Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mission Point Nursing & Physical Rehab Center Of D during CMS and state inspections, most recent first.
Improper Food Storage and Kitchen Sanitation: The kitchen had multiple food storage issues, including undated chicken soup, undated turkey lunch meat, raw hamburgers with an incorrect date, uncovered and unlabeled fish, and an opened barbeque sauce bottle stored in the pantry instead of refrigeration. The kitchen floor under and between the fryer and stove was heavily soiled. Resident refrigerators on two floors also contained unlabeled, undated leftovers and opened drinks, and an LPN stated food and drinks should be labeled and dated.
Failure to Obtain PASARR Screening for Resident with Intellectual Disability: The facility did not ensure a PASARR screening was obtained for a resident with profound intellectual disability, dementia, and behavioral symptoms. The SW stated the resident had never had a Level II and initially said no Level I had been received, then later acknowledged the resident should have had a Level I screening. A revised Level I form was completed showing all screening criteria were met, including an intellectual disability manifested before age 22.
Failure to Provide Wheelchair Cushion for Resident With Stage 3 Pressure Injury: A resident with a stage 3 sacro coccyx pressure injury was repeatedly observed sitting in a wheelchair without a cushion, and the resident stated the bottom hurt and requested one. An LPN, CNA, DON, and Unit Manager all acknowledged the resident did not have a wheelchair cushion despite the pressure ulcer, while the MDS indicated a wheelchair pressure relief device and the care plan and Kardex did not include one.
An LPN administered medication through a resident’s PEG tube without verifying tube placement first. The LPN later confirmed the omission and stated placement should be checked before every use; the DON said staff are expected to verify PEG tube placement every time before using it. The resident had diagnoses including respiratory failure, metabolic encephalopathy, tracheostomy, gastrostomy, and tremors, and the facility policy required tube placement verification before feeding or medication administration.
An LPN performed deep suctioning on a resident with acute and chronic respiratory failure with hypoxia, a tracheostomy, and other diagnoses without hyperoxygenating first. The LPN stated they did not know hyperoxygenation was needed before deep suctioning, while the DON said staff are expected to hyperoxygenate residents before the procedure. The facility’s tracheostomy care policy did not address hyperoxygenation.
The facility's Dietary Department was found to have unsanitary conditions, with four out of five kitchen ceiling vents soiled with grease, rust, and corrosion, and surrounding tiles showing black, greasy lint spots. The Dietary Manager and Maintenance Director indicated a lack of clarity in cleaning responsibilities, and the DON confirmed the need for replacement of the affected areas. This deficiency had the potential to impact 50 residents receiving meals from the kitchen.
The facility failed to revise care plans in a timely manner for three residents, leading to deficiencies in care planning. A resident experienced a fall, but the care plan was not updated until months later. Another resident was prescribed anxiety medication without a corresponding care plan. A third resident's fall care plan was not revised after a witnessed fall, despite facility policy requiring updates after such incidents.
A facility failed to ensure an Advance Directive was completed for a resident with Acute Respiratory Failure and Muscle Weakness, who was also being treated for CRE. The resident had moderately impaired cognition and required extensive assistance with ADLs. During a review, it was found that there was no signed Advance Directive in the resident's EMR. Interviews with the Social Worker and DON confirmed the absence of the document, emphasizing its importance in honoring the resident's wishes.
A resident with cognitive impairments and other medical conditions was observed with unkempt hair over several days, indicating a failure in providing adequate hair care. The resident's care plan required staff assistance for personal hygiene, but interviews revealed that not all nurse aides were capable of braiding hair, and the usual aide was unavailable. The DON confirmed the responsibility for hair grooming but could not explain the oversight.
A resident with cerebral infarction and paraplegia did not receive the recommended restorative therapy for limited ROM, despite increased shoulder pain. The facility failed to complete necessary documentation and implement a ROM program, as confirmed by the DON. The resident's restorative log showed minimal therapy provided, contrary to facility policy.
A resident with Carbapenem-resistant Enterobacteriaceae (CRE) did not receive appropriate infection control measures. The resident, requiring extensive assistance and on transmission-based precautions, was served meals on regular dishes without PPE use by staff. Inconsistencies in precautionary measures were noted, with staff unaware of proper procedures. The facility's infection prevention program was not adequately followed.
