Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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.
Failure to submit abuse investigation results within the required timeframe. The NHA, who served as the abuse coordinator, submitted the incident report and investigation summary for a resident-to-resident abuse allegation but believed there was extra time beyond the 5-day requirement. The DON stated abuse allegations must be reported within 24 hours and the investigation submitted within 5 days. The involved residents had severe cognitive impairment, and one resident was sent for a psychiatric evaluation after the unprovoked altercation.
A resident with morbid obesity, moderate cognitive impairment, and dependence on staff for toileting hygiene fell from a bariatric bed during incontinence care when staff did not ensure the resident was centered in the bed or adequately supervised while turning. The resident reported being instructed to cross one leg over the other and turn, then sliding off the bed when they flung their leg over, with only one staff member actively changing them. Facility records and CNA interviews showed the resident was close to the bed’s edge, staff positioning was inadequate, and required witness statements were not obtained in accordance with the facility’s fall reduction policy.
A resident with severe cognitive impairment and multiple medical conditions was transferred to a hospital in the afternoon for behavioral symptoms, as documented in nursing progress and discharge notes. However, the March MAR shows that an LPN documented administration of bedtime doses of magnesium oxide, metoprolol tartrate, and Seroquel later that evening, within the facility’s established bedtime medication window, even though the resident was no longer in the building. The DON confirmed the discrepancy between the transfer documentation and the recorded medication administration, indicating that medications were charted as given after the resident had been discharged.
Surveyors found that two common bathrooms were not properly cleaned or maintained, with soiled towels left on the floor, brown streaks on the wall, an empty soap dispenser, and a used razor left out. Staff interviews confirmed that these issues should have been addressed according to facility policy, but were not.
The facility did not ensure an RN was on duty for eight consecutive hours daily, as required, with no coverage on specific dates. The DON acknowledged the expectation of daily RN coverage, especially given the residents' complex medical needs. The facility lacked a specific RN coverage policy, relying on CMS guidelines.
The facility failed to maintain cleanliness and proper food storage in the kitchen, with soiled surfaces, inadequate sealing of food in the freezer, and improper sanitation of reusable meal service ware. The dishwashing machine did not reach the required temperature for sanitization, leading to the use of disposable tableware. Additionally, the resident refrigerator contained undated and unlabeled food items, and lacked a thermometer and temperature log.
The facility did not maintain safe and sanitary conditions for kitchen equipment, as observed with the coffee machine and walk-in cooler drain lines lacking proper air gaps, leading to potential contamination risks. The Dietary Manager and NHA acknowledged the deficiencies, which contravened the 2013 FDA Food Code requirements.
A facility failed to maintain a urinary catheter drainage bag in a dignified manner for a resident, resulting in a deficiency. The resident, who had a history of schizophrenia and muscle weakness, was observed with an exposed catheter drainage bag without a dignity cover. The Nurse Manager acknowledged the cover should have been in place, and the DON confirmed the expectation for privacy bags. The facility's policy emphasized maintaining resident dignity, but the catheter bag was not covered as required.
The facility failed to provide adequate hygiene and personal care for two residents. One resident with schizophrenia and physical impairments had long, jagged fingernails despite needing total assistance. Another resident with severe cognitive impairment had an unkempt beard, although he preferred to be clean-shaven. The care plans lacked specific interventions, and there was no documentation of care refusals.
A facility failed to ensure timely physician response to pharmacy recommendations for a resident with multiple diagnoses, including heart failure and Parkinson's Disease. Despite repeated pharmacy consultations recommending changes to the resident's Xanax prescription, there was no documented physician response for several months. The DON confirmed the expectation for physician response to pharmacist reviews, but documentation was lacking, leading to the deficiency.
A resident reported that food items listed as always available were not consistently provided, as confirmed by the Dietary Manager. The resident, with intact cognition, expressed dissatisfaction with the availability of menu options, and it was observed that certain items were missing from the kitchen. The NHA confirmed that the always available menu should offer a variety of options during kitchen hours.
