Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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.
A resident with significant psychiatric history and other chronic conditions was admitted with orders for Depakote ER 1,500 mg at bedtime, but the facility transcribed and administered Depakote delayed-release instead. MARs and the discharge order summary showed the wrong formulation was used throughout the stay, and an LPN later acknowledged the transcription error after discharge. The resident’s chart also noted a history of mood and behavior concerns, hallucinations, and labile behavior.
The facility failed to maintain a clean, comfortable, and homelike environment on the A, B, and D units. Surveyors observed overflowing bagged soiled linens stored on the floor, a strong urine odor in the front lobby and hallways, and heavily soiled ceiling vent grids and washable filters at the lobby and nursing stations. The Housekeeping/Maintenance Director acknowledged the soiled vents, said housekeeping should have cleaned them, and stated some were missed; the director also reported no monitoring of the ceiling ventilation systems.
Failure to Protect Residents from Abuse and Neglect: Staff exchanged profanity with a resident after a request for coffee, residents used derogatory and disparaging language toward each other during bingo, a nurse allegedly failed to timely provide ordered pain medication after repeated call light requests, and two residents were involved in a physical altercation in which one struck the other in the face. The facility later acknowledged verbal abuse, neglect, and physical abuse in its interviews and records.
Failure to Report Resident Abuse and an Injury of Unknown Origin: The facility did not report witnessed resident-to-resident verbal abuse during bingo, where one resident used derogatory language toward another and a third resident was also involved. The Administrator later acknowledged the incident should have been reported as verbal abuse. The facility also did not report a resident’s unexplained fatal entrapment, where the resident was found with the head stuck between the bed and dresser, had no pulse or respirations, and was pronounced deceased; the Administrator said she was notified but did not report it to the State Agency.
Plumbing, drain, and ice machine cleanliness deficiencies were observed in the kitchen area. Surveyors noted sewer gas odor near the grease trap and multiple drains, dark soil buildup on kitchen sink drain lines, pink substance forming on the ice machine drip panel, and plumbing cross-connection concerns including a janitor sink water line without a wasting/vented T device and a garbage disposal sink with a submerged jet inlet and no cross-connection prevention in place.
Failure to Investigate Injury of Unknown Origin: A resident with impaired cognition, dependence for most care, and no fall history was found deceased with his head wedged between the bed and wardrobe after being last seen alive repositioned and changed. The nurse pronounced the resident dead and an incident report was completed, but no investigation was documented. The Administrator said there was no specific investigation and did not interview the CNA who provided care or found the resident, while the DON stated the event was not investigated and should have been.
Failure to care plan for an ileostomy. A resident with intact cognition and an ostomy stated she needed help emptying and changing the bag, but the comprehensive care plan had no ileostomy-related interventions. The DON stated any type of ostomy should be included in the care plan, and the facility policy required a baseline care plan with instructions for special needs.
Failure to Keep Walker at Bedside for Resident With Falls History: A resident with dementia, Parkinson’s Disease, impaired cognition, and a history of falls had a care plan intervention requiring the walker to be kept next to the bed during rounding and med pass, but staff observed the walker and wheelchair placed across the room instead of at bedside. The resident later had a fall after attempting unassisted ambulation to the bathroom, and the record identified the root cause as unassisted ambulation.
Nephrostomy drainage bags were found positioned above kidney level for a resident with nephrostomy tubes, despite an order to keep the bags below the kidneys for dependent drainage. The resident, who had acute kidney failure, bladder cancer, hydronephrosis, and moderately impaired cognition, was observed in bed on multiple occasions with both bags placed on an overbed tray table or pillow above the bed level; the DON confirmed the bags should be below the kidneys, and the resident said staff put them on the tray table after emptying them.
A resident with lung cancer had a change in condition with twitching, altered responsiveness, and later a hospital transfer by EMS, but the record lacked a documented reason for the transfer, a transfer form, a complete change of condition assessment, and a readmission note. Earlier, the resident also had a severe oxygen desaturation episode that was documented incompletely, with no recorded physician response or documented instructions from the physician.
Failure to Follow Pressure Ulcer Treatment Orders: A resident with an unstageable coccyx pressure injury, diabetes, heart failure, and impaired cognition had wound care orders for NS cleansing, Medihoney, and dressings, later with calcium alginate added. The wound consultant said Medihoney had been ordered from the start, but the TAR did not show it until about a month later, and the resident’s wound remained largely slough-covered on observation. A prior coccyx dressing order was also discontinued and never documented as being done.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents, as observed by surveyors during their review.
A resident with complex psychiatric and neurological diagnoses was subjected to mistreatment when a CNA placed a hand over the resident's mouth to muffle yelling during care. Another CNA witnessed the incident and reported it to facility management. The staff member involved expressed frustration with the resident's behavior and made an inappropriate comment about the resident's mental health.
A resident admitted with alcohol dependence and withdrawal did not have the hospital's CIWA-Ar protocol for lorazepam administration reconciled or implemented upon admission. The DON and physician were unaware of the protocol on the discharge medication list, resulting in the protocol not being reviewed or acted upon.