The facility failed to document a thorough investigation of a resident-to-resident altercation involving two residents, one with intact cognition and the other with severe cognitive impairment. The incident was observed by a CNA, but necessary wellness visits were not documented in the clinical records, contrary to the facility's policy on abuse, neglect, and exploitation. The NHA acknowledged the oversight but did not provide additional documentation during the exit conference.
A resident did not receive a prescribed Lidocaine 2.5% pain gel due to its unavailability as a floor stock item. Despite the resident's report of pain and swelling, the medication was not administered from the time it was ordered. The LPN confirmed the absence of the gel, and the DON admitted to not being aware of the issue due to a communication lapse. The facility's policy to notify the prescriber when medication is unavailable was not followed.
A resident with no cognitive impairment was not provided timely incontinence care, as observed by surveyors. The resident, who should have been checked every two hours, was found with a heavily soiled brief and reported not being changed since the previous night. Despite facility protocols requiring regular checks and communication between shifts, the care plan was not followed, leading to a deficiency citation.
A facility failed to follow infection control standards for a resident with COPD and Type 2 Diabetes. Observations showed a CNA did not perform hand hygiene before and after glove use while handling soiled items and providing personal care. Interviews confirmed the CNA and DON were aware of the proper protocol, which was not followed, posing a risk of cross-contamination.
A resident with early onset dementia eloped from the facility after the front door's keypad code was disabled, allowing exit via motion sensor. The resident traveled to a physician's office without staff knowledge. Investigation revealed inadequate supervision by a CNA, who was terminated, and an RN from a now-unused agency. The resident was not previously considered at risk for elopement.
A facility failed to administer and document wound care treatments per physician orders for a resident with multiple pressure ulcers. The resident's Treatment Administration Record showed missing treatments on several dates across December, January, and February. The DON confirmed that undocumented treatments are assumed not to have been done, violating the facility's wound treatment policy.
A resident with a stage IV pressure ulcer did not receive daily dressing changes as required, and an LPN mistakenly documented the treatment as completed. The DON confirmed that treatments must be performed before documentation and emphasized the need for truthful record-keeping.
Improper Food Storage and Kitchen Sanitation
Penalty
Summary
The facility failed to properly store food items in the kitchen, remove undated and unlabeled food from the kitchen walk-in cooler and resident refrigerators, and adequately clean kitchen surfaces. During an initial kitchen tour with the Kitchen Manager, two containers of chicken soup were observed in the walk-in cooler without dates, an opened box of turkey lunch meat was undated, an opened box of raw hamburgers was dated 12/1/26 and the Kitchen Manager stated the date was wrong and was unsure when they were opened or whether they were still good, and a tray of fish was uncovered, unlabeled, and undated. In the pantry, an opened 158 oz barbeque sauce bottle was observed, and the Kitchen Manager stated it should be stored in the refrigerator. The flooring under and between the deep fryer and stove was heavily soiled, and the Kitchen Manager stated the floor should be deep cleaned. Resident refrigerators on the third and fourth floors were also observed with LPNs. The third-floor refrigerator contained unlabeled and undated food leftovers and unlabeled and undated opened drinks, and the LPN stated all food and drinks should be labeled and dated. The fourth-floor refrigerator contained unlabeled and undated food leftovers, and the LPN stated nursing was responsible for maintaining resident refrigerators and that all food should be labeled and dated. The NHA stated the expectation was for kitchen staff to follow kitchen policies and the food code, and that the kitchen should be clean and sanitary and food should be stored properly. Facility policy required refrigerated food outside the original package to be labeled, dated, and monitored, and food brought in by family or visitors to be labeled with the resident name and date.
Failure to Obtain PASARR Screening for Resident with Intellectual Disability
Penalty
Summary
The facility failed to ensure a PASARR screening was obtained for one resident with diagnoses that included restlessness and agitation, irritability and anger, profound intellectual disabilities, and other developmental disorders of scholastic skills. The resident’s EHR showed admission to the facility and a quarterly MDS indicating severe cognitive impairment (BIMS=1) and a need for supervision for most ADLs. During interview, the SW stated the resident had never had a Level II and that the department had not received a Level I, despite the resident having a diagnosis of intellectual disability. The SW later acknowledged the resident should have had a Level I screening and that the resident had an intellectual/developmental disability in addition to dementia. A revised Level I Screening Form was then presented, documenting that all six screening criteria were marked yes, including a diagnosis of intellectual disability or related condition manifested before age 22, with explanations listing schizoaffective disorder, bipolar type; unspecified intellectual disabilities; dementia; and use of Seroquel and Namenda for behaviors. The facility policy stated residents with a newly evident or possible serious mental disorder, intellectual disability, or related condition are to be referred promptly for a Level II resident review.