A resident with a history of multiple health conditions was left in bed for an extended period without timely assistance for bathing, dressing, and transferring. Despite the resident's requests and the care plan's requirements for assistance, staff failed to provide necessary care, resulting in the resident expressing frustration and anger. The Nursing Home Administrator confirmed that the staff did not meet the facility's expectations for resident care.
A resident with cognitive impairment and mobility issues suffered a fractured rib after a CNA attempted a Hoyer lift transfer alone, contrary to facility policy requiring two-person assistance. The CNA admitted to the error, and the facility's policy clearly mandates that mechanical lifts should not be operated solo.
Failure to Submit Abuse Investigation Results Within Required Timeframe
Penalty
Summary
The facility failed to ensure staff reported the results of an abuse investigation to the State Agency within five working days of the incident for two residents involved in a resident-to-resident abuse allegation. On 04/21/2026, a Facility Reported Incident was submitted regarding an allegation that R56 hit R15 on the left side of the face/head area without provocation. The investigation report was received on 04/30/2026, and the facility's abuse investigation summary documented that no injury was reported and that R56 was sent to the hospital for a psychiatric evaluation. During interviews, the NHA, identified as the facility's abuse coordinator, stated he submitted the incident report and investigation summary but believed he had extra time beyond the five-day requirement. The DON stated that abuse allegations must be reported within 24 hours and the investigation submitted within five days, and that the NHA was responsible for the submission. R15's record showed diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, vascular dementia, and anxiety disorder, with a BIMS score of 0 out of 15 indicating severe impairment. R56's record showed diagnoses including bipolar disorder, traumatic brain injury, and adjustment disorder, with a BIMS score of 0 out of 15 indicating severe cognitive impairment. The facility's abuse policy stated the Administrator would report the results of the investigation when final within 5 working days of the incident.
Failure to Safely Position and Supervise Resident During Incontinence Care Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide safe positioning assistance and adequate supervision during incontinence care, resulting in a fall from bed for resident R103. R103, who resides in a bariatric bed and reported being unable to walk or stand but able to move about in bed, stated that they fell out of bed a few days prior while staff were providing incontinence care one side at a time. R103 described being instructed to cross one leg over the other and turn, and reported that they did not realize how close they were to the edge of the bed; when they flung their leg over, they slid off the bed onto the floor. R103 reported that only one staff member was changing them at the time, and that a mechanical lift plus three staff were needed to return them to bed. Record review showed that R103 had diagnoses including acute respiratory failure with hypoxia, morbid obesity, and age-related physical debility, with a Minimum Data Set documenting moderate cognitive impairment and dependence on staff for toileting hygiene. A nurse progress note documented that on the morning of the fall, the CNA reported the resident had rolled out of bed during care, and the nurse found the resident on the floor on their left side with the bed in a low position. The fall incident report similarly recorded that the resident rolled out of bed during care and that, per CNA F’s statement, the resident was asked to turn onto their side and continued rolling, inadvertently rolling out of bed. The root cause analysis documented that the interdisciplinary team determined the resident was not positioned in the center of the bed when staff entered to complete care rounds, and that both CNAs were attempting to reposition the resident to the center of the bed when the resident rolled out of bed. Interviews with CNAs involved revealed inconsistencies and gaps in supervision and positioning practices. CNA G stated that despite the resident’s size, the resident was very mobile and considered a two-person assist for safety, and reported that they were in the process of changing the resident when the fall occurred. CNA G initially claimed that both CNAs were on opposite sides of the bed such that there was no room for the resident to fall, but later said they did not know where CNA F was positioned and then stated they did not remember. CNA F reported that the resident was somewhat close to the edge of the bed, not centered, and that during turning for incontinence care the resident threw their top leg over the other and fell off the bed on the opposite side, while CNA G was at the foot of the bed rather than at the center on the opposite side. The Director of Nursing confirmed that witness statements from the CNAs were not obtained as required by the facility’s fall reduction policy and acknowledged that if staff had been positioned close to the bed and used a draw sheet to move the resident to the middle of the bed prior to care, the fall could have been prevented.