A resident did not receive appropriate care for existing pressure ulcers, and the facility did not take adequate steps to prevent new ulcers from developing, as observed and documented by surveyors.
Facility staff did not follow a psych NP's recommendation to rule out a UTI in a resident with dementia who exhibited behavioral changes. Despite a documented history of agitation linked to UTIs and ongoing symptoms, staff did not obtain a repeat urinalysis. The resident was later hospitalized, where sepsis and a UTI were diagnosed, and the DON acknowledged the recommendation had been missed.
A resident with dementia who required full staff assistance experienced a significant weight loss over a short period, but staff failed to confirm the loss, notify the DON, or update the nutrition care plan as required by facility policy. The DON was not informed of the weight change, and no follow-up actions were documented.
The facility did not set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action, resulting in the lack of a systematic process for identifying and addressing quality issues.
A resident with severe cognitive impairment and multiple diagnoses received opioid pain medications, but there were repeated discrepancies between the MAR and controlled substance records. Doses were documented as administered on the MAR but not reflected on the CS forms, with no refusals or explanations noted. The DON acknowledged gaps in the auditing process, and facility policy requiring reconciliation of controlled substance records was not consistently followed.
The facility's kitchen was found to have several sanitation deficiencies, including improper storage of raw and cooked foods, a dirty ice scoop holder, and a hose sprayer touching a soiled drain board. These issues were confirmed by the Dietary Manager and violated FDA Food Code regulations.
The facility failed to maintain a safe and clean environment, with deficiencies including overbed tray tables with exposed particle board, sharp sink vanity edges, soiled privacy curtains, and dusty ceiling vents. The Maintenance Manager acknowledged the issues but cited limitations in replacing tables, while the Maintenance & Housekeeping Manager did not provide clear responses regarding routine cleaning of vents.
A facility failed to ensure consistent documentation and communication for a resident receiving dialysis. The resident, with acute kidney failure and end-stage kidney disease, was scheduled for dialysis twice a week, but the MDS assessment did not reflect this. Documentation and assessments were missing for six treatments, and there was no follow-up with the dialysis center when paperwork was not returned. The DON confirmed the missing documentation and acknowledged the issue.
The facility failed to secure medication storage areas, with an LPN leaving a medication room door propped open and loose pills found in a medication cart. Insulin pens were improperly stored with food items, and a treatment cart was left unlocked near residents. The DON acknowledged these practices violated facility policy.
The facility failed to ensure accurate MDS assessments for two residents. One resident with end-stage renal disease was incorrectly marked as not receiving dialysis, despite having orders for it. Another resident was inaccurately documented as being discharged to a hospital instead of an assisted living facility. The errors were acknowledged by the MDS Coordinator.
A resident with impaired cognition and multiple diagnoses was found with undated and dated dressings on their arm, with no orders for wound care documented. The facility failed to ensure proper assessments and documentation, as the Wound Care Nurse and Consultant Wound Provider were unaware of the dressings, and the LPN who applied the initial dressing did not recall placing an order for changes. The DON confirmed that nurses should ensure physician orders are in place, as per facility policy.
The facility failed to ensure proper infection control practices during medication administration for two residents. An LPN was observed not performing hand hygiene before and after administering oral medications and eye drops to a resident. Additionally, the LPN did not perform hand hygiene after retrieving and administering Gabapentin to another resident. The DON acknowledged the oversight, which was against the facility's hand hygiene policy.
The facility failed to ensure proper sanitizing and washing practices for dishes and utensils, and lacked proper hand washing facilities in the kitchen. The kitchen had been without hot water for weeks to months, leading staff to use boiling water for washing. However, the sanitizing process was not conducted according to standards, with expired test strips and incorrect solution temperatures. The facility's policy and FDA guidelines were not followed, posing a risk of improper sanitation.
A resident admitted for hospice respite care, with severe cognitive impairment and total dependence on staff for ADLs, did not have their clothing changed for two days. The facility's failure to update the care plan in a timely manner resulted in CNAs not being informed of the need to change the resident's clothing daily, as confirmed by the DON.
A facility failed to readmit a resident after a hospital transfer, despite the resident being medically cleared. The resident had severe cognitive impairment and a history of aggressive behavior, which was known prior to admission. The decision not to readmit was made by Corporate, but the facility did not provide the required documentation or notice to the family. The facility's policy requires a 30-day written notice before involuntary transfer or discharge, which was not followed.
