Below average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Rehabilitation Ce during CMS and state inspections, most recent first.
Improper Garbage and Dumpster Area Maintenance: Surveyors observed two dumpsters with open lids and overflowing garbage, broken furniture, and boxes, with food debris scattered around the area by squirrels and birds. Birds were seen pecking holes in garbage bags, exposing contents to gnats and flies, and flies were observed near the dumpster area and kitchen entrance. The dietary manager said maintenance was responsible for cleaning the area and that garbage was collected twice weekly, while the maintenance director noted renovation and furniture replacement contributed to the open dumpsters and food debris.
A resident's room and bathroom were found to be in disrepair and unclean, with issues such as chipped paint, holes in the wall, thick dust on the fan and vent, black residue on bathroom walls, and unpleasant odors. The resident, who had multiple chronic conditions and intact cognition, reported the facility had long been aware of the need for repairs and cleaning. Staff interviews confirmed lapses in reporting and addressing these environmental concerns.
Failure to maintain privacy during wound care. An RN and CNA were observed providing wound care to a resident's sacrum/coccyx area without drawing the privacy curtain or closing the room door, allowing the resident to be visible from the hallway. The resident was cognitively intact and had diagnoses including DM2, COPD, HTN, anxiety, bipolar disorder, and suicidal ideations. The CNA, RN, and DON all confirmed the door should have been closed and the curtain drawn during the procedure.
A resident with severe cognitive impairment and total dependence was observed in a standard hospital bed with feet hanging off the end and the foot board removed and propped against the wall. Staff reported the bed had been in disrepair for weeks, and interviews showed confusion about the order status and what equipment was needed. The resident’s record documented a 6-foot height, while the facility had received a bariatric bed but had not ensured an appropriately sized, functional bed was in place.
Medication Documented as Given Without Being Administered: An LPN documented a resident’s Cyclosporine 0.05% eye drops as administered on the MAR even though the dose was not given. The resident, who had COPD, DM, and a history of fractures, reported missing the eye drops, and the LPN later found an unopened single-dose package at the bedside and acknowledged it could not have been administered.
Failure to Provide Required Grooming and Nail Care: Two residents who needed staff assistance with ADLs did not receive grooming services. One resident with hemiplegia and impaired cognition reported that hair care had not been provided for months and was observed with unkempt hair, while another resident with moyamoya disease and quadriplegia was observed with dirty, untrimmed fingernails and toenails and said staff would not clean or cut them. Staff and the ADL care plans indicated CNAs were responsible for hair grooming, shaves, and nail care, and there was no documentation of refusal.
Failure to Provide Timely Vision Services: A resident with an intraocular lens and glasses prescription had broken glasses taped together with wound care tape, limiting use of the glasses. The resident reported the glasses had been broken for about a year and were not worn often because the tape interfered with seeing. Record review showed no vision care plan, no nursing or SS notes about the broken glasses, and the resident had not been seen for an eye exam since the prior consult; the SSM and NHA were unaware of the issue.
A resident did not receive prescribed cyclosporine eye drops because the medication was not available in the med cart, yet an LPN documented the dose as administered on the MAR. The resident reported not getting the drops for several days, and a room check found no eye drops at the bedside. Pharmacy records showed the drops had been delivered and signed for, but staff could not explain where they were placed.
Kitchen equipment was not maintained in safe operating condition. The South Bend stove had heavy baked-on residue and ash, one front gas eye was coated with an unknown whitish substance and soot, and staff were constantly readjusting gas gauges and repositioning cookware because the stove eyes were not functioning properly. The gauges/knobs were not calibrated adequately, causing pans and fryers to burn during food prep, and the Dietary Mgr acknowledged skillets were being discarded because their inner surfaces were damaged. The convection oven and equipment racks also had years of accumulated grease and food residue.
A resident with a history of cardiac issues was repeatedly reported by CNAs and a roommate to be in distress, exhibiting signs such as unresponsiveness and white foam at the mouth. Despite these reports, the RN on duty did not assess or monitor the resident, dismissing the concerns as the resident 'just sleeping.' The resident was later found unresponsive by the day shift nurse, who initiated emergency measures, but the resident was pronounced deceased. The failure to assess and respond to the change in condition constituted a deficiency in care.
The facility was found to have sanitation and supply deficiencies, including a lack of trash can liners, soiled shower gurney pads, and missing paper towels at handwashing sinks. Observations on multiple floors revealed these issues, with staff acknowledging the need for proper cleaning and supply maintenance. Despite this, no further documentation was provided during the exit conference.
A resident with severe cognitive impairment and multiple health conditions suffered a facial laceration in a facility. The LPN failed to perform necessary neurological checks or complete an incident report. Despite hypoglycemia being monitored, other vital signs were not reassessed, leading to the resident's transfer to a hospital for bradycardia and hypoglycemia. The DON noted procedural failures, including lack of proper monitoring and documentation.