Inaccurate MAR Documentation for Medications After Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate medical record regarding medication administration for a resident with severe cognitive impairment and multiple diagnoses, including acute respiratory failure with hypoxia, hypertension, and bipolar disorder. The resident was admitted in late September and discharged in early March. On the day of discharge, nursing documentation shows that the resident was transferred to a local hospital in the mid-afternoon due to behavioral symptoms, with a discharge note at 3:33 PM and a nursing progress note at 3:38 PM confirming that EMTs responded to a 911 call, the resident’s guardian consented to transfer, and the physician and DON were notified. The resident was transported to the hospital via stretcher and was no longer in the facility after that time. Despite the resident’s transfer out of the building that afternoon, the March Medication Administration Record (MAR) documented that bedtime doses of magnesium oxide 400 mg BID for hypomagnesemia, metoprolol tartrate 100 mg BID for tachycardia, and Seroquel 25 mg BID for bipolar disorder were administered by an LPN at bedtime that same day. The LPN assigned to the second shift stated that bedtime medications were to be given at 9 PM, with a one-hour window before or after, but could not recall whether the resident was in the building around that time. The DON confirmed that the facility’s bedtime medication administration window was between 7 PM and 10 PM and, upon reviewing the MAR and progress notes, questioned how the medications could have been administered when the resident had already been transferred to the hospital, indicating that someone documented administration of medications after the resident had been discharged from the facility.
Failure to Maintain Clean and Safe Resident Bathrooms
Penalty
Summary
Surveyors observed that two common resident bathrooms were not effectively cleaned or maintained, resulting in unsanitary and unsafe conditions. In the back hall bathroom, a small wash basin containing used, soiled towels was found on the floor, and four irregular streaks of solid brown matter were noted on the wall above and to the right of the wash basin. The Certified Nurse Aide (CNA) present indicated that resident showers had not yet been given on the day shift and that CNAs were responsible for removing soiled towels after use. In the front hall bathroom, the soap dispenser near the handwashing sink was empty, and a used disposable razor was left on the shelf above the sink. The CNA stated that housekeeping staff were responsible for ensuring soap was available in the bathrooms. During interviews, the Housekeeping Supervisor confirmed that the back hall bathroom should have been cleaned and sanitized after use and that staff should have reported the need for cleaning. The supervisor also explained that the brown streaks on the wall were likely caused by a towel soiled with feces being tossed and hitting the wall. The razor should have been disposed of in the appropriate sharps container, and soap dispensers should be refilled when low. The Nursing Home Administrator and Director of Nursing both acknowledged that the soiled towels, brown stains, and empty soap dispenser should have been addressed, and that all used linen and razors should be properly removed and discarded after use. Facility policy requires routine cleaning and disinfection of common areas and immediate cleaning of visibly soiled surfaces.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for eight consecutive hours a day, seven days a week, as required. This deficiency was identified during a review of the nurses' schedule for July, August, and September 2024, which revealed a lack of RN coverage on September 2nd and September 8th, 2024. The staffing coordinator acknowledged difficulties in securing RN coverage for weekends. The Director of Nursing (DON) confirmed that there were instances when an RN was not available, despite the expectation of 8-hour RN coverage daily. The facility's resident population included individuals with complex medical needs such as tube feedings, intravenous medications, and previous residents with tracheostomies, all of which require RN supervision. The facility did not have a specific RN coverage policy and instead referred to the Center for Medicare and Medicaid Services guidelines.