Medication transcription error for Depakote formulation
Penalty
Summary
The facility failed to transcribe a medication accurately from physician orders for one resident who was admitted with multiple diagnoses including bipolar disorder, schizoaffective disorder, depression, anxiety, pseudobulbar affect, heart failure, deep vein thrombosis, arthritis, spinal stenosis, and back pain. The resident’s hospital discharge documents and referral form identified divalproex 1,500 mg as Depakote ER to be given at bedtime, but the facility’s EMR and MAR reflected Depakote delayed-release instead of extended-release throughout the stay. The resident’s February, January, and March MARs showed divalproex sodium delayed-release was administered as 1,500 mg at bedtime, including periods where three 500 mg tablets were given together at night. The order summary at discharge also listed delayed-release 500 mg tablets, three at bedtime, rather than the extended-release formulation documented in the hospital records. A progress note entered after discharge stated the Depakote had not been transcribed correctly from the hospital discharge instructions and that the resident had been receiving delayed-release instead of extended-release medication. During interviews, an LPN acknowledged the transcription error and confirmed the resident received the medication at night only, not in a staggered schedule. The DON and physician were made aware after discharge, and the psychiatric NP stated the medication reconciliation documentation did not specify ER or delayed-release. The resident had a care plan noting risk for mood and behavior changes, a history of hallucinations and hearing voices, and was described as labile and religiously preoccupied, but the record showed the medication order was not transcribed as written from the hospital discharge instructions.
Soiled vents, urine odors, and overflowing linens
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for residents on the A, B, and D units. On 3/30/2026, surveyors observed bagged soiled linens overflowing from vendor-provided storage containers and being stored on the floor, with a strong urine odor present in the area near the building entrance. Staff W, the Housekeeping/Maintenance Director, stated that laundry pickup occurred on Monday, Wednesday, and Friday around 11:00 AM and that Monday was the heaviest collection day, and indicated they could check whether another collection bin was available. Staff W also stated that housekeeping staff cleaned the carpeting in the urine-odor areas each morning after arriving. During the survey, a complaint allegation stated that the entire unit smelled like rotting bodies and urine. Surveyors noted a strong urine odor immediately upon entering the front lobby, and the odor remained prevalent throughout the front lobby and hallways on the A, B, and D units. Two ceiling air units in the front lobby had vent grids heavily soiled with stringy dust debris. Additional observations at the A/B nursing station and D nursing station revealed heavily soiled ceiling vent air units and heavily soiled internal washable filters with dust debris. Staff W acknowledged the soiled condition of the vents and filters, stated housekeeping should have cleaned them, and reported that some were missed. Staff W also stated they did not monitor the ceiling ventilation systems and that the contracted heating and cooling company must have missed a couple.
Failure to Protect Residents from Verbal Abuse, Physical Abuse, and Neglect
Penalty
Summary
The facility failed to protect residents from verbal abuse, physical abuse, and neglect involving multiple residents. The cited issues involved a staff member exchanging profanity with a resident after the resident requested coffee, a resident-to-resident verbal altercation during bingo that included derogatory and disparaging remarks, an allegation that a nurse did not timely respond to a resident’s repeated requests for pain medication, and a resident-to-resident physical altercation in which one resident struck another after being hit on the buttocks. For one incident, a dietary/kitchen aide refused a resident’s request for coffee, and the resident responded with profanity. The staff member then replied with profanity and walked away. The incident was witnessed by a nurse, and the facility later acknowledged that verbal abuse had occurred, although it had initially been documented as inconclusive. The resident involved had diagnoses including bipolar disorder with psychotic features, mild neurocognitive disorder, Parkinson’s disease, schizoaffective disorder, chronic pain syndrome, and PTSD, and the resident reported being upset that staff should not have spoken that way. A separate resident-to-resident incident involved a resident with intact cognition who reported being called a derogatory name related to sexual orientation during bingo. Facility documentation showed that the resident had also used insulting language toward another resident and that another resident had responded with a derogatory remark and comments about the resident acting like a little girl. The administrator later stated the incident had not been reported because it was verbal and the resident had started it, even though the documentation included disparaging remarks. Another incident involved a resident with intact cognition and advanced cancer diagnoses who reported that a nurse turned off the call light and left the room after the resident requested pain medication, then returned later without giving the medication and left again, resulting in a prolonged wait before the medication was provided. The administrator stated the event was considered neglect because the resident needed narcotic pain medication regularly due to hospice status and aggressive cancer diagnoses. The report also described a physical altercation between two residents, one with severe cognitive impairment and vascular dementia and the other with intact cognition and schizoaffective disorder/dementia. Facility records showed one resident went up to the other, yelled, and hit the other on the buttocks; the other resident turned and struck back in the chin/face with a closed fist. The facility’s investigation included resident statements and staff observations, but the summary did not include a conclusion, and the incident was reported to the State Agency as unsubstantiated. During interview, the administrator acknowledged that the resident who punched the other in the face had committed physical abuse.