Failure to Provide Wheelchair Cushion for Resident With Stage 3 Pressure Injury
Penalty
Summary
The facility failed to apply a wheelchair cushion for one resident with a stage 3 sacro coccyx pressure injury. The resident stated that there was no wheelchair cushion and that the bottom hurt, and the resident was observed sitting in a wheelchair without a cushion on multiple occasions, including in the dining room and while with CNA D and LPN E. When asked about the wheelchair, LPN E stated the resident did not have a wheelchair cushion and should have one because of the stage 3 pressure ulcer on the bottom, and CNA D agreed that the resident should have a cushion and did not have one. The DON and Unit Manager F also stated the resident did not have a wheelchair cushion and should have one because of the stage 3 pressure ulcer on the coccyx. Record review showed the resident was admitted with diagnoses including congestive heart failure and need for assistance with personal care, had moderate impaired cognition, was dependent for wheelchair mobility, and had a stage 3 pressure injury present on admission. The MDS indicated a wheelchair pressure relief device, but the Kardex and care plan did not reveal a wheelchair pressure relief device or wheelchair cushion intervention. Facility policy stated residents at risk for pressure injuries should have interventions documented in the plan of care, including pressure-redistributing support surfaces, and the therapy screening policy stated wheelchairs and wheelchair cushions are to be screened for and documented for new admissions.
Failure to Verify PEG Tube Placement Before Medication Administration
Penalty
Summary
Nursing staff failed to verify PEG tube placement before administering medication through a resident’s feeding tube. On 1/22/2026 at 1:49 PM, an LPN administered medication through R6’s PEG tube without checking tube placement first. On interview the next day, the LPN confirmed the placement was not checked before the medication was given and stated they had checked placement earlier when morning medication was administered, but should check PEG tube placement prior to every use. The DON stated staff are expected to verify PEG tube placement every time before using it. R6 was admitted with diagnoses including acute and chronic respiratory failure with hypoxia, metabolic encephalopathy, tracheostomy, gastrostomy, and tremors, and the MDS noted the BIMS could not be completed. The facility policy titled Care Plan and Treatment of Feeding Tube states tube placement will be verified before beginning a feeding or before administering medication.
Deep Suctioning Performed Without Hyperoxygenation
Penalty
Summary
The facility failed to ensure nursing staff provided respiratory care in accordance with acceptable standards of clinical practice during deep suctioning for one resident, R6. On 1/22/2026 at 1:39 PM, an LPN was observed performing deep suctioning on R6 without providing hyperoxygenation before starting the procedure. The resident’s record showed R6 was admitted with acute and chronic respiratory failure with hypoxia, metabolic encephalopathy, tracheostomy, gastrostomy, and tremors, and the MDS noted the BIMS could not be completed. During interview on 1/23/2026, the LPN stated they did not know hyperoxygenation should have been provided before deep suctioning, and the DON stated staff are expected to hyperoxygenate residents prior to deep suctioning. The facility policy titled Tracheostomy Care, revised 1/24, did not address hyperoxygenation.
Unsanitary Conditions in Dietary Department
Penalty
Summary
The facility failed to maintain a sanitary environment in the Dietary Department, as observed during a follow-up inspection. Four out of five ceiling vents in the kitchen were found to be soiled with grease, rust, and corrosion, while the surrounding ceiling tiles exhibited black, greasy lint spots. The Dietary Manager acknowledged the issue, noting that although the outer portions of the vents had been cleaned, the inner linings and adjacent ceiling tiles required deep cleaning or replacement. The Maintenance Director clarified that their department was responsible for cleaning vents throughout the facility, but not those in the Dietary Department. The Director of Nursing (DON) was informed of the unsanitary conditions in the kitchen, and upon inspection, confirmed the need for replacement of the soiled tiles and rusted vents. The facility's policy on cleaning interior vents did not specify responsibility for the kitchen area, leading to a lack of clarity in maintenance duties. According to the 2019 Food Code, physical facilities must be cleaned as often as necessary to prevent contamination, and ventilation systems should be maintained to avoid being a source of contamination. The deficiency had the potential to affect 50 residents who received meals from the kitchen.
