in her bed alert and able to be interviewed. Observed R4 with long dirty fingernails, hair appeared not groomed and matted, and teeth with what appeared to be food particles and mouth odor. During an interview, R4 was asked to recall the last time the staff assisted with scheduled showers, oral care, washing and hair grooming. R4 stated, I can't remember. R4 said I would like to get my fingernails cut. On 2/1/2024 at 9:33 a.m., R4 was observed lying in bed with long dirty fingernails, hair appeared not groomed and matted, unable to observe teeth due to a staff assisting R4 with breakfast. After breakfast at 9:59 a.m., R4 stated, I can't remember the last time I got up out of bed to have a shower, had my teeth brushed or my mouth rinsed…

    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 · D2024-02-01 · 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 observation, interview, and record review, the facility failed to implement skin care treatments for one resident (R59) out of three residents reviewed for non-pressure related skin conditions, resulting in the potential for delay in healing. Findings include: During interviews on 1/30/24 at 8:36 AM and 1/31/24 at 11:16 AM, Resident #59 (R59) was observed in his room awake and lying in bed. R59 stated, The foot doctor was supposed to order some cream, but I ain't got it yet. R59 denied that staff had applied lotion or cream to his right leg. R59 denied that he had refused the application of lotion. The skin on the front of R59's lower right leg appeared to be very dry and scaly. On 1/31/24 at 11:22 AM, interviews and observations were conducted with Licensed Practical Nurse (LPN) D. The contents of the medication cart and treatment cart for R59's unit were checked and Amlactin lotion (medication used to treat dry, scaly skin conditions) for R59 was not in either cart. LPN D said she ordered medications…

    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 · D2024-02-01 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to date two opened respiratory inhaler devices of one resident (R30), resulting in the potential to administer outdated medications with incorrect effectiveness. Findings include: Medication Cart 1st-Floor On 1/31/2024 at 9:00 a.m. during a medication administration observation (Med-Pass) with Licensed Practical Nurse (LPN) D a Respiratory inhaler (Spiriva Respimat inhaler aerosol) was observed opened with no date. LPN D confirmed there was no date written and was asked should the respiratory inhaler be dated. LPN D observed the pharmacy instruction written on the medication package to Date after opened and said, yes, it should have been dated. LPN D said the discard instruction is written on the package by pharmacy to discard after 10/23/2024, it's not expired but I don't know when it was opened. LPN D continued to pull medication from the medication cart and observed a second respirator inhaler (Advair Diskus) not dated. LPN D confirmed…

    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

“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 3 of 52.8+0.2 vs chain
Health inspection 2 of 52.3-0.3 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 BAYS HOLDING LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 12/17/2020
LITTLE, MARTHAIndividualW-2 MANAGING EMPLOYEEsince 12/17/2020
THOMPSON, LAKESIAIndividualW-2 MANAGING EMPLOYEEsince 12/17/2020
MALI, HARIIndividualCORPORATE OFFICERsince 12/17/2020
MISSION POINT MANAGEMENT SERVICES LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 12/17/2020

2 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.

$7.4M
Net patient revenuemost recent cost report
-36.2%
Operating marginrevenue minus expenses
$1.5M
Related-party expense15% of expenses
Who pays — share of resident-days
Medicaid 71%Medicare 6%Other / private 23%

About 71% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.5M paid to related parties — landlords or management companies under common ownership — equal to about 15% 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

$410per resident / day
operating cost
$12,467per month
≈ monthly operating cost
$301per 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 235468. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-15, 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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