Failure to Report Resident Abuse and an Injury of Unknown Origin
Penalty
Summary
The facility failed to report witnessed resident-to-resident verbal abuse and an injury of unknown origin to the State Agency. During review of a separate verbal abuse concern involving a staff member and one resident, additional resident-to-resident abuse concerns were identified involving three residents during bingo. One resident, who had a BIMS score of 15 and diagnoses including bipolar disorder, neurocognitive disorder, schizoaffective disorder, and generalized anxiety disorder, reported that another resident called him a derogatory name related to sexual orientation. The same resident also reported that he was upset during bingo because another resident was called names and because of how the bingo screen was positioned. Another resident with a BIMS score of 15 stated he did not use the derogatory term but did call the first resident a fat punk and said he acted like a little girl. A third resident with a BIMS score of 3 and severe cognitive impairment was also involved in the incident. The Administrator later acknowledged the incident should have been reported and stated it was not reported because it was verbal and the resident had started it. Facility documentation and staff interviews showed the bingo incident involved derogatory and disparaging remarks between residents, but it was not treated as reportable abuse at the time. The activity staff member who witnessed the event reported that the first resident was upset, another resident intervened, and the first resident became increasingly upset. The staff member said the incident was reported to CNAs, nurses, and later to their supervisor, but not immediately to the abuse coordinator. The Activity Director later stated the staff member had only reported that the resident was upset and left, and that no derogatory statements were reported to them. The Administrator later acknowledged that the derogatory remarks should have been identified as verbal abuse and that staff should have notified the abuse coordinator immediately. The facility also failed to report an injury of unknown origin involving a resident who was admitted, readmitted, and later expired in the facility. That resident had moderately impaired cognition, one-sided upper and lower extremity impairment, and was dependent on staff for toileting hygiene, rolling, transferring, and moving from sitting to lying. Progress notes documented that the resident was last seen alive after being repositioned and changed, then was found out of bed with the head stuck between the bed and wardrobe, face down, with no pulse, respirations, or heart sounds and was pronounced deceased. The Administrator, who was also the Abuse Coordinator, stated she was notified that the resident was found with the head stuck between the bed and dresser and deceased, but she did not report the incident to the State Agency and did not provide a reason. The nurse assigned to the resident reported the resident was found wedged between the bed and armoire in an unusual position, could not be freed without moving furniture, and was not a fall risk and unable to move himself in bed.
Plumbing, Drain, and Ice Machine Cleanliness Deficiencies
Penalty
Summary
The facility failed to maintain general cleanliness and repair of plumbing and the ice machine. During a kitchen tour with the dietary manager, sewer gas odor was observed near the sub floor grease trap by the 3-compartment sink, at 3 in-floor drains, and near 3 kitchen sink drains. The dietary manager stated he had a diminished sense of smell and was not aware of the odor or what the issue might be. He also stated the grease trap was serviced about every 6 months and that the building was serviced by the village sanitary sewer. At a later interview, the dietary manager said service records should be with the maintenance supervisor or administrator and that it would probably be a good idea to have the grease trap serviced more frequently. The maintenance director stated no plumbing service records were available, that the last service was in August 2025, and that the grease trap had been cleaned/serviced annually. Observations also found two kitchen sink drain lines with dark soil buildup at the end of the drain line, the kitchen ice machine drip panel with spots of a pink substance forming, the D Hall janitor sink connected to the chemical supply tower with an atmospheric vacuum breaker but no wasting/vented T device, and the garbage disposal sink with a submerged jet inlet below the sink flood rim and no cross-connection prevention in place when the inlet valve was turned on and water came out.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown origin for one resident who was admitted, later readmitted, and died in the facility. The resident had moderately impaired cognition, one-sided impairment of the upper and lower extremities, and was dependent on staff for toileting hygiene, rolling, transferring, and going from sitting to lying. The resident did not stand or walk and had no history of falls. According to the record, the resident was last seen alive after being repositioned and changed, and was later found out of bed with his head stuck between the bed and wardrobe, face down, with no pulse, no respirations, and no heart sounds. The nurse pronounced the resident deceased and notified the Administrator, DON, and unit managers. An incident report documented the same event, but no investigation was included with the report. When questioned, the Administrator stated there was no specific investigation and that the progress notes were the documentation for the event. The Administrator also reported she did not interview the CNA who provided care or found the resident, and did not interview the roommate. The DON stated the event was not investigated and should have been. The facility policy identified physical injury of unknown source as a possible indicator of abuse and stated that an immediate investigation is warranted when suspicion of abuse, neglect, or exploitation occurs.
Failure to Care Plan for Ileostomy
Penalty
Summary
The facility failed to develop a comprehensive care plan to address a resident's ileostomy for one resident reviewed for ostomies. The resident was observed sitting on the side of the bed and stated she had an ileostomy and needed assistance emptying and changing the bag. The clinical record showed the resident was admitted with diagnoses including kidney disease, osteoarthritis, and ileostomy status, and the MDS assessment indicated intact cognition and the presence of an ostomy. Review of the resident's comprehensive care plan revealed no care plan for the ileostomy. The DON stated that if a resident had any type of ostomy, it should be included in the care plan. The facility policy on care planning stated that the facility will develop and implement a baseline care plan for each resident that includes instructions needed to provide effective and person-centered care, including any special needs.