Deficiency in Timely Care Plan Revisions
Penalty
Summary
The facility failed to revise care plans in a timely manner for three residents, leading to deficiencies in care planning. Resident R10 experienced a fall on 10/6/24, but the care plan was not updated until 12/11/24, after the fall was identified during a survey. The Director of Nursing acknowledged that the care plan update was not timely and should have been completed within 24 hours of the fall. Resident R260 was prescribed hydroxyzine for anxiety starting on 11/19/24, and received the medication on multiple occasions in December 2024. However, there was no care plan addressing the anxiety diagnosis or the use of hydroxyzine, which the Director of Nursing agreed should have been included. Resident R7, who has a history of falls and other significant medical conditions, experienced a witnessed fall on 10/29/24. Despite this incident, the resident's fall care plan, originally created on 8/15/24, was not revised to reflect the new fall. The facility's policy requires care plan revisions quarterly and after each fall, but this was not adhered to in R7's case. These failures in timely care plan revisions for the residents indicate a deficiency in the facility's care planning process.
Failure to Complete Advance Directive for a Resident
Penalty
Summary
The facility failed to ensure an Advance Directive was completed for one resident, identified as R210, among fourteen residents reviewed. This deficiency was identified during an interview and record review process. R210 was admitted to the facility with diagnoses including Acute Respiratory Failure and Muscle Weakness and was being treated for Carbapenem-resistant Enterobacteriaceae (CRE), a bacterium resistant to certain antibiotics. The resident had moderately impaired cognition and required extensive assistance with activities of daily living. During the review, it was discovered that there was no signed Advance Directive in the resident's Electronic Medical Record (EMR). Interviews with the Social Worker and the Director of Nursing confirmed the absence of the Advance Directive, highlighting the importance of such a document in honoring the resident's wishes regarding life-sustaining measures or withholding medical treatment.
Failure to Provide Adequate Hair Care for Resident
Penalty
Summary
The facility failed to provide adequate hair care for a resident, resulting in poor grooming. The resident, who has Down Syndrome, diabetes mellitus, dry eye syndrome, seizure disorder, and cognitive impairments, was observed on multiple occasions with unkempt hair. The resident's care plan indicated a dependency on staff for personal hygiene, including hair care. However, observations over several days showed that the resident's hair was not groomed, with dry and unbraided patches visible. Interviews with facility staff revealed that nurse aides were responsible for the resident's hair care, particularly on shower days, which were scheduled for Mondays and Thursdays. However, it was noted that not all aides were capable of braiding hair, and the aide who usually performed this task was not available. The Director of Nursing confirmed the responsibility of nurse aides for hair grooming but could not explain why the resident's hair was not attended to. There was no documented evidence of hair care being provided in the task assignments for the resident during the observed period.
Failure to Provide Restorative Therapy for Resident with Limited ROM
Penalty
Summary
The facility failed to consistently provide restorative therapy for a resident with limited range of motion (ROM). The resident, who was admitted with diagnoses including cerebral infarction and paraplegia, reported not receiving any rehabilitation or exercises, despite experiencing increased shoulder pain. The resident's Minimum Data Set (MDS) indicated intact cognition and functional limitation in ROM impairment to both upper extremities. A physical therapy discharge summary recommended a functional maintenance program, including a ROM program, but the necessary documentation and orders for this program were not completed or implemented. The facility's records did not show a therapy to restorative form completed for the resident's physical therapy discharge, and there were no orders, care plans, or Kardex entries for a restorative ROM program. The resident's restorative log for November showed only one instance of ROM being provided, with subsequent dates marked as not applicable, despite no refusals being noted. The Director of Nursing confirmed that the resident was not receiving the necessary restorative services and acknowledged the error in the restorative log. The facility's policy requires communication and implementation of restorative nursing plans, which was not followed in this case.
Inadequate Infection Control Measures for Resident on Precautions
Penalty
Summary
The facility failed to implement appropriate infection prevention and control measures for a resident diagnosed with Carbapenem-resistant Enterobacteriaceae (CRE), a bacterium resistant to certain antibiotics. The resident, who had moderately impaired cognition and required extensive assistance with activities of daily living, was observed to have received a regular meal tray on regular dishes, despite being on transmission-based precautions. Certified Nursing Assistant (CNA) H delivered the meal without using personal protective equipment (PPE), even though PPE was available outside the resident's room, which was marked for transmission-based precautions. The room door was left open, and the resident did not receive an isolation tray. Interviews with staff revealed inconsistencies in the implementation of precautions. CNA H indicated that special precautions were only taken during personal care, while Licensed Practical Nurse (LPN) F noted that the resident received regular trays during the day and Styrofoam trays at night, without understanding the reason for this discrepancy. The Director of Nursing (DON) confirmed that the resident was to remain on transmission-based precautions until cleared by test results and should receive meals on Styrofoam trays. The facility's infection prevention and control program, which mandates training and competence in infection control practices, was not adequately followed, leading to the observed deficiency.
