Care Citations

Mission Point Nursing & Physical Rehabilitation Ce

1400 Poplar Street, Hancock, MI, 49930 · 9064826644

On the CMS record

Overall rating (CMS)
1 / 5
Health inspection rating
1 / 5
Staffing rating
4 / 5
Certified beds
39
Ownership type
For profit - Corporation
Chain
MISSION POINT HEALTHCARE SERVICES

Inspection findings on record (52)

Quoted exactly as CMS published them. We do not rewrite findings.

— Resident Assessment and Care Planning Deficiencies

Tag 0656 · scope/severity F · potential for more than minimal harm

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0801 · scope/severity F · potential for more than minimal harm

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0802 · scope/severity F · potential for more than minimal harm

Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0812 · scope/severity F · potential for more than minimal harm

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Recorded as corrected on .

— Administration Deficiencies

Tag 0835 · scope/severity F · potential for more than minimal harm

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Recorded as corrected on .

— Administration Deficiencies

Tag 0865 · scope/severity F · potential for more than minimal harm

Have a plan that describes the process for conducting QAPI and QAA activities.

Recorded as corrected on .

— Administration Deficiencies

Tag 0867 · scope/severity F · potential for more than minimal harm

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Recorded as corrected on .

— Administration Deficiencies

Tag 0868 · scope/severity F · potential for more than minimal harm

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0881 · scope/severity F · potential for more than minimal harm

Implement a program that monitors antibiotic use.

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0882 · scope/severity F · potential for more than minimal harm

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0657 · scope/severity D · potential for more than minimal harm

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0676 · scope/severity D · potential for more than minimal harm

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0695 · scope/severity D · potential for more than minimal harm

Provide safe and appropriate respiratory care for a resident when needed.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0759 · scope/severity D · potential for more than minimal harm

Ensure medication error rates are not 5 percent or greater.

Recorded as corrected on .

— Administration Deficiencies

Tag 0847 · scope/severity D · potential for more than minimal harm

Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

Recorded as corrected on .

— Environmental Deficiencies

Tag 0919 · scope/severity E · potential for more than minimal harm

Make sure that a working call system is available in each resident's bathroom and bathing area.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0572 · scope/severity D · potential for more than minimal harm

Give residents a notice of rights, rules, services and charges.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0684 · scope/severity D · potential for more than minimal harm

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0692 · scope/severity D · potential for more than minimal harm

Provide enough food/fluids to maintain a resident's health.

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0880 · scope/severity L · immediate jeopardy

Provide and implement an infection prevention and control program.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0584 · scope/severity F · potential for more than minimal harm

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Recorded as corrected on .

— Nursing and Physician Services Deficiencies

Tag 0726 · scope/severity F · potential for more than minimal harm

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Recorded as corrected on .

— Nursing and Physician Services Deficiencies

Tag 0730 · scope/severity F · potential for more than minimal harm

Observe each nurse aide's job performance and give regular training.

Recorded as corrected on .

— Nursing and Physician Services Deficiencies

Tag 0732 · scope/severity F · potential for more than minimal harm

Post nurse staffing information every day.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0812 · scope/severity F · potential for more than minimal harm

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Recorded as corrected on .

— Administration Deficiencies

Tag 0838 · scope/severity F · potential for more than minimal harm

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Recorded as corrected on .

— Administration Deficiencies

Tag 0851 · scope/severity F · potential for more than minimal harm

Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0881 · scope/severity F · potential for more than minimal harm

Implement a program that monitors antibiotic use.

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0887 · scope/severity F · potential for more than minimal harm

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Recorded as corrected on .

— Environmental Deficiencies

Tag 0909 · scope/severity F · potential for more than minimal harm

Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0700 · scope/severity E · potential for more than minimal harm

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0808 · scope/severity E · potential for more than minimal harm

Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0623 · scope/severity D · potential for more than minimal harm

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0684 · scope/severity D · potential for more than minimal harm

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0689 · scope/severity D · potential for more than minimal harm

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0942 · scope/severity D · potential for more than minimal harm

Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.

Recorded as corrected on .

— Administration Deficiencies

Tag 0944 · scope/severity D · potential for more than minimal harm

Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0945 · scope/severity D · potential for more than minimal harm

Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.

Recorded as corrected on .

— Nursing and Physician Services Deficiencies

Tag 0947 · scope/severity D · potential for more than minimal harm

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0624 · scope/severity G · actual harm

Prepare residents for a safe transfer or discharge from the nursing home.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0623 · scope/severity D · potential for more than minimal harm

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0745 · scope/severity D · potential for more than minimal harm

Provide medically-related social services to help each resident achieve the highest possible quality of life.

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0609 · scope/severity D · potential for more than minimal harm

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0610 · scope/severity D · potential for more than minimal harm

Respond appropriately to all alleged violations.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0812 · scope/severity F · potential for more than minimal harm

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0880 · scope/severity F · potential for more than minimal harm

Provide and implement an infection prevention and control program.

Recorded as corrected on .

— Environmental Deficiencies

Tag 0921 · scope/severity F · potential for more than minimal harm

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0689 · scope/severity E · potential for more than minimal harm

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0550 · scope/severity D · potential for more than minimal harm

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0561 · scope/severity D · potential for more than minimal harm

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0684 · scope/severity D · potential for more than minimal harm

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0690 · scope/severity D · potential for more than minimal harm

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Recorded as corrected on .

Source: Centers for Medicare & Medicaid Services (CMS) · CMS Certification Number 235552