Deficiencies in Kitchen Cleanliness and Food Storage
Penalty
Summary
The facility failed to maintain proper cleanliness and sanitation standards in the kitchen, as observed during a survey. Surfaces in the kitchen, including the inside of the ice scoop container, the sides and bottom vents of the vegetable and supplement reach-in freezers, and the top and middle cooking utensil drawers, were visibly soiled with food debris, grease, and grime. Additionally, a double bar above the three-compartment sink was heavily soiled, and a maintenance worker was observed cleaning it with a putty knife, removing significant amounts of grease, dust, and grime. The dishwashing machine was not consistently reaching the required temperature to sanitize dishes, leading to the use of disposable tableware for meal service. Food storage practices were also found to be inadequate. In the meat freezer, an opened box of turkey sausage was not properly sealed, exposing the contents to the freezer air. The resident refrigerator on the third floor contained undated and unlabeled food items, including a snack pack and a carton of milk past its sell-by date. The refrigerator and freezer lacked a thermometer, and there was no temperature log maintained to ensure proper storage conditions. The facility's failure to properly clean and sanitize reusable meal service ware was also noted. Reusable meal trays and dome plate covers were not adequately sanitized, with the trays being washed in soapy water and the plate covers not being sanitized before lunch service. The Dietary Manager acknowledged the insufficient cleanliness and the need to redo cleaning assignments. The Director of Nursing confirmed the absence of a thermometer and temperature log in the resident refrigerator and freezer, and the Nursing Home Administrator admitted there was no excuse for the dirty kitchen conditions.
Improper Drainage Connections in Kitchen Equipment
Penalty
Summary
The facility failed to maintain equipment used in food service operations in a safe and sanitary condition, leading to potential contamination risks. During an inspection, it was observed that the drain line from the coffee machine was partially positioned on a metal plate, creating a direct connection between the coffee machine drain line and the floor drain. Additionally, the drain line from the walk-in cooler lacked an unobstructed vertical space between its end and the floor drain, indicating an absence of a proper air gap. The Dietary Manager acknowledged that there should have been an air gap for both the coffee machine and the walk-in cooler. The Nursing Home Administrator confirmed that the coffee machine drainpipe needed adjustment and the walk-in cooler drain was improperly air gapped. The 2013 FDA Food Code specifies that a direct connection should not exist between the sewage system and a drain from equipment used for food, portable equipment, or utensils.
Failure to Maintain Dignity for Resident with Urinary Catheter
Penalty
Summary
The facility failed to maintain a urinary catheter drainage bag in a dignified manner for a resident, resulting in a deficiency. The resident, who was observed on two separate occasions, had their urinary catheter drainage bag exposed without a dignity cover. The resident was in bed, with a contracted right arm and was confused, able to answer basic questions. The urine in the drainage bag was described as cloudy and amber-colored. The resident's medical history included schizophrenia, contracture of the right elbow, muscle wasting, multiple fractures, and muscle weakness. The care plan for the resident specified that the catheter and tubing should be positioned below the bladder and covered for dignity. The issue was brought to the attention of the Nurse Manager, who acknowledged that the dignity cover should have been in place and suggested it might have fallen off. The Director of Nursing also confirmed the expectation that all urinary drainage bags should have a privacy bag for dignity. The facility's policy on promoting and maintaining resident dignity, dated February 2025, emphasized the importance of protecting and promoting resident rights and maintaining privacy. Despite these policies, the facility did not ensure the resident's catheter drainage bag was covered, leading to the deficiency.
Deficiencies in Resident Hygiene and Personal Care
Penalty
Summary
The facility failed to provide adequate hygiene and daily care for two residents, resulting in deficiencies in their personal care. Resident R4, who has a history of schizophrenia, contracture of the right elbow, muscle wasting, multiple fractures, and muscle weakness, was observed with long and jagged fingernails on both hands. R4's care plan indicated total assistance with personal hygiene, including nail care on bath days and as necessary. However, the Director of Nursing noted that R4 sometimes refuses care, which is documented in the care plan. Resident R8, who has a diagnosis of debility and severely impaired cognition, was observed with a full, long, and unkempt beard despite expressing a preference to be clean-shaven. The care plan for R8 required partial/moderate assistance with personal hygiene, but there were no specific interventions for shaving, and no history of refusing care was documented. The Unit Manager stated that staff should assist R8 with shaving and document any refusals, but a review of progress notes revealed no such documentation.