The facility failed to ensure medications for three residents were not expired. An LPN observed that menthol-zinc oxide ointment for three residents and a tube of diclofenac sodium were expired. The LPN and DON acknowledged that these medications should have been reordered and discarded. No additional information was provided during the exit conference.
The facility's kitchen was found to be unsanitary, with dirty floors, overflowing trash, and inappropriate storage of items like charcoal and fire starter liquid. Equipment and food storage practices were inadequate, with expired spices, undated food items, and incomplete temperature logs. The facility's pest control reports indicated ongoing cleanliness concerns. The administrator acknowledged the issues, but the deficiencies have the potential to affect all residents consuming food from the kitchen.
The facility failed to maintain a safe and functional environment, with issues such as broken privacy curtains, a damaged bed, and defective televisions. Residents reported maintenance concerns, including a broken bed and a worn wheelchair, which were not promptly addressed. The facility's elevators and common areas also showed signs of neglect, with non-functional indicator lights and stained ceiling tiles.
Two incidents of resident-to-resident abuse occurred in the facility, resulting in significant injuries. In one case, a resident was pushed from their wheelchair by another resident, leading to a head injury. In another incident, a confrontation between two residents resulted in physical injuries. Both incidents were not adequately monitored by staff, highlighting deficiencies in ensuring a safe environment.
The facility failed to ensure PASARR forms were reviewed and submitted for two residents, leading to potential unmet care needs. One resident with severe cognitive impairment did not receive a necessary Level II screening, while another had an outdated PASARR form with no recent assessment. The facility's policy requires timely evaluations and tracking of PASARR status, which was not followed.
The facility failed to follow professional standards for medication administration for two residents. One resident's medications were left unattended and improperly crushed without a physician's order, while another resident missed multiple doses due to unavailability. The facility's policies require physician orders for crushing medications and immediate reordering of unavailable medications, which were not followed.
The facility failed to monitor the weight of two residents at nutrition risk, leading to undetected weight changes. One resident with a feeding tube had inconsistent weight records, and another experienced a significant weight loss that was not promptly addressed. The facility's weight monitoring policy was not followed, resulting in these deficiencies.
A resident with a feeding tube experienced frustration and complications due to the facility's failure to remove the tube despite no longer needing it. The resident was able to eat and drink normally, and the tube was causing infection and leakage. Staff were aware and advocated for removal, but the physician refused, leading to the deficiency.
A facility experienced a 37.1% medication administration error rate due to a nurse's inability to access the MAR on the medication cart, leading to reliance on memory and paper notes. This resulted in multiple errors for two residents, including incorrect dosages, administering medications not ordered, and failing to administer scheduled medications. The DON confirmed no electronic issues and emphasized the importance of following the facility's Medication Administration policy.
A resident with paraplegia and multiple sclerosis did not receive physician-ordered lab tests due to a failure in the facility's process. The tests, scheduled every three months, were not completed for June-July 2024 because the lab did not receive the order. The DON confirmed the oversight, which violated the facility's policy on timely lab services.
A resident with severely impaired cognition and missing teeth was not scheduled for a physician-ordered dental appointment due to a lack of consent from the legal guardian. The facility failed to document a request for consent, resulting in the resident not receiving necessary dental care.
A facility failed to ensure PPE was worn during wound care for a resident with a Stage III pressure ulcer. Despite signage indicating enhanced barrier precautions, a nurse performed wound care without PPE. The resident had impaired cognition and was dependent on most ADLs. Facility policy requires gowns and gloves during high-contact activities to prevent transmission of multidrug-resistant organisms, but staff did not adhere to these guidelines.
A resident with dementia reported $150 missing from their coat pocket, but the facility's investigation was insufficient. Only three CNAs were interviewed, and the police were not notified. The facility's policy requires a thorough investigation and law enforcement notification, which were not fully executed.
Improper Garbage and Dumpster Area Maintenance
Penalty
Summary
Dispose of garbage and refuse properly was cited after surveyors observed two of the facility’s dumpsters with open lids and overflowing garbage, broken and/or furniture, and boxes. The surrounding grounds were littered with food particles that had fallen from garbage bags by squirrels and birds, and birds were observed pecking holes in the bags and exposing the garbage contents to gnats and flies. Flies were also observed near the dumpster area and adjacent hall and back door to the kitchen. The dietary manager stated that maintenance was responsible for cleaning the area and confirmed garbage was collected on Mondays and Wednesdays weekly. On a later observation, the surrounding grounds had been swept, but the garbage lids remained open. The maintenance director confirmed the garbage collection days and stated the facility had been in renovation and replacing furniture, and that the open dumpsters and food debris created an environment for pests to hide and harbor.