Failure to Document Investigation of Resident Altercation
Penalty
Summary
The facility failed to thoroughly conduct and document an investigation of a resident-to-resident altercation involving two residents, R103 and R104. The incident occurred when R103 pulled up R104's pants and pushed him in the back, as observed by a Certified Nurse Aide. Although the facility self-reported the incident, the investigation was incomplete as it lacked documentation of wellness visits for both residents, which were necessary to ensure there was no mental anguish resulting from the incident. The Nursing Home Administrator acknowledged the importance of documenting wellness visits in the residents' clinical records, but no such documentation was found. R103 was admitted with diagnoses including Crohn's Disease and protein-calorie malnutrition, with an assessment indicating intact cognition. R104 was admitted with diagnoses including encephalopathy and dementia, with an assessment indicating severe cognitive impairment. Despite the facility's policy on abuse, neglect, and exploitation requiring thorough documentation and efforts to protect residents from harm, the Social Worker did not complete or document wellness visits for either resident. During the exit conference, the Nursing Home Administrator did not provide additional documentation or information.
Failure to Provide Prescribed Pain Gel Medication
Penalty
Summary
The facility failed to provide a prescribed pain gel medication, Lidocaine 2.5%, for a resident, resulting in the resident not receiving the medication as ordered by the physician. The resident, who was admitted with a diagnosis of difficulty in walking, reported pain and swelling in her feet and stated that she had not received the Lidocaine gel prescribed to alleviate her pain. The medication was supposed to be a floor stock item, but it was unavailable for administration from the time it was ordered on June 13, 2024, through June 17, 2024. The Licensed Practical Nurse (LPN) confirmed that the Lidocaine gel was not available and had not been administered, although the resident's pain was managed with another medication. A communication note indicated that the pharmacy was contacted, but there was no documentation that the physician or the Director of Nursing (DON) was informed about the missing medication. The DON acknowledged that the unit manager did not read the communication note, leading to the oversight in ordering the medication. The facility's policy requires that the prescriber be contacted if a medication is delayed or unavailable, which was not followed in this case.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident, identified as R101, who was observed sitting in a wheelchair with a noticeable urine smell in the room. R101, who had no cognitive impairment and a BIMS score of 15 out of 15, reported needing assistance to be washed and have a dry diaper put on. The resident's care plan indicated that they should be checked every two hours for episodes of incontinence. However, observations revealed that R101's brief was heavily soiled, and the resident reported not being changed since 10:30 p.m. the previous night. Certified Nursing Assistant (CNA) A was observed providing incontinence care to R101 for the first time during the shift at 9:44 a.m. Licensed Practical Nurse (LPN) B and the Director of Nursing (DON) both stated that residents should be checked and changed every two hours, with rounds completed at the beginning of each shift. The facility's policy also required communication between staff at shift changes and routine monitoring of residents. Despite these protocols, the facility did not adhere to the care plan for R101, resulting in a deficiency citation.
Infection Control Deficiency: Improper Glove Use and Hand Hygiene
Penalty
Summary
The facility failed to adhere to infection control standards, specifically regarding glove use and hand hygiene, for a resident identified as R101. Observations revealed that soiled linen was left on the floor of R101's room, visible from the hallway. R101, who was readmitted to the facility with diagnoses including Chronic Obstructive Pulmonary Disease (COPD) and Type 2 Diabetes, was noted to have no cognitive impairment. During multiple observations, a Certified Nursing Assistant (CNA) was seen entering R101's room and performing various tasks without proper hand hygiene before and after glove use. The CNA handled soiled items, touched personal items, and performed personal care on R101 without changing gloves or washing hands as required by the facility's hand hygiene policy. Interviews with the CNA and the Director of Nursing (DON) confirmed that the expected protocol was not followed. The CNA acknowledged that hands should be washed before and after glove use, while the DON reiterated that hand hygiene should be performed in conjunction with glove use and that personal items should not be touched while wearing gloves. The facility's hand hygiene policy, revised in December 2020, clearly states that gloves do not replace hand hygiene and that hand hygiene should be performed before donning and after removing gloves. These lapses in infection control practices resulted in a potential risk for increased cross-contamination and infection among the vulnerable resident population.