Failure to Respond to Pharmacy Recommendations in a Timely Manner
Penalty
Summary
The facility failed to ensure a physician responded to pharmacy recommendations in a timely manner for a resident with multiple diagnoses, including heart failure, Parkinson's Disease, and psychotic disorder. The resident was receiving antipsychotic and antianxiety medications, including Xanax, which was prescribed on an as-needed basis. Pharmacy consultations identified irregularities on three occasions, recommending the discontinuation or specific ordering of Xanax in accordance with federal guidelines. However, there was no documented response from the physician to these recommendations until several months later. The Director of Nursing (DON) confirmed that the pharmacist conducts monthly medication reviews and makes recommendations for changes if necessary, with the expectation that the physician will respond. Despite this process, the DON could not provide documentation showing that the physician had reviewed and responded to the pharmacist's recommendations in a timely manner. The facility's policy on Medication Regimen Review requires staff to act upon all recommendations, but this was not adhered to in the case of the resident, leading to the deficiency noted in the report.
Failure to Provide Always Available Menu Items
Penalty
Summary
The facility failed to ensure that food items listed as always available were consistently on hand to honor resident food preferences, specifically for one resident. During an interview, the resident expressed dissatisfaction with the availability of food options, indicating that the menu items were not always available. An observation confirmed that certain items, such as sliced turkey lunch meat and cottage cheese, were not in stock in the kitchen, despite being listed on the always available menu posted in the resident's room. The Dietary Manager acknowledged that these items should have been available and noted that cottage cheese had been removed from the menu. Further interviews revealed that the resident, who had intact cognition, was able to communicate his food preferences and occasionally ordered from the always available menu when he desired something other than the main menu entree. The Nursing Home Administrator confirmed that the always available menu was intended to provide a variety of food options to meet residents' preferences and should be accessible during kitchen hours. Despite being given the opportunity, the facility did not provide any additional documentation or information before the end of the survey.
Failure to Provide Timely Personal Care
Penalty
Summary
The facility failed to provide timely personal care for a resident, resulting in untimely assistance with bathing, dressing, and transferring to their wheelchair. On multiple occasions, the resident was observed in bed wearing a soiled brief and a stained t-shirt, with an odor of stool present. The resident expressed feelings of frustration and anger due to the lack of assistance. Despite the resident's call light being on and their verbal requests for help, staff did not perform necessary bathing or dressing, and the resident remained in bed for an extended period. The resident, who had a history of Peripheral Vascular Disease, Cerebral Infarction, Hypertension, Immunodeficiency, and Non-Pressure Chronic Ulcer, was cognitively intact with a BIMS score of 15. Their care plan required assistance with activities of daily living, including bathing, dressing, and transfers using a Hoyer lift. However, the staff did not adhere to these care plan interventions, leaving the resident in a state of neglect. The Nursing Home Administrator acknowledged the expectation for staff to dress and assist residents out of bed, which was not met in this case.
Inadequate Assistance During Mechanical Lift Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to ensure adequate assistance during a mechanical lift transfer for a resident, resulting in a fall and subsequent fracture of the right rib. The resident, who had a history of hemiplegia and hemiparesis following a cerebral infarction, was being transferred using a Hoyer lift by a CNA without assistance, contrary to the facility's policy requiring two people for such transfers. During the transfer, the hooks from the Hoyer pad slipped off, causing the resident to fall onto the bed frame, leading to hospitalization for a fractured rib. The CNA involved admitted to transferring the resident alone, acknowledging the mistake and the requirement for assistance during mechanical lift transfers. The Director of Nursing confirmed that staff are trained upon hire and receive annual competency checks for Hoyer lift use, emphasizing the importance of using two people for safety. The facility's Mechanical Lift policy explicitly states that a mechanical lift should not be operated alone, highlighting the failure to adhere to established safety protocols.
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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) |
|---|---|---|---|---|
| Boulevard Temple Care Center, Llc | 1.4 mi | ★★★★★ | 5 | 0 |
| The Villa At The Park | 1.8 mi | ★★★★★ | 9 | 0 |
| St. Joseph's, A Villa Center | 1.9 mi | ★★★★★ | 6 | 0 |
| Mission Point Nursing & Physical Rehabilitation Ce | 2.4 mi | ★★★★★ | 26 | 0 |
| Heritage Manor Nursing And Rehabilitation Center | 2.9 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.