Failure to Maintain Clean and Homelike Resident Room and Bathroom
Penalty
Summary
A deficiency was identified when one resident's room was found to be in poor repair and unclean during observation, interview, and record review. The room had a loud unpleasant odor, chipped paint, holes in the wall over the bed, and a fan with thick dust particles blowing from it. The bathroom contained multiple areas of black residue on the wall and behind the toilet, a vent covered with thick dust, holes in the wall near the tissue holder, and brown stains and scuff marks on the bathroom door. The resident confirmed that the bathroom was filthy and uncomfortable, and stated that the facility had been aware of the needed repairs and cleaning for a long time. During interviews, the Maintenance Director acknowledged the worsening condition of the black areas on the wall, attributing them to mud used for sealing cracks and holes, and stated that staff are supposed to report such issues in the TELS system for repair orders. The Maintenance Director also indicated that housekeepers are responsible for dusting vents and fans, and agreed that the level of dust was unacceptable. The Regional Director of Operation confirmed the need for cleaning and repairs in the room and bathroom. The resident involved had diagnoses including chronic obstructive pulmonary disease, hypertension, multiple sclerosis, and Parkinsonism, and was assessed as having intact cognition.
Failure to Maintain Privacy During Wound Care
Penalty
Summary
The facility failed to provide privacy for one resident during wound care. On 8/21/2025 at 11:30 AM, RN S and CNA R were observed providing wound care to R3's sacrum/coccyx area without drawing the privacy curtain around the bed or closing the room door, allowing the resident's exposed body to be visible from the hallway. R3 was admitted with diagnoses including type 2 diabetes, COPD, hypertension, generalized anxiety, bipolar disorder, and suicidal ideations, and the quarterly MDS dated 7/7/2025 showed a BIMS score of 15 out of 15, indicating the resident was cognitively intact. CNA R later confirmed the door was left open during the wound care and stated it should have been closed, RN S acknowledged the door was left open and said it should have been closed during the procedure, and the DON stated the privacy curtain should have been completely drawn and the door closed during wound care.
Failure to Provide an Appropriate and Functional Bed
Penalty
Summary
The facility failed to provide a bed that was appropriate and in good condition for one resident, R66, who was non-verbal, had severe cognitive impairment, and was dependent on all activities of daily care. R66 was observed sitting upright in a standard hospital bed while watching television, with feet hanging off the end of the bed. The foot board was off the bed and propped against the wall, and the resident appeared taller than the length of the bed. The resident’s admission MDS documented a height of 72 inches (6 feet) and diagnoses including schizophrenia, dementia with behavioral disturbance, antisocial personality disorder, myopia, candidiasis, and a stage 3 pressure ulcer of the left upper back. Staff interviews showed the bed had been in disrepair for a couple of weeks, and the nurse’s aide said R66 had kicked the foot board off and was getting a new bigger bed. The aide was uncertain of the bed order status, and an LPN stated she was not aware the resident needed a new bed. The ADON said the bed had been ordered and was waiting for maintenance, and presented a work order showing the new bariatric bed was delivered to the facility, but an extender was not ordered until later. The DON said she was new to the facility and was unaware of the resident’s needs and that the bed was broken. Maintenance staff said they were not aware the mattress had been delivered and believed the resident needed a new frame rather than an extender or new mattress. The facility policy stated staff shall make efforts to reasonably accommodate residents’ needs and preferences in their physical environment.
Medication Documented as Given Without Being Administered
Penalty
Summary
The facility failed to follow standards of practice for medication administration for one resident when a single-dose eye medication was documented as administered on the MAR even though it had not been given. The resident, who had COPD, diabetes, and a history of fractured ribs and sternum, had a BIMS score of 15/15 and a physician’s order for Cyclosporine emulsion 0.05% eye drops, 1 drop in both eyes twice daily for dry eyes due to inflammation. There was no order allowing medications at the bedside and no assessment or evaluation for self-administration. On 8/21/25, the resident reported not receiving all of the eye drops and said the white-box Cyclosporine eye drops had not been given for a couple of days. The MAR showed the LPN documented the 10:00 AM dose as administered, but the LPN later stated the medication was not available in the cart and therefore was not administered. The medication cart contained no Cyclosporine eye drops for the resident, and the LPN then retrieved one single-dose package from the bedside that was unopened and intact. The LPN acknowledged the eye drops could not have been administered if the package was unopened and that it should not have been signed out as administered.
