Mission Point Nursing: Elopement After No Care Plan - MI
Nobody called it in. Nobody searched. A neighbor did.
The neighbor found the resident, identified in inspection records as R302, and eventually talked them into coming back. It was the neighbor who then called the facility to report what had happened. By the time RN C received that phone call, at approximately 9:15 PM, R302 had been unaccounted for since roughly 4 PM.
When inspectors asked the administrator on August 14 to identify which staff member had been assigned to R302 during the gap between 3 PM, when the day-shift CNA went off duty, and 7 PM, when CNA E came on, the administrator did not provide an answer.
The five-hour disappearance was not the only failure inspectors documented. It was the result of one.
R302 had been admitted to Mission Point with a primary diagnosis of alcohol dependence and withdrawal. The facility had a written policy, dated June 2023, that described substance use disorder care in detail, including individualized care plans, counseling access, and medication-assisted treatment options. The policy stated that assessment and care planning would include goals "person-centered and individualized to reflect and maximize the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety."
No care plan had been created for R302's alcohol dependence. No interventions had been documented. Nothing.
When inspectors interviewed Social Worker H on August 13, they asked about the care plan for R302's substance use disorder. The social worker's response was direct: "I honestly didn't know we had that policy." H added that they would review the policy and speak with the administrator. The social worker also acknowledged they had not typically created care plans for substance use disorder at all, for any resident.
The Director of Nursing, interviewed the following morning, said care plans of that type were usually the social worker's responsibility. Shortly after saying that, the DON confirmed they could not find any substance use disorder documentation for R302 anywhere in the record. The DON said they would begin educating staff.
The administrator, also interviewed that morning, acknowledged the problem. When inspectors raised the connection between the missing care plan and the elopement, the administrator said staff had been re-educated on the elopement policy.
Not the substance use disorder policy. The elopement policy.
Inspectors noted that the administration team had failed to re-educate staff on the substance use disorder policy at all. No further documentation or explanation was provided before the survey closed.
R302, for their part, confirmed to inspectors that the neighbor's home had felt like "a good space" when they arrived there. They confirmed that facility staff had come to the neighbor's house and persuaded them to return. The inspection record does not describe what condition R302 was in when they were found, or what happened during those five hours, or whether they had obtained alcohol.
The inspection was conducted on August 14, 2025, following a complaint. CMS rated the harm level as minimal harm or potential for actual harm.
A resident admitted because their addiction had become dangerous enough to require inpatient care walked out of that facility and reached a neighbor's house before anyone with a job title came looking.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mission Point Nursing & Physical Rehabilitation Ce from 2025-08-14 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: July 4, 2026 · Our methodology
Mission Point Nursing & Physical Rehabilitation Ce in Holly, MI was cited for violations during a health inspection on August 14, 2025.
The neighbor found the resident, identified in inspection records as R302, and eventually talked them into coming back.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.