Failure to Keep Walker at Bedside for Resident With Falls History
Penalty
Summary
The facility failed to consistently implement fall prevention interventions according to one resident’s plan of care. The resident had a care plan for potential injury related to a history of falls, weakness, poor safety awareness, routine psychotropic medication use, and Parkinsonism with impaired gait. An intervention initiated on 3/10/25 directed staff to ensure the walker was next to the bed during all rounding and during medication pass each shift, but on 3/30/26 and 3/31/26 the resident was observed sleeping in bed with the walker and wheelchair placed across the room near the window rather than at bedside. The resident had a fall on 3/24/26 and was found on the floor of his room lying on his left side after reporting he was getting up to go to the bathroom. A Nursing: Antigravity Team Note dated 3/25/26 documented the root cause as unassisted ambulation to the bathroom and noted the prior intervention to ensure the walker was next to the bed during all rounding and during medication pass. The resident was admitted to the facility on 3/26/21 and readmitted on [DATE] with diagnoses including dementia and Parkinson’s Disease, and an MDS assessment dated [DATE] showed moderately impaired cognition and a history of falls.
Nephrostomy drainage bags positioned above kidney level
Penalty
Summary
The facility failed to ensure nephrostomy tube drainage bags were positioned for dependent drainage for one resident with nephrostomy tubes. The resident was admitted with diagnoses including acute kidney failure, bladder cancer, and hydronephrosis, and had a BIMS score of 12/15 indicating moderately impaired cognition. The physician order dated 3/3/26 directed staff to keep the nephrostomy tubing taped to the skin and connected to a drainage bag placed below the level of the kidneys. During multiple observations, the resident was lying in bed while both nephrostomy drainage bags were positioned above the height of the bed and above the level of the resident’s kidneys. On 3/30/25 at 9:34 AM, one bag was on an overbed tray table and the other was on a pillow against the wall; neither bag nor tubing appeared to have drainage fluid. The same condition was observed again on 3/30/26 at 12:35 PM and on 3/31/26 at 12:27 PM, when both bags were still lying on the tray table above the resident. The DON stated that nephrostomy drainage bags should be below the level of the kidneys for dependent drainage, and the resident said staff would place the bags on the tray table after emptying them.
Failure to Document Change in Condition and Hospital Transfer
Penalty
Summary
The facility failed to thoroughly assess and document a change in condition for one resident who was sent to the hospital and later returned the same day. On 3/30/26, the resident was observed in bed with twitching movements, disheveled appearance, and mumbled responses that were difficult to understand, and was later seen leaving the facility on a stretcher with EMS. The clinical record contained a Medication Administration Note stating the resident was sent to the hospital, but there was no documentation explaining why the transfer occurred, no progress note documenting the reason for the hospital transfer, no transfer form, and no change of condition assessment showing what was happening with the resident at the time of the event. There was also no progress note documenting the resident’s readmission back to the facility. The resident had been admitted to the facility with a diagnosis that included lung cancer. The record also showed an earlier change in condition when the resident reported trouble breathing and an oxygen saturation of 68% on 4L, requiring a non-rebreather on 6L before returning to 96%, but the change of condition assessment was incomplete and left blank, and there was no documentation of the physician’s response or whether the physician was reached. Staff interviews confirmed that the resident was sent to the hospital because he was not verbally responding, but the expected discharge emergent note, physician order, and transfer form were not completed, and instructions from the physician regarding oxygen monitoring were also not documented.
Failure to Follow Pressure Ulcer Treatment Orders
Penalty
Summary
The facility failed to follow physician/extender pressure ulcer treatment orders for a resident with an unstageable coccyx pressure injury. The resident was admitted and readmitted with diagnoses including acute and chronic respiratory failure, diabetes, and heart failure, and had moderately impaired cognition on the MDS. A weekly skin sweep identified an open area on the coccyx, and a wound consult on 2/18/26 documented an unstageable pressure injury measuring 1.8 cm by 2 cm by 0.1 cm with 70% slough and 30% granulation. The wound consultant ordered cleansing with normal saline, application of Medihoney gel daily and as needed, and a secondary dressing, with the plan discussed with the treatment nurse. Subsequent wound consults on 2/25/26, 3/4/26, and 3/11/26 continued the Medihoney treatment plan, and later consults on 3/18/26 and 3/25/26 added calcium alginate while continuing normal saline, Medihoney, and a dressing daily and as needed. However, the February TAR only showed barrier cream to the buttocks, and the March TAR did not begin Medihoney wound care until 3/12/26. During observation on 4/1/26, the wound still appeared almost completely obscured with yellow slough and was measured at 2 cm by 1.6 cm by 0.1 cm with 90% slough and 10% granulation. The wound consultant stated she had ordered Medihoney from the beginning and was not aware it had not been started for about a month, and the DON stated all treatment orders should be entered into the TAR and initiated. The record also showed a discontinued order for cleansing the coccyx with normal saline and applying a border gauze or coccyx dressing until wound care was seen, which was never documented as having been done.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Protect Resident from Staff Mistreatment
Penalty
Summary
A staff member failed to protect a resident's right to be free from mistreatment. During an incident, a Certified Nurse's Aide (CNA) was observed placing her hand over a resident's mouth while the resident was yelling during care. Another CNA witnessed this action, which resulted in the resident's voice being muffled, and confronted the staff member. The CNA who committed the act reportedly expressed frustration with the resident's behavior and made an inappropriate comment about the resident's mental health status. The incident was reported to the nurse manager and subsequently to the facility administrator. The resident involved had a medical history including parkinsonism, bipolar disorder with severe psychotic features, and schizoaffective disorder. The facility's policy prohibits abuse, neglect, and exploitation, and requires immediate investigation of any allegations. The staff member accused of the mistreatment was suspended and later terminated following the incident. The deficiency centers on the failure to protect the resident from physical and psychosocial harm by a staff member during the provision of care.