Failure to Provide Required Grooming and Nail Care
Penalty
Summary
The facility failed to provide ADL assistance for two residents who were unable to complete grooming and personal care needs. R63 was observed sitting in bed with unkempt hair and reported that staff had not offered hair care, stating that the hair had not been combed, brushed, or braided since approximately three months earlier. R63 said the hair needed to be combed because the braids had been in place for a long time and that embarrassment occurred because the hair was not combed. The EHR showed R63 was admitted with asthma, hemiplegia, and anemia, had moderately impaired cognition with a BIMS score of 08/15, and required one-person assistance with grooming/hygiene. The ADL care plan documented the need for staff assistance with dressing, personal hygiene, oral care, and bathing, and there was no documentation of refusal. R77 was observed lying in bed with long, untrimmed, dirty fingernails and both feet with long, thick, untrimmed, discolored toenails. R77 stated that staff would not clean or cut the fingernails and toenails and requested that they be cut and cleaned. The EHR showed R77 had diagnoses including moyamoya disease, major depressive disorder, diabetes mellitus type two, cerebral infarction, chronic obstructive pulmonary disease, and quadriplegia, and was able to communicate needs during interview. The ADL care plan documented total dependence for dressing, personal hygiene, and bathing, with no documentation of refusal. Staff interviews indicated CNAs were responsible for ADL care such as shaves, nail care, and hair grooming, and the DON stated CNAs were to provide nail care, shaves, and hair grooming on scheduled shower days and as needed.
Failure to Provide Timely Vision Services
Penalty
Summary
The facility failed to provide vision services in a timely manner for one resident, R104, resulting in the resident being unable to use glasses to improve vision. On 8/19/2025, R104 was observed sitting at the bedside and was alert and oriented to person, place, and situation. The resident had a wad of white wound care tape on the right side of the glasses and stated the glasses broke about a year ago, that he would not be able to get new glasses for another year, and that he did not wear them often because the tape got in the way of seeing at times. R104 also stated he had been told there would be a wait to see if the glasses could be repaired and that the nurse had put tape on the glasses to keep them together so they could be worn. Record review showed R104 was admitted on 2/19/19 with diagnoses including intraocular lens. The annual MDS documented the resident as cognitively intact, requiring limited one-person assistance with ADLs, and noted adequate vision with no corrective lenses. There was no vision care plan addressing vision impairment, and there were no nursing or social services progress notes documenting vision impairment or broken glasses. An eye exam consultation dated 6/2/23 documented pseudo mania in both eyes and a glasses prescription dispensed with follow-up as needed. Social Service Manager O stated the facility was unaware the glasses needed repair or replacement, confirmed the resident was last seen by the doctor on 6/2/23, and said the resident somehow was not put on the list to be seen. The Nursing Home Administrator stated they did not know the resident wore glasses or that there was a problem with them.
Pharmacy Services Failure With Missing Eye Drops and Incorrect MAR Documentation
Penalty
Summary
The facility failed to provide adequate pharmacy services when one resident did not have prescribed cyclosporine 0.05% eye drops available for administration. During medication administration, the LPN reported the eye drops were not in the medication cart, and the resident stated they had not received the drops for about 5 to 6 days and that staff kept saying they did not have them. The resident had diagnoses including COPD, diabetes, and a history of fractured ribs and sternum, and had no cognitive impairment with a BIMS score of 15/15. The physician had ordered cyclosporine emulsion 0.05% eye drops, 1 drop in both eyes twice daily for dry eyes due to inflammation. The MAR showed the eye drops were documented as administered even though the medication was not available in the cart. One LPN initially stated the drops were not available and later said they were at the bedside, but the resident disagreed and said they were not in the room. Inspection of the resident's room found no eye drops or other medications at the bedside. Pharmacy records showed 30 single-dose cyclosporine eye drops had been delivered to the facility and signed for by an LPN, and the pharmacist stated a refill request was denied because a 15-day supply had already been delivered. The facility's medication guidelines stated medications received from the pharmacy should be placed in the medication cart and that documentation should occur immediately after administration, but the report documented that the eye drops were not located and were charted as given.
Kitchen Equipment Not Maintained in Safe Operating Condition
Penalty
Summary
The facility failed to ensure kitchen equipment was maintained in a safe operating condition. During an observation in the kitchen on 8/20/25 at 12:00 P.M., the South Bend stove was heavily soiled with accumulated baked-on food residue and ash, and one front gas eye was coated with a whitish unknown substance and covered with soot that impaired its function. Staff using the stove were observed constantly readjusting the gas gauges and repositioning cooking equipment because the stove eyes were not functioning properly, and the gauges/knobs were present but not calibrated adequately, causing the bottoms of pans and fryers to burn during food preparation. The Dietary Manager acknowledged that skillets were being discarded because the inner surfaces were damaged, and due to the condition of the stove only one full pan of food could be positioned on it for cooking. The South Bend Double Deck Convection oven was also soiled with old accumulated grease and ash, with visible grease residue on the sides, and the racks for both the stove and convection oven appeared to have years of accumulated food residue. The Dietary Manager stated staff had cleaned and tried to remove the buildup, but the stoves were old and had years of usage.
