Mission Point Nursing: Malnourished Resident Denied Food - MI
The woman, identified as Resident 54 in inspection documents, weighed just 77.4 pounds when inspectors arrived at Mission Point Nursing & Physical Rehabilitation Center in August. She had been admitted with spastic quadriplegic cerebral palsy and moderate protein-calorie malnutrition.
Despite her diagnosis and extremely low weight, facility staff had excluded her from the evening snack program entirely.
"She did not get snacks in the evenings, she did not always like the food being served and she was hungry in the evenings and would like to get snacks," inspectors wrote after interviewing the resident on August 19. "Sometimes someone would give her something, but she needed assistance to eat and it was hard to get someone to assist her at snack time."
The resident has bilateral arm and hand contractures and depends completely on staff to eat, according to her assessment records. Inspectors observed her lying in bed, appearing "small and very thin."
When they watched a nursing assistant help her with breakfast the next morning, the resident couldn't open any items on her meal tray without help.
The facility's dietary manager maintained a list of 45 residents who received evening snacks. The 77-pound woman wasn't on it.
When inspectors asked the dietary manager on August 21 whether the resident received evening snacks, he said he would check. Fifteen minutes later, he provided the list that excluded her name.
The facility's registered dietitian offered a simple explanation for why the malnourished resident had been denied snacks: "R54 had never asked for evening snacks."
But the resident had told inspectors the opposite. She wanted evening snacks and was hungry without them.
When pressed about why evening snacks weren't included in the woman's nutritional care plan given her 77-pound weight, the dietitian "acknowledged the concern" and said he would add her to the snack list.
The director of nursing gave inspectors the same explanation as the dietitian. The resident "had never asked for evening snacks," the nursing director said, though she agreed "it would be a good idea since R54 only weighed 77.4 pounds."
A review of nursing assistant documentation found no record of snacks ever being provided to the resident. Her nutritional care plan, last revised in February, contained no intervention for providing evening snacks.
The facility's own weight monitoring policy requires staff to identify and implement interventions "consistent with the resident's assessed needs" to maintain proper nutritional status.
Federal inspectors found the facility violated regulations requiring nursing homes to provide adequate food and fluids to maintain residents' health. They classified the violation as causing minimal harm or potential for actual harm.
The inspection was conducted in response to a complaint filed against the facility.
For a resident diagnosed with moderate protein-calorie malnutrition who weighs 77 pounds and depends entirely on others to eat, evening snacks represent more than comfort. They're a basic nutritional intervention that facility staff systematically denied while maintaining detailed lists of who qualified for extra food.
The resident told inspectors exactly what she needed. Staff spent months not listening.
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 2025-08-21 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: June 20, 2026 · Our methodology
Villa at Pine Place in Clarkston, MI was cited for violations during a health inspection on August 21, 2025.
She had been admitted with spastic quadriplegic cerebral palsy and moderate protein-calorie malnutrition.
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.