Above average — CMS composite of the measures below.
The next survey window likely opens around February 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 Of during CMS and state inspections, most recent first.
Kitchen hand sinks were observed with hot water temperatures below the required 85 F, including sinks near the maintenance hall and dish machine room. In addition, a ceiling vent cover and the surrounding ceiling in the Dietary Mgr office had a buildup of dust and debris.
Failure to monitor and document bowel function: A resident with ESRD on HD, HF, hemiplegia, bilateral foot amputation, diabetes, and a daily fluid restriction had no documented BM for more than four days. The resident was receiving scheduled oxycodone-acetaminophen, had PRN laxative orders in place, and staff were unaware the resident needed bowel care intervention; the DON confirmed there was no documented assessment, inquiry, or initiation of the standing constipation protocol.
Medication administration errors occurred when an LPN spilled part of a crushed medication dose for a resident with a G-tube and still documented the full dose as given, and when an RN administered insulin from a Toujeo Max SoloStar pen without priming it and removed it immediately after injection instead of following the manufacturer’s instructions. These errors involved incorrect dose delivery and failure to follow medication administration guidance.
An LPN left a blister pack of losartan unsecured and unattended on top of a medication cart while entering a resident’s room, and also returned a prepared cup of medications to the cart after a resident declined them. The DON stated nurses are expected to secure blister packs back into the cart when walking away and agreed it was unsafe to leave medications unattended; facility policy stated staff should not leave medications or chemicals unattended and should dispose of unused medication portions.
Infection control practices were not maintained for several residents. A resident with chronic respiratory failure had an unbagged nasal cannula and BiPAP mask stored without barriers, and an LPN placed medication cups on an overbed table and medication cart without barriers while administering meds to two residents, including one with a feeding tube. The LPN also handled a pen that fell to the floor and returned it to her pocket. An RN later attached a needle to an insulin pen without cleansing the pen end first.
The facility failed to implement fall prevention measures for two residents, leading to multiple falls. One resident, with a history of falls and various health conditions, experienced several incidents due to inconsistent implementation of care plan interventions like non-skid footwear and 15-minute safety checks. Another resident, at risk due to conditions like Parkinsonism, did not receive the required supervision, with staff failing to perform 15-minute checks and inconsistent documentation. The DON acknowledged the documentation issues, contributing to the deficiencies.
The facility failed to maintain accurate documentation for 15-minute safety checks for two residents, both identified as fall risks. One resident had 133 days of missing charting, while the other had inconsistencies over 5 days and was observed without checks for 30 minutes. The DON noted that staff often charted at shift end, leading to inaccuracies.
During an influenza outbreak, a facility failed to ensure proper infection control practices. Staff did not perform hand hygiene between resident rooms during meal tray delivery, and droplet precaution protocols were not followed, as staff entered rooms without required eye protection. Additionally, respiratory equipment was not stored properly, and an insulin pen was not disinfected before being returned to the medication cart.
A facility failed to assess and monitor a resident's urostomy, leading to inadequate care. The resident, with a history of bladder cancer and chronic kidney disease, was admitted with a urostomy and a UTI. Despite the resident's self-reported ability to manage their urostomy, the facility did not assess the urostomy upon admission or thereafter. The RN responsible for charting urostomy care did not personally assess the site, and the DON confirmed the absence of a specific policy for urostomy care. The resident also admitted to not washing their hands before performing urostomy care, contributing to the ongoing UTI.
A resident was found with a tube of Nystatin cream on her nightstand, despite the application order being completed days prior. The Nursing Home Administrator confirmed that treatment creams should be stored in treatment carts and that CNAs are not allowed to administer treatments. The resident did not have a self-administration assessment, indicating a failure in medication storage protocols.
A resident with ataxia and right-sided hemiplegia did not consistently receive necessary adaptive dining equipment, such as built-up silverware, as outlined in their care plan. Observations showed that the resident's meal trays often lacked the required utensils, and a single foam device was provided instead, which was not suitable for the resident's needs. Staff interviews confirmed the oversight, and no policy on adaptive equipment was provided by the facility.