Failure to Assess and Respond to Change in Condition Resulting in Resident Death
Penalty
Summary
A deficiency occurred when facility staff failed to assess and monitor a resident who exhibited a change in condition, resulting in a lack of timely emergency medical intervention. The resident, who had a history of significant cardiac issues including myocardial infarction, hypertension, and episodes of unresponsiveness, was reported by both their roommate and two CNAs to be in distress around 5 a.m. The CNAs and the roommate observed the resident with their head tilted back, mouth open, and white foam coming from the mouth, and repeatedly notified the on-duty RN. Despite these reports, the RN did not perform an assessment, obtain vital signs, or attempt to arouse the resident, instead stating the resident was just sleeping and snoring, which was not unusual for them. The CNAs continued to express concern to the RN, but the RN did not return to the room or further evaluate the resident. The roommate also attempted to alert the RN multiple times and expressed regret for not calling 911 themselves. The RN later confirmed to the Director of Nursing that they were informed by staff and the roommate about the resident's condition but did not act, citing other tasks. The resident was ultimately found unresponsive by the day shift nurse, who immediately began emergency measures and called EMS, but the resident was pronounced deceased shortly thereafter. The resident's medical record indicated prior episodes of acute distress, including previous hospitalizations for heart attack and unresponsiveness, and a care plan that required monitoring for chest pain, shortness of breath, and changes in condition. The facility's policy required staff to recognize and manage changes in condition, but the RN failed to follow these protocols, resulting in a lack of timely assessment and intervention for the resident.
Plan Of Correction
Element 1: Resident 602 no longer resides at the facility. Element 2: Current residents are at risk for requiring emergency care or experiencing adverse events if Change of Condition is not recognized and assessed in a timely manner. Education was completed prior to survey including review for other residents to determine any ongoing needs secondary to Change in Condition. A follow-up 1x audit was completed for the past 3 days to determine any residents experiencing a Change of Condition that required further assessment or monitoring. Concerns were addressed as needed. Element 3: Current staff were re-educated on Recognizing Change of Condition and steps to take regarding needed assessments and monitoring. Licensed nurses were re-educated on needed assessments, documentation, and notification when a Change of Condition is recognized. Staff who do not receive the education by the date of compliance will receive education on the day of work. Non-compliance with the education on the day of work. Non-compliance with the education will result in 1:1 education or written discipline per policy. System Change: Increase Monitoring. Element 4: DON/designee will complete audits of 24-hour report for Change of Condition including any needed Assessment and Documentation daily M-F x 4 weeks then weekly x 4 weeks and ongoing per QA committee recommendations. Results of audits will be reported to QAPI monthly x 3 months and PRN. DON is responsible for ongoing compliance.
Sanitation and Supply Deficiencies in Facility
Penalty
Summary
The facility failed to maintain a sanitary and adequately supplied environment, as observed during a tour of the third and second floors. On the third floor, a trash can in a resident's room lacked a liner and contained trash, while the shower gurney pad was found to be soiled and stained. Additionally, the handwashing sink in the shower room lacked paper towels and a waste receptacle. Similar issues were noted on the second floor, where no paper towels were available for the handwashing sink in the shower room. Further observations on the third floor revealed that the trash can still lacked a liner, and the shower gurney pad remained soiled. Housekeeper J noted specific stains on the gurney pad, indicating it had not been cleaned properly. CNA K confirmed the gurney pad should be washed and dried after use, and the DON stated that the gurney should be disinfected after each use, and trash cans should be cleaned, disinfected, and lined. Despite these acknowledgments, no additional documentation or information was provided by the Nursing Home Administrator or DON during the exit conference.
Inadequate Assessment and Monitoring After Resident Injury
Penalty
Summary
The facility failed to provide adequate assessment and care for a resident, identified as R105, following an injury. R105, who had severe cognitive impairment and multiple diagnoses including vascular dementia and diabetes mellitus-type 2, was found with a laceration on the right side of the face. The incident occurred when the resident was resting her head on a table. Despite the injury, there was no documented assessment of vital signs such as blood pressure, respirations, pulse oximetry, or heart rate between the time of the injury and the resident's transfer to the hospital. The Licensed Practical Nurse (LPN) responsible for R105 at the time of the incident did not perform necessary neurological checks or complete an incident report. The LPN attempted to contact the primary care provider but only reached a voicemail. The resident's blood sugar levels were monitored, revealing hypoglycemia, but other vital signs were not reassessed. The Director of Nursing (DON) noted that the LPN should have initiated neurochecks and monitored the resident more closely following the injury. The resident was eventually transferred to a local hospital due to bradycardia and hypoglycemia. The DON acknowledged that the LPN did not follow proper procedures, including failing to notify the DON and not completing an incident report. The facility's documentation was incomplete, lacking evidence of consistent monitoring and vital sign assessments during the critical period following the injury.