Failure to Reconcile and Implement CIWA-Ar Protocol on Admission
Penalty
Summary
The facility failed to ensure that all admission orders were reported and reconciled with the physician for a resident admitted with a primary diagnosis of alcohol dependence with withdrawal. Upon review, it was found that the hospital discharge medication list included a CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol) protocol for administering lorazepam based on withdrawal assessment scores. This protocol specified dosing and reassessment intervals, as well as instructions to notify the provider if certain thresholds were met. However, the as-needed CIWA protocol was not reconciled or implemented upon admission, unlike the other medications listed on the discharge summary. Interviews with the Director of Nursing (DON) and the assigned physician revealed that neither was aware of the CIWA protocol included in the hospital discharge documentation. The physician confirmed that they had not been informed of the protocol, and the DON acknowledged being unaware of its presence on the discharge medication list. There was no documentation or evidence that the protocol was reviewed or acted upon at the time of admission.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that necessary interventions to manage existing pressure ulcers and prevent additional ones were not consistently carried out for affected residents.
Failure to Follow Psych NP Recommendation and Identify UTI in Resident with Behavioral Changes
Penalty
Summary
Facility staff failed to follow the recommendation of a psychiatric nurse practitioner to rule out underlying medical causes, specifically a urinary tract infection (UTI), in a resident with dementia who exhibited increased anxiety, agitation, and aggression. The psych NP had documented that the resident had a history of significant agitation in the presence of acute medical issues, particularly UTIs, and advised that if behavioral changes persisted, a repeat urinalysis should be considered. Despite ongoing behavioral changes, the medical record showed that a repeat urinalysis was neither considered nor obtained as recommended. The resident continued to display behavioral disturbances, including verbal aggression toward another resident, and was later transported to the hospital by family due to concerns about a change in mental status. Hospital records confirmed the presence of sepsis due to Enterobacter species, with bacteremia secondary to a UTI, and the resident was started on intravenous antibiotics. The Director of Nursing later acknowledged being unaware of the psych NP's recommendation and confirmed that the repeat urinalysis had been missed.
Failure to Identify and Address Significant Weight Loss
Penalty
Summary
The facility failed to identify, follow up, and adhere to its policy regarding significant weight loss for one resident with dementia who required staff assistance for all activities of daily living. The resident experienced a weight loss of 16.4 pounds in less than a month, as documented in the medical record. There was no evidence that a re-weight was performed to confirm the loss, nor was there any documentation of clarification of the recorded weight, notification to the dietician or physician, monitoring, or interventions or modifications to the resident's nutrition plan of care. The facility's policy required comparison of newly recorded weights to previous weights to determine if a re-weight was necessary, but this process was not followed. The DON confirmed that they were not notified of the weight loss and that therapy staff, who obtained the weights, did not inform them of the significant change.
Failure to Establish Ongoing Quality Assessment and Assurance Group
Penalty
Summary
The facility failed to establish an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. This inaction resulted in the absence of a systematic process for identifying, reviewing, and addressing quality issues within the facility. As a result, there was no formal mechanism in place to ensure that quality deficiencies were consistently identified or that appropriate corrective actions were developed and implemented.
Failure to Document and Account for Controlled Substances
Penalty
Summary
The facility failed to ensure proper documentation and accountability of controlled substances for one resident, as evidenced by multiple discrepancies between the Medication Administration Records (MARs) and the corresponding Controlled Substance (CS) records. The resident in question had diagnoses including fibromyalgia, cerebral atherosclerosis, and unspecified dementia with agitation, and was receiving both scheduled and PRN opioid pain medications. The MARs indicated that medications such as Hydrocodone-Acetaminophen and Morphine Sulfate were administered at scheduled times, but these administrations were not consistently documented on the CS forms as required. Specific instances were identified where the MAR showed that doses were given, but there was no corresponding entry on the CS form, nor any documentation of refusal or explanation in the progress notes. For example, doses of Hydrocodone-Acetaminophen and Morphine Sulfate were marked as administered on the MAR but were missing from the CS records on several dates. In some cases, the CS forms reflected different administration times or omitted doses entirely, and in other cases, doses were documented as held on the MAR but still recorded as removed on the CS form. During an interview, the Director of Nursing acknowledged awareness of issues with controlled substance documentation and described a process of auditing CS forms for missing entries, but not for discrepancies between the MAR and CS forms. Facility policy required that controlled substance inventory be regularly reconciled with the MAR and documented accordingly, but this was not consistently followed, resulting in incomplete and inaccurate records for controlled substance administration.