Kitchen Hand Sinks Had Inadequate Hot Water and Dust Accumulated on Ceiling Vent
Penalty
Summary
The facility failed to maintain general cleanliness and repair of the premises. During observation, the two hand sinks in the kitchen were found to have hot water temperatures below the required level: the sink closest to the maintenance hallway measured 81 degrees and the sink near the dish machine room measured 80 degrees at 4:17 PM, and earlier the dish machine room hand sink measured 82 degrees while the sink closest to the maintenance hall measured 80 degrees. Maintenance Director G stated that the water heater had recently been replaced and the mixing valve was turned down too low. In a separate observation in the Dietary Manager's office just off the hall to the kitchen, a ceiling vent cover and the surrounding ceiling were observed with a buildup of dust and debris.
Failure to Monitor and Document Bowel Function
Penalty
Summary
The facility failed to identify a change in bowel health for one resident who had end-stage renal disease, heart failure, right side hemiplegia, bilateral foot amputation, diabetes, and received hemodialysis. The resident was cognitively intact, had a 1000 cc daily fluid restriction, and was observed eating breakfast with only coffee on the tray and no other visible fluids. When interviewed, the resident said the last bowel movement was “the other day” but could not provide more detail about bowel frequency. Review of the resident’s record showed the last documented bowel movement was on 3/5/2026 at 8:06 p.m., with no documented bowel movement through the time of review on 3/10/2026, more than four days later. The resident had active PRN orders for MiraLax after no bowel movement for 2 days and Dulcolax suppository after no bowel movement for 72 hours, and the MAR showed scheduled oxycodone-acetaminophen was consistently administered. Nursing staff reported they were unaware of the lack of documented bowel movement and did not receive a list indicating the resident needed bowel care intervention. The DON confirmed there was no documentation of staff inquiry, resident assessment, or initiation of standing constipation orders, and the facility’s bowel protocol required intervention after 3 days without a bowel movement.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure that medication was administered at the correct dose and according to manufacturer recommendations for two residents, resulting in a medication error rate of 6.4% from 2 of 31 opportunities for error. For one resident who received medications through a G-tube, an LPN was observed crushing a medication tablet, adding water to it in a 30 ml plastic medication cup, and stirring it with a plastic spoon after the medication did not dissolve. The medication spilled over the sides of the cup onto the bedside table while the nurse continued stirring, and approximately 25% of the cup’s contents spilled before the remaining medication was administered. The LPN signed the MAR as if the full dose had been given, despite the resident not receiving the prescribed amount. For another resident, an RN prepared and administered 80 units of Toujeo Max SoloStar insulin without first priming the pen and then removed the pen immediately after injecting the dose without holding it against the skin. The RN stated the pen did not require priming, while the DON stated insulin pens need to be primed before adjusting to the prescribed amount and that the injection button should be held against the skin after delivery, though she did not know for how long. The manufacturer instructions provided in the report state to perform a safety test before each injection and to hold the injection button in and slowly count to 5 to ensure the full dose is delivered.
Unsecured medications left unattended on medication cart
Penalty
Summary
The facility failed to properly store medications in one of two medication carts reviewed. On 3/10/26 at 7:58 AM, an LPN prepared 11 medications for Resident #15 and placed the medication cup on the resident’s overbed table while she replaced a medication patch on the resident’s left upper posterior arm. After placing the patch, the LPN picked up the cup to administer the medications, but the resident said he did not want the medications at that time. The LPN returned the cup of medications to the medication cart and placed it in the top drawer. Later that morning, the same LPN prepared seven medications for Resident #28, including a losartan tablet obtained from a blister pack. The LPN left the medication cart and entered the resident’s room with the blister pack still on top of the medication cart, unsecured and unattended. After administering the medications, the surveyor asked why the blister pack had been left on the cart, and the LPN said she forgot to secure it back into the cart with the rest of the resident’s medications. The DON stated nurses are expected to return blister packs to the medication cart when walking away and agreed it was unsafe to leave medications unsupervised and unattended atop the cart. The facility policy stated staff should not leave medications or chemicals unattended and should dispose of unused medication portions.