Expired Medications Found in Treatment Cart
Penalty
Summary
The facility failed to ensure that medications for three residents, identified as R113, R115, and R116, were not expired. During an observation of the second-floor treatment cart with an LPN, it was found that a four-ounce tube of menthol-zinc oxide ointment for R113 had expired on 9/5/24, for R115 on 10/27/24, and for R116 on 10/4/24. Additionally, a 3.53-ounce tube of diclofenac sodium was found to have expired on 3/28/24. The LPN acknowledged that these medications should have been reordered and the expired ones discarded. The DON confirmed that the outdated medications should have been discarded and the diclofenac sodium reordered. No additional documentation or information was provided by the Nursing Home Administrator and DON during the exit conference.
Sanitation and Equipment Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to maintain a sanitary kitchen environment, as observed during an initial tour with the Dietary Manager (DM). The kitchen floor was dirty with brown stains and food debris, and trash cans were overflowing with food waste. The dry storage room contained inappropriate items such as an open bag of charcoal and fire starter liquid stored with kitchen items. Additionally, the food prep area was cluttered with dust, debris, and non-functional equipment, including a slicer and a strainer. The walk-in cooler and freezer were not properly maintained, with issues such as ice buildup and improperly stored food items. The facility's equipment and food storage practices were inadequate, as evidenced by expired spices and undated food items in the spice rack and storage areas. The dish machine temperature logs were incomplete, and there were leaks in the three-compartment sink drains. The basement storage freezer had significant ice buildup, and the temperature fluctuated when the door was opened. The facility's pest control reports indicated ongoing cleanliness and sanitation concerns, which had been previously brought to the facility's attention. During a follow-up observation, the kitchen staff lacked a working thermometer to check food temperatures, and the cooking temperature logs were incomplete. The facility administrator acknowledged the concerns and mentioned that the new dietary manager was implementing systems to ensure staff followed facility processes. However, the report highlights the facility's failure to maintain a clean and safe kitchen environment, which has the potential to affect all residents consuming food from the kitchen.
Deficiencies in Facility Maintenance and Resident Equipment
Penalty
Summary
The facility failed to maintain a safe and functional environment, as observed in multiple resident rooms and common areas. In one room, privacy curtains were not functional, with broken hooks and unclean conditions, including a large reddish-brown stain. Another room had a broken bed with a missing footboard, and the resident reported that it had been broken for about a month. Despite the resident's report, no maintenance had been conducted to fix the bed. Additionally, a bedside table in another room was missing veneer, creating non-cleanable and sharp areas. Further deficiencies were noted in the facility's provision of entertainment equipment. A resident reported not having a television in their room despite requests, and another resident's television was defective, with a distorted picture. The facility's elevators also had issues, with non-functional floor indicator lights and slow operation, causing inconvenience to users. Ceiling tiles with brown stains were observed in the hallway, indicating potential water damage or leaks. A resident's wheelchair was found to be in poor condition, with multiple ripped spots and missing foam on the armrest. Despite the resident's need for a new wheelchair, it remained unchanged over several days. The facility's maintenance director reported that issues were addressed when brought to their attention, but the observations suggest a lack of timely response to maintenance needs. The facility was under new management, which was reportedly in the process of making improvements to the physical environment.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure an environment free from physical abuse for two residents, resulting in significant injuries. One resident was pushed over in their wheelchair by another resident, leading to a head injury and hospitalization. The incident occurred in the dining room, where the resident was attempting to protect another female resident from the aggressor's advances. The aggressor, who had a history of restlessness and agitation, was not being adequately monitored by staff at the time of the incident. Another incident involved a physical altercation between two residents, where one resident entered another's room uninvited, leading to a confrontation. The resident who was intruded upon reported being hit and responded by hitting the intruder multiple times, resulting in visible injuries. Both residents involved in this altercation had cognitive impairments, with one having a severely impaired cognition score. The staff did not witness the incident, and the altercation was only reported after the fact. The facility's policies on abuse prevention were not effectively implemented, as evidenced by the lack of staff intervention and monitoring in both incidents. The facility's investigation confirmed the occurrences of these altercations, highlighting deficiencies in maintaining a safe environment for residents. The incidents were substantiated based on injuries, staff reports, and resident accounts, indicating a failure to protect residents from abuse and ensure their safety.