Sanitation Deficiencies in Kitchen Storage and Equipment
Penalty
Summary
The facility failed to maintain the kitchen in a sanitary manner, as observed during an inspection. In the Traulsen reach-in cooler, raw chicken was stored directly on top of a box of cooked diced chicken, and raw pork was placed on top of a box of corn chowder soup. This improper storage of food items was confirmed by the Dietary Manager (DM) J, and it violated the 2017 FDA Food Code section 3-302.11, which mandates the separation and segregation of raw animal foods to prevent cross-contamination. Additionally, the ice scoop holder was found with black debris on the inside bottom surface, which was acknowledged by DM J. This condition did not comply with the FDA 2017 Model Food Code, Section 3-304.12, which requires in-use utensils to be stored in a clean, protected location. Furthermore, the hose sprayer at the soiled side of the dish machine was observed hanging down and touching the soiled drain board, which was also noted by DM J. This situation contravened the 2017 FDA Food Code section 5-202.13, which requires an air gap to prevent backflow contamination.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by several deficiencies observed during the survey. Overbed tray tables in multiple rooms, including D150, D151, D156, and others, were found with missing plastic edging and exposed rough particle board, making them difficult to sanitize properly. Additionally, the sink vanities in rooms C138, C142, and C143 had sharp edges due to missing laminate, posing a potential safety hazard. The privacy curtain in room D151 was soiled with dark brown debris, and the ceiling vent covers in the main dining room and fishbowl lounge were coated with dust, with mold-like stains observed on the ceiling surrounding one of the vents. The Maintenance Manager acknowledged awareness of the issues with the overbed tray tables but stated that the facility could only replace two tables per month. Despite being fully staffed, the Maintenance & Housekeeping Manager did not provide a clear response regarding the routine cleaning and maintenance of vents, relying instead on a contracted company to clean them three times a year. The electronic reporting system used for maintenance issues was mentioned, but no concerns with privacy curtains were acknowledged. The inability to properly sanitize the porous surfaces of the tray tables was recognized, yet the replacement rate remained limited to two tables per month.
Inadequate Dialysis Documentation and Communication
Penalty
Summary
The facility failed to ensure consistent documentation and communication for a resident receiving dialysis services. The resident, who was admitted with acute kidney failure, end-stage kidney disease, and dependence on renal dialysis, was scheduled for dialysis every Tuesday and Saturday. However, the Minimum Data Set (MDS) assessment did not identify the resident as currently receiving dialysis services. Additionally, there were missing documentation and assessments for six dialysis treatments, indicating a lack of communication and assessment of the resident's condition pre and post dialysis. The facility's policy required nursing staff to provide a report to the dialysis provider regarding the resident's condition and treatment provisions each dialysis day. If no written report was received upon the resident's return, the nursing staff was to call the dialysis provider for a report. Despite this policy, there was no documentation of follow-up communication with the dialysis center when paperwork was not returned with the resident. The Director of Nursing confirmed the missing documentation and assessments, acknowledging the concern.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure the proper storage and security of medications and biologicals, as observed in two medication rooms, one treatment cart, and one medication cart. During a medication administration observation, an LPN propped open the medication room door with a crash cart, leaving it unattended and accessible. Loose pills without patient identifiers were found in a medication cart drawer, which were acknowledged by an LPN and disposed of improperly. Additionally, the medication storage room on D hall contained insulin pens stored improperly alongside food items, including a large opened container of applesauce and moldy grapes. The treatment cart on D hall was found unlocked and unsupervised, with three residents seated nearby. A nurse returned to the medication cart next to the treatment cart but did not secure the treatment cart until prompted by the surveyor. The facility's policy requires that medication rooms, carts, and supplies be locked when not attended by authorized personnel, and refrigerated medications be stored separately from food items. The Director of Nursing acknowledged the issues and confirmed that the observed practices were against facility policy.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate assessments for two residents during the Minimum Data Set (MDS) evaluations. One resident, who was admitted with acute kidney failure and end-stage renal disease, was incorrectly marked as not receiving dialysis in their MDS assessment, despite having physician orders for dialysis twice a week since admission. The MDS Coordinator, Nurse 'E', acknowledged the error, stating they were unaware of the resident's dialysis treatment, which was documented in the resident's orders and progress notes. Another resident, admitted with dementia, atrial fibrillation, and hypertension, was inaccurately documented as being discharged to a short-term general hospital in their MDS assessment. However, records indicated the resident was actually discharged to an assisted living facility. Nurse 'E' admitted to mistakenly selecting the wrong discharge location during the assessment process.