Resident Elopement Due to Disabled Keypad Code and Inadequate Supervision
Penalty
Summary
The facility failed to provide a safe environment and adequate supervision for a resident, identified as R801, who eloped from the facility without staff knowledge. The incident occurred when R801 exited through the front door, which had a disabled keypad code, allowing the door to open with a motion sensor only. This deficiency was discovered after R801's personal physician's office contacted the facility to report the resident's presence at their office. R801 had left the facility with personal belongings, traveled to a nearby shelter, and then took buses to reach the physician's office. The resident was not injured and refused to return to the facility, opting instead to be transported to a local hospital. The investigation revealed that the keypad code on the front door had been disabled at a switchbox, but video surveillance did not capture how this occurred. The Nursing Home Administrator noted that a Certified Nursing Assistant (CNA) assigned to R801 was terminated for not properly supervising the resident, as they were observed with closed eyes, appearing to be asleep during their shift. Additionally, a Registered Nurse (RN) from an agency no longer used by the facility was also assigned to R801. R801's electronic health record indicated multiple diagnoses, including early onset dementia, but the resident was not considered at risk for elopement according to previous assessments. The resident had a Legal Guardian who was informed of the incident.
Failure to Administer and Document Wound Care Treatments
Penalty
Summary
The facility failed to administer wound care treatments per physician orders for a resident (R504) who was admitted with multiple pressure ulcers. The resident had a BIMS score of 15 out of 15, indicating cognitive intactness, and required maximal assistance with bed mobility and was dependent on transfers. The resident's care plan included specific wound care treatments for various pressure ulcers, but these treatments were not consistently documented or administered as ordered on multiple dates in December 2023, January 2024, and February 2024. The Treatment Administration Record (TAR) for December 2023 showed missing wound care treatments on 12/25/23 and 12/30/23 for all listed wounds. Similarly, the TAR for January 2024 revealed missing treatments on 1/11/24, 1/14/24, and 1/16/24. In February 2024, the TAR indicated missing treatments on 2/2/24, 2/7/24, 2/8/24, 2/9/24, 2/10/24, and 2/11/24. These omissions were confirmed during an interview with the Director of Nursing (DON), who stated that if treatments are not documented, it is assumed they were not performed. The facility's policy on wound treatment management and documentation, reviewed in February 2024, mandates that wound treatments be provided according to physician orders and documented on the TAR. The failure to adhere to this policy resulted in the cited deficiency, as the required wound care treatments were not consistently administered or recorded for the resident, potentially impacting their health and recovery.
Failure to Perform and Accurately Document Wound Treatment
Penalty
Summary
The facility failed to perform a wound treatment prior to documenting its completion for one resident (R506) who was reviewed for pressure ulcers. On 3/5/24, R506 reported that the dressing on his left hip wound, dated 3/3/24, had not been changed daily as required. Later that day, R506 confirmed that the dressing had still not been changed. LPN A admitted to not having changed the dressing and mistakenly documenting that the treatment was completed in the Electronic Medical Record (EMR). The Director of Nursing (DON) confirmed that it is against facility policy to document treatments before they are performed and emphasized the expectation for truthful documentation and treatment provision by the nursing staff. R506's medical history includes Diabetes Mellitus Type 2, difficulty walking, and the need for assistance with personal care. The resident's Minimum Data Set (MDS) indicated a moderate cognitive impairment and a stage IV pressure ulcer on the left hip. The care plan required daily wound and skin treatments, which were documented as completed from 3/1/24 to 3/5/24, despite evidence that the dressing had not been changed as scheduled. This discrepancy highlights a failure in adhering to the prescribed wound care regimen and accurate documentation practices.
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Illustrative
What surveyors actually found near you
We read the 1,104 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Detroit
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Regency At Chene | 0.4 mi | ★★★★★ | 1 | 0 |
| Hamilton Nursing Home | 1.6 mi | ★★★★★ | 10 | 0 |
| Qualicare Nursing Home | 1.7 mi | ★★★★★ | 8 | 0 |
| Riverview Health & Rehab Center | 2 mi | ★★★★★ | 0 | 0 |
| Mission Point Nursing & Physical Rehabilitation Ce | 2.1 mi | ★★★★★ | 26 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.