Infection Control Lapses During Equipment Storage and Medication Administration
Penalty
Summary
The facility failed to provide barriers for resident care equipment and failed to maintain infection control practices during medication administration for four residents. Resident #10 had chronic respiratory failure with hypoxia and used supplemental oxygen and a non-invasive ventilator. On multiple observations, the resident’s nasal cannula connected to a portable oxygen tank was unbagged and lying across the back of the wheelchair without a barrier, and the BiPAP was observed unbagged on the nightstand with the face portion of the mask resting directly on the surface without a barrier beneath it. When interviewed, the resident stated staff did not clean or change the BiPAP or mask and did not change or bag the nasal cannula when not in use, and said no bag had been provided for the BiPAP mask. During medication administration, an LPN prepared medications for Resident #15 and placed the medication cup on the resident’s overbed table without a barrier while replacing a medication patch. After the resident declined the medications, the cup was placed on top of the medication cart and then in the top drawer without a barrier, and the cart was not cleaned or sanitized before the nurse continued preparing medications for other residents. For Resident #28, the same LPN entered the room with six cups of crushed medications and placed them on the overbed table without a barrier, then placed them on top of the medication cart and in the drawer without a barrier. The LPN later returned the cups to the room, placed them again on the overbed table without a barrier, and also picked up a pen that had fallen to the floor and placed it on the overbed table before returning it to her pocket after medication administration. Resident #38 had diabetes and received daily insulin. An RN removed a Toujeo Max SoloStar insulin pen from the medication cart and placed a needle on the pen without first cleansing the end of the injection pen. The DON stated nurses are expected to clean the ends of insulin pens with alcohol before applying needles, and also stated that items set down and returned to the medication cart should use barriers and that medication carts should be cleaned and sanitized when potentially infectious items are placed on or in them. Facility policies also stated that BiPAP masks or nasal pillows should be stored in a mesh bag or approved container when not in use, oxygen delivery devices should be stored in a sanitary manner, and contaminated medications should be stored separately.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to implement fall prevention interventions for two residents, leading to multiple incidents. Resident #5, who had a history of falls and was at risk due to various health conditions, experienced several falls. Despite having a care plan that included measures such as ensuring non-skid footwear and conducting 15-minute visual safety checks, these interventions were not consistently implemented. On one occasion, the resident fell and sustained a serious injury when the 15-minute checks were not documented as required, and on another occasion, the resident was not wearing non-skid footwear as per the care plan. Resident #6, who was cognitively intact but at risk for falls due to conditions like Parkinsonism and diabetic neuropathy, also did not receive the necessary supervision. The care plan for this resident included 15-minute visual safety checks and frequent reminders to use the call light. However, observations revealed that staff did not perform these checks as planned, and documentation was inconsistent, with staff charting at the end of shifts rather than at the required intervals. The Director of Nursing acknowledged the discrepancies in documentation and the challenges in ensuring that the 15-minute checks were completed effectively. The facility's failure to adhere to the care plans and ensure proper supervision and documentation contributed to the deficiencies observed in the care of these residents.
Inaccurate Documentation of Safety Checks for Residents
Penalty
Summary
The facility failed to implement and maintain accurate and complete documentation for 15-minute safety checks for two residents. Resident #5, who has multiple diagnoses including COPD, heart failure, and legal blindness, was identified as a fall risk and required 15-minute visual safety checks due to cognitive impairment and frequent attempts to ambulate unassisted. However, a review of Resident #5's electronic medical record revealed 133 days of missing 2-hour charting and several entries recorded at the exact same time, indicating that staff did not properly document whether the checks were completed. Resident #6, admitted with diagnoses such as Parkinsonism and diabetic neuropathy, also required 15-minute visual safety checks following a fall. Despite this requirement, there were inconsistencies in completing the checks over a 5-day period, and an observation on one day showed no staff completing the checks for a continuous 30-minute period. The Director of Nursing explained that the 2-hour charting was intended to confirm the completion of 15-minute checks, but acknowledged that staff often charted at the end of their shifts, leading to inaccuracies in documentation.