Failure to Ensure Proper Wound Care and Documentation
Penalty
Summary
The facility failed to provide appropriate assessments, monitoring, and treatments for a resident with non-pressure wound care needs. The resident, who had moderately impaired cognition and required assistance for all activities of daily living, was observed with undated and dated dressings on their left arm, with visible drainage. The clinical records did not contain any orders for wound care or dressing changes, and the resident was unsure of the reason for the bandages. A skin tear was noted after the resident rolled out of bed, but no further assessments or documentation were completed. The Wound Care Nurse and a Consultant Wound Provider were unaware of the dressings on the resident's arm, and the Licensed Practical Nurse who initially dressed the wound did not recall placing an order for dressing changes. The Director of Nursing confirmed that nurses should ensure physician orders are in place for dressings and treatments. The facility's policy requires wound treatments to be provided according to physician orders and documented appropriately, which was not followed in this case.
Inadequate Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to ensure appropriate infection control practices during medication administration for two residents. On the morning of February 5th, a Licensed Practical Nurse (LPN) was observed administering oral medications to a resident without performing hand hygiene before or after the process. Additionally, the LPN retrieved and administered lubricating eye drops to the same resident without performing hand hygiene, even after donning gloves. The LPN later acknowledged the oversight in hand hygiene. Later that morning, the same LPN was observed administering Gabapentin to another resident without performing hand hygiene after retrieving the medication from a separate medication room. The Director of Nursing was informed of these incidents and acknowledged that hand hygiene should be performed before and after medication administration, as per the facility's hand hygiene policy dated January 2024.
Improper Sanitizing Practices and Lack of Hot Water in Kitchen
Penalty
Summary
The facility failed to ensure proper sanitizing and washing practices were used to clean dishes and utensils, and did not provide proper hand washing facilities in the kitchen. This deficiency was identified during an investigation following a complaint about the lack of hot water in the kitchen. Observations revealed that the kitchen staff were using boiling water to wash dishes and utensils, and then rinsing and sanitizing them in a three-compartment sink. However, the sanitizing process was not conducted according to professional standards, as the sanitizing solution was not at the correct temperature and the test strips used to check the solution's concentration were expired. Interviews with staff members, including the Administrator and Dietary Manager, confirmed that the kitchen had been without hot water for weeks to months. The staff reported using disposable foam containers and plastic cutlery to serve food, while reusable items were washed with boiling water. Despite these efforts, the sanitizing process was not properly executed. For instance, a staff member was observed submerging a pot in the sanitizing solution for only one second instead of the required one minute, and another staff member did not test the sanitizing solution before use. The facility's policy on the use of the three-compartment sink was not followed, as the sanitizing solution was not tested for appropriate concentration before use, and the water temperature was not maintained at the required level. The FDA Food Code specifies that handwashing sinks must provide water at a minimum temperature, and the sanitizing solution must be at a specific temperature and concentration. These requirements were not met, leading to the potential risk of improper sanitation of dishware and utensils used by the residents.
Failure to Assist Resident with Dressing
Penalty
Summary
The facility failed to provide assistance with dressing for a resident who was admitted for hospice respite care. The resident, who had diagnoses including heart failure and dementia, was totally dependent on staff for activities of daily living, including dressing. A complaint was submitted alleging that the resident's clothing was not changed for two days. Upon investigation, it was confirmed that the resident's clothing was indeed not changed during this period. The Director of Nursing (DON) confirmed that the care plan for the resident was not updated in a timely manner to include tasks for changing the resident's clothing daily. The resident's family had provided clothing and a nightgown for each day of the stay, and it was the facility's expectation that clothing would be changed daily. However, due to the lack of an updated care plan, the Certified Nursing Assistants (CNAs) were not informed of this task, leading to the deficiency.
Failure to Readmit Resident After Hospital Transfer
Penalty
Summary
The facility failed to permit a resident, who was transferred to the hospital, to return to the facility after being medically cleared. The resident, who had severe cognitive impairment and a history of aggressive behavior, was initially admitted to the facility despite known behavioral issues. The facility's decision not to readmit the resident was made by Corporate, citing the resident's aggressive behavior and attempts to elope as reasons. However, the facility did not provide the required documentation or notice to the resident's family regarding the decision not to readmit. The facility's policy requires a 30-day written notice before involuntary transfer or discharge, which was not adhered to in this case. The Nursing Home Administrator and Director of Nursing acknowledged that the resident was not an appropriate admission, and the Admissions Director indicated that Corporate had instructed the facility to increase admissions, leading to the acceptance of the resident. The facility's failure to follow proper procedures and provide adequate notice resulted in a deficiency citation.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
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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.
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 Holly
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wellbridge Of Fenton | 3.2 mi | ★★★★★ | 9 | 0 |
| Fenton Healthcare | 4 mi | ★★★★★ | 5 | 0 |
| Wellbridge Of Grand Blanc | 6.4 mi | ★★★★★ | 14 | 0 |
| The Oaks At Woodfield | 6.6 mi | ★★★★★ | 2 | 0 |
| Caretel Inns Of Linden | 7.6 mi | ★★★★★ | 40 | 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.