Failure to Complete PASARR Level II Screenings
Penalty
Summary
The facility failed to ensure that Preadmission Screening and Annual Resident Review (PASARR) forms were properly reviewed, revised, and submitted to the local state agency for two residents, resulting in potential unmet intellectual and developmental disability care needs. Resident R102 was admitted with diagnoses including major depressive disorder and psychotic disorder. The Minimum Data Set (MDS) indicated severe cognitive impairment and a need for assistance with daily activities. Although a PASARR form was completed, a necessary Level II screening was not requested, and the social worker acknowledged the oversight during an interview. Resident R79, with diagnoses including schizoaffective disorder and delusional disorders, had a PASARR form dated over two years prior, with no updated assessment in the record. The social worker indicated that the previous social worker should have updated the form and sent it to the local Community Mental Health Services Program for a Level II assessment. The current social worker had not yet reviewed R79's case but was working to update outstanding assessments. The facility's policy requires coordination with the PASARR program to ensure appropriate care for individuals with mental disorders or intellectual disabilities. The policy outlines the need for timely Level II evaluations and the responsibility of the Social Services Director to track PASARR screening status. However, the facility did not adhere to these guidelines, leading to the deficiencies noted in the report.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards of practice for medication administration for two residents, R101 and R44. For R101, medications were left unattended on the breakfast tray, and extended/delayed release medications were crushed without a physician's order. R101, who had severely impaired cognition and required assistance with eating, was observed with a medication cup containing nine whole pills on his breakfast tray. Registered Nurse G admitted to crushing the medications without an order, stating it was easier for R101 to take them that way. The facility's policy requires a physician's order for crushing medications, and the medications in question should not have been crushed according to the manufacturer's guidelines. For R44, the facility failed to ensure the availability of prescribed medications, resulting in missed doses. R44, who had moderately impaired cognition, was not administered their prescribed Fluticasone spray and Claritin on multiple occasions. Nurse S confirmed the unavailability of Fluticasone in the medication cart and indicated it needed to be reordered. The Director of Nursing acknowledged that the standard practice was to reorder medication after the first missed dose and that the nursing staff needed education on proper procedures. The facility's guidelines emphasize the importance of administering medications as prescribed and documenting the administration immediately. The deficiencies highlight a lack of adherence to medication administration protocols, including the improper crushing of medications and failure to ensure the availability of prescribed medications. These actions and inactions led to the residents not receiving their medications as intended, which is a violation of professional standards and facility policies.
Failure in Weight Monitoring for Residents at Nutrition Risk
Penalty
Summary
The facility failed to ensure proper weight monitoring for two residents at nutrition risk, leading to undetected weight changes. Resident 27, who had a history of stroke, dysphagia, and dementia, was observed with a tube feeding setup but no feeding present. The resident's weight had not been documented since May, despite a significant weight loss noted in March. A Registered Dietitian indicated that residents receiving tube feedings should be weighed at least monthly if stable, or weekly if there are significant changes. However, the resident's weight was not recorded until August, and a discrepancy of 14.4 pounds was noted within three days, which could not be explained by the Director of Nursing. Resident 71, with diagnoses including schizophrenia and alcohol abuse, experienced a 20-pound weight loss over three weeks, which was not addressed promptly. The resident's weight records showed consistent weights until a sudden drop in July. The Registered Dietitian requested a re-weigh, and the weight was confirmed to be accurate, but the significant weight change was not explained. The facility's weight monitoring policy requires weights to be obtained upon admission, weekly for the first four weeks, and at least monthly thereafter, with significant changes defined by specific percentages over set periods. The failure to adhere to this policy resulted in undetected weight changes for both residents.
Failure to Remove Unnecessary Feeding Tube
Penalty
Summary
The facility failed to remove a feeding tube from a resident, R29, when there was no longer a valid clinical indication for its use. R29 expressed frustration with the presence of the unused feeding tube, which was causing swelling, redness, and drainage at the insertion site, as well as leakage through visible holes in the tube. Despite the resident's ability to eat and drink normally, and having gained weight, the physician refused to remove the tube, leading to the resident's discomfort and dissatisfaction. Observations revealed that the feeding tube was not properly secured and was leaking, causing stains on the resident's clothing. The resident was observed eating regular meals without difficulty and consuming a significant portion of his meals. The nursing staff, including RN C, were aware of the issues with the feeding tube and had been advocating for its removal, but the physician did not respond to their requests. The Director of Nursing (DON) also communicated with the physician, who insisted on keeping the tube in place due to concerns about potential weight loss. The facility's policy on feeding tubes requires that they be used according to physician orders and that any complications be reported to the physician. Despite signs of infection and the resident's improved nutritional status, the feeding tube was not removed. The resident's legal guardian was also informed of the situation and expressed confusion as to why the tube had not been removed, given the resident's ability to eat and gain weight. The facility's failure to address the resident's concerns and the complications associated with the feeding tube led to the deficiency noted in the report.