Infection Control Deficiencies During Influenza Outbreak
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during a facility-wide influenza outbreak. Observations revealed that staff did not perform hand hygiene between resident rooms during meal tray delivery, increasing the risk of cross-contamination. Specifically, a Certified Nurse Aide (CNA) was seen delivering meal trays to multiple rooms without sanitizing hands in between, despite the facility being in the midst of an influenza outbreak. Additionally, the facility did not adhere to droplet precaution protocols in resident rooms. Staff, including a Registered Nurse (RN) and a CNA, entered rooms under droplet precautions wearing only surgical masks without the required eye protection. This was contrary to the facility's policy and CDC guidelines, which mandate full coverage of eyes, nose, and mouth in such situations. Furthermore, the RN failed to disinfect an insulin pen before returning it to the medication cart, risking cross-contamination with other residents' medications. The facility also neglected proper infection control practices for respiratory equipment. Observations showed that residents' CPAP and nebulizer equipment were not stored in protective bags, and distilled water containers were left undated. This oversight in maintaining sanitary conditions for respiratory equipment further contributed to the potential spread of infections among residents and staff.
Failure to Assess and Monitor Urostomy Care
Penalty
Summary
The facility failed to properly assess and monitor a resident's urostomy, leading to a deficiency in care. The resident, who had a history of bladder cancer and chronic kidney disease, was admitted with a urostomy and a urinary tract infection (UTI). Despite the resident's self-reported ability to manage their urostomy, the facility did not conduct an assessment of the urostomy upon admission or thereafter. The resident indicated that they had not received urostomy care from the facility since admission, and the staff relied on the resident's self-care without verifying the condition of the urostomy site. The Registered Nurse (RN) responsible for charting urostomy care admitted to not personally assessing the urostomy, instead relying on the resident's self-reports. Additionally, the Director of Nursing (DON) confirmed the absence of a specific policy for urostomy care and acknowledged that the facility had not assessed the resident's ability to care for the urostomy. The resident also admitted to not washing their hands before performing urostomy care, a fact unknown to the DON. This lack of assessment and monitoring, combined with inadequate hygiene practices, contributed to the resident's ongoing UTI and the facility's failure to provide appropriate care.
Improper Storage of Topical Medication
Penalty
Summary
The facility failed to appropriately store topical treatment medication for a resident, identified as Resident #1, who was observed with a tube of Nystatin cream on her nightstand. The resident had been admitted to the facility with diagnoses including obesity and had intact cognition as per her Minimum Data Set assessment. The physician's order for the Nystatin cream was to apply it to the vaginal folds every shift from the 1st to the 7th of each month for preventative skin care and candidiasis prophylaxis. However, the order for application had been completed two days prior to the first observation and four days prior to the second observation, indicating that the cream should not have been left at the bedside. During an interview, the Nursing Home Administrator confirmed that treatment creams should be stored in treatment carts and that Certified Nurse Aides are not permitted to administer treatments. Additionally, the resident did not have a self-administration of medications assessment, which would have been necessary for her to keep the medication at her bedside. The review of the resident's physician orders, assessments, and care plan showed no interventions, orders, or assessments for self-administration of medications, highlighting a lapse in adherence to medication storage protocols.
Failure to Provide Adaptive Dining Equipment
Penalty
Summary
The facility failed to provide necessary dining adaptive equipment for a resident with ataxia and right-sided hemiplegia, who required built-up utensil handles for self-feeding. Despite the resident's care plan and Kardex indicating the need for built-up tubing on silverware to improve grip, observations revealed that the resident frequently did not receive the required adaptive equipment. On multiple occasions, the resident's meal trays lacked the built-up silverware, and instead, a single red tube-like foam device was provided, which was not attached to any silverware. The resident expressed difficulty in gripping smaller items and a preference for the built-up silverware, indicating a consistent failure to meet his needs. Interviews with facility staff, including a Registered Dietician, confirmed that the resident was supposed to receive built-up silverware with every meal, and it was the responsibility of the facility staff to apply the adaptive equipment. Despite this, the facility did not provide a policy regarding adaptive equipment when requested by the Nursing Home Administrator. This lack of adherence to the resident's care plan and failure to provide necessary adaptive equipment led to the deficiency identified by the surveyors.
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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 Roscommon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Grayling Nursing & Rehabilitation Community | 11.7 mi | ★★★★★ | 13 | 0 |
| Munson Healthcare Crawford Continuing Care Center | 12.7 mi | ★★★★★ | 7 | 0 |
| King Nursing & Rehabilitation Community | 16.9 mi | ★★★★★ | 1 | 0 |
| The Villa At Rose City | 23.3 mi | ★★★★★ | 17 | 0 |
| The Villa At West Branch | 23.9 mi | ★★★★★ | 1 | 0 |
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