Medication Administration Errors Result in High Error Rate
Penalty
Summary
The facility failed to maintain a medication administration error rate of less than five percent, resulting in a 37.1% error rate. This was observed during a medication administration process involving two residents. Registered Nurse (RN) C was unable to use the computer on the medication cart to access the Medication Administration Record (MAR) and instead used a computer at the nurse's station to write down medications on paper. This led to multiple medication errors for Resident R73, including administering medications that were not due, incorrect dosages, and medications that were not ordered. Additionally, RN C failed to administer several prescribed medications that were scheduled for the 10:00 AM dose. For Resident R29, RN C also made errors by administering a medication that was not ordered and failing to administer two medications that were scheduled for the 10:00 AM dose. RN C admitted to relying on memory for some medications and mentioned a verbal order from a physician that had not been processed. The Director of Nursing (DON) confirmed that there were no electronic issues and that printed MARs were available as a backup. The DON stated that RN C should have contacted the unit manager instead of relying on memory or paper notes. The facility's Medication Administration policy emphasizes the importance of administering medications as prescribed and following the Five Rights (Right Resident, Right Drug, Right Dose, Right Route, and Right Time). The policy also outlines procedures for verifying medications against the MAR at multiple stages. However, RN C's actions deviated from these procedures, leading to the observed medication errors.
Failure to Complete Physician-Ordered Lab Tests
Penalty
Summary
The facility failed to ensure that a physician-ordered laboratory diagnostic was completed for a resident diagnosed with paraplegia and multiple sclerosis. The resident, who had intact cognition, was admitted to the facility with a physician's order for several laboratory tests to be conducted every three months starting in April 2024. However, upon review of the resident's medical record, it was found that the laboratory results for June-July 2024 were missing, indicating that the ordered tests were not completed as required. During an interview with the Director of Nursing (DON), it was revealed that the facility did not have the lab results for the specified period due to an issue with the laboratory not receiving the order. The facility's policy mandates the provision of timely laboratory services, but in this case, the facility did not meet this requirement, resulting in a deficiency. The DON acknowledged the oversight and indicated that the lab orders would be rewritten and followed up for completion.
Failure to Schedule Dental Appointment for Cognitively Impaired Resident
Penalty
Summary
The facility failed to schedule a physician-ordered dental appointment for a resident with severely impaired cognition, resulting in the resident not being seen by a dentist. The resident, who was admitted with Medicaid benefits and had diagnoses including schizophrenia and alcohol abuse, was observed with missing and decayed teeth. A physician had ordered a dental evaluation for the resident due to left jaw swelling, but there was no documentation indicating that the resident had been seen by a dentist. The social worker acknowledged that the dentist had not seen the resident because the legal guardian had not signed a dental services consent form. However, there was no documentation in the electronic health record to show that the legal guardian had been requested to sign the consent form. The legal guardian confirmed that they had not been asked to provide consent but would have done so immediately if requested. The facility's policy requires assisting residents in obtaining dental care, but this was not followed in this case.
Failure to Use PPE During Wound Care
Penalty
Summary
The facility failed to ensure that personal protective equipment (PPE) was worn during wound care for a resident with a Stage III pressure ulcer. During an observation, a registered nurse (RN) entered the resident's room to perform wound care without applying any PPE, despite signage on the door indicating the need for enhanced barrier precautions. The resident, who had impaired cognition and was dependent on most activities of daily living, was admitted with a diagnosis of a pressure ulcer on the right buttock. The facility's policy on enhanced barrier precautions, last revised in March 2024, requires the use of gowns and gloves during high-contact resident care activities to prevent the transmission of multidrug-resistant organisms. Interviews with the Director of Nursing and the Infection Control Preventionist confirmed that staff should follow these guidelines and wear PPE during wound care. However, the RN and assisting staff did not adhere to these precautions, leading to the deficiency.
Inadequate Investigation of Misappropriation Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of misappropriation involving a resident's missing money. The resident, who had dementia and moderately impaired cognition, reported that $150 was missing from their coat pocket. The facility's investigation was limited to interviewing three CNAs, none of whom reported seeing the money or being near the coat after it was hung up. The resident could not recall the exact amount of money initially reported, and the facility did not verify the source of the funds, as they typically do not distribute $50 bills. The facility's administrator, who is also the abuse coordinator, did not interview other staff or residents who might have had contact with the resident or could have witnessed the incident. Additionally, the police were not notified of the allegation because the facility did not witness the resident having the money. The facility's policy requires a comprehensive investigation, including interviewing all involved parties and notifying law enforcement when necessary, but these steps were not fully executed in this case.
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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.
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Nursing homes near Detroit
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Qualicare Nursing Home | 1.5 mi | ★★★★★ | 8 | 0 |
| St. Joseph's, A Villa Center | 1.7 mi | ★★★★★ | 6 | 0 |
| Hamilton Nursing Home | 1.7 mi | ★★★★★ | 10 | 0 |
| Regency At Chene | 1.8 mi | ★★★★★ | 1 | 0 |
| Mission Point Nursing & Physical Rehab Center Of D | 2.1 mi | ★★★★★ | 17 | 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.