Mission Point Nursing & Physical Rehabilitation Ce

F 0550

part of their uniform. At that time, CNA ‘M’ stated out loud from Resident R70’s table, “I have one too (name badge), but it fell off.

Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Mission Point Nursing & Physical Rehabilitation Ce

4800 Clintonville Rd Clarkston, MI 48346

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

implementing punitive measures, SW ‘H' reported they felt that was a concern but was something Administration said they had to do.On 8/20/25 at 12:00 PM, an interview was conducted with the Administrator. When asked about the facility's process for smoking, the Administrator reported when they first started at the facility about a year ago, there were many issues with residents smoking or sharing cigarettes and they had implemented smoking agreements that were signed on admission and discussed disciplinary processes if the residents were found in violation.The Administrator was requested to review their smoking policy and acknowledged the one they referenced was an outdated policy and the current policy (referenced above) was the current policy and did not include punitive measures. When asked about

the facility conducting room searches when there is no concerns with illegal substances, the Administrator acknowledged the recent regulatory language and recent State Agency/Provider training and stated they might not have been using the most updated policy and Resident R49 was disciplined based on the former smoking policy (prior to 2/2025).

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Mission Point Nursing & Physical Rehabilitation Ce

4800 Clintonville Rd Clarkston, MI 48346

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0558

Reasonably accommodate the needs and preferences of each resident.

Level of Harm - Minimal harm or potential for actual harm

Based on observation, interview, and record review, the facility failed to ensure a pull cord for the overbed light was accessible to the resident for one (Resident R60) of one resident reviewed for accommodation of needs.

Findings include:On 8/19/25 at 9:58 AM, Resident R60 was observed lying in bed with oxygen in place via nasal cannula. The overbed light on the wall above their bed was observed to have a pull string that was tied up and hung down approximately one foot and was not able to be reached when in bed. They reported they rarely left their room and preferred to stay in bed. When asked about their room environment and if they had any concerns, Resident R60 discussed several concerns including the light above their bed. When asked to explain further, Resident R60 stated, I can't reach my light to turn on cause they never brought me a longer cord.Additional

observations on 8/20/25 and 8/21/25 revealed the cord remained tied up and not within reach.On 8/20/25 at 1:20 PM, an interview was conducted with the Maintenance Director (Staff ‘O‘) who reported they had worked at the facility for about 30 years. Staff ‘O' was asked to observe Resident R60's room and confirmed the short length of the overbed light and reported those had likely been like that since the rooms were renovated a while ago.According to the facility's policy titled, Safe and Homelike Environment dated 4/2024: .The facility will provide and maintain adequate and comfortable lighting levels in all areas.The Maintenance Director will perform periodic rounds to ensure functioning lights.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Mission Point Nursing & Physical Rehabilitation Ce

4800 Clintonville Rd Clarkston, MI 48346

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

Federal health inspectors cited Mission Point Nursing & Physical Rehabilitation Ce in Clarkston, MI for a deficiency under regulatory tag F-F0583 during a standard health inspection conducted on 2025-08-21.

Category: Resident Rights Deficiencies

The facility was found deficient in the following area: Keep residents' personal and medical records private and confidential.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 13 deficiencies cited during this inspection of Mission Point Nursing & Physical Rehabilitation Ce.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-09.

Federal health inspectors cited Mission Point Nursing & Physical Rehabilitation Ce in Clarkston, MI for a deficiency under regulatory tag F-F0584 during a standard health inspection conducted on 2025-08-21.

Category: Resident Rights Deficiencies

The facility was found deficient in the following area: 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.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 13 deficiencies cited during this inspection of Mission Point Nursing & Physical Rehabilitation Ce.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-09.

Federal health inspectors cited Mission Point Nursing & Physical Rehabilitation Ce in Clarkston, MI for a deficiency under regulatory tag F-F0600 during a standard health inspection conducted on 2025-08-21.

Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies

The facility was found deficient in the following area: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 13 deficiencies cited during this inspection of Mission Point Nursing & Physical Rehabilitation Ce.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-09.

Federal health inspectors cited Mission Point Nursing & Physical Rehabilitation Ce in Clarkston, MI for a deficiency under regulatory tag F-F0602 during a standard health inspection conducted on 2025-08-21.

Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies

The facility was found deficient in the following area: Protect each resident from the wrongful use of the resident's belongings or money.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 13 deficiencies cited during this inspection of Mission Point Nursing & Physical Rehabilitation Ce.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-09.

F 0689 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

six hours (to relieve anxiety).Review of Resident R8's Physical Therapy (PT) Evaluation and Treatment, dated 8/07/25, showed a full body shower sling was recommended for bathing. The assessment revealed Resident R8 did not need PT services, as they were at baseline (no change in their prior level of function while at the facility). The assessment revealed the hospice recommendations for safe transfers and high risk for displacement. There was no documentation or plan to educate staff on transfers noted in their documentation provided by the facility. On 8/21/25 at 10:38 a.m., Resident R8's guardian, Guardian Z, reported in a phone interview they had been made aware of Resident R8's fall out of bed on 7/23/25, and the cause related to Resident R8 needing 2-person assistance with bed mobility. Guardian Z clarified they did not suspect any abuse and understood Resident R8 fell out of bed by accident when CNA AA rolled Resident R8 out of bed during care. Guardian Z confirmed Resident R8 was dependent on staff for all personal care and used a Hoyer lift for transfers prior to their fall. Guardian Z said they had observed staff transferring Resident R8 in an unsafe manner with the Hoyer lift, with Resident R8 nearly sliding out of the lift sling. Guardian Z reported they were concerned about Resident R8's increased pain since their fall and had placed Resident R8 on hospice care after their fall on 7/23/25, upon return to the facility on 8/07/25. Review of the fall reduction policy, dated 2/2025, revealed, Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize likelihood of falls.4. Standard Fall Risk Protocols: a. Implement universal environmental recommendations that decrease the risk of resident falling, including, but not limited to: .ii. Bed is locked.iii. Call light and frequently used items are within reach. Review of the policy, Safe Resident Handling/Transfers, dated 8/09/24, revealed, It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable environment for the resident while keeping the employees safe in accordance with current standards and guidelines .

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Mission Point Nursing & Physical Rehabilitation Ce

4800 Clintonville Rd Clarkston, MI 48346

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

Federal health inspectors cited Mission Point Nursing & Physical Rehabilitation Ce in Clarkston, MI for a deficiency under regulatory tag F-F0690 during a standard health inspection conducted on 2025-08-21.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 13 deficiencies cited during this inspection of Mission Point Nursing & Physical Rehabilitation Ce.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-09.

F 0692

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

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview and record review the facility failed to provide snacks for a resident with low body weight for one (Resident R54) of three residents reviewed for nutrition. Findings include: On 8/19/25 at 9:06 AM, Resident R54 was observed lying in her bed. Resident R54 appeared to be small and very thin and bilateral arm and hand contractures were observed. Resident R54 was asked about care at the facility. Resident R54 explained 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. 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.Review of the clinical record revealed Resident R54 was admitted into the facility on [DATE REDACTED] with diagnoses that included: spastic quadriplegic cerebral palsy, moderate protein-calorie malnutrition and anxiety disorder. According to the Minimum Data Set (MDS) assessment dated [DATE REDACTED], Resident R54 was cognitively intact. The MDS assessment also indicated Resident R54 was dependent on staff for eating.Review of Resident R54's weights revealed the most recent weight dated 8/7/25 was 77.4 pounds.Review of Resident R54's nutritional care plan revised 2/17/25 revealed no intervention for providing evening snacks.Review of a 30 Day Look Back of Certified Nursing Assistant (CNA) documentation for Snacks revealed no snacks documented as given or eaten.On 8/20/25 at 8:43 AM, observation of CNA F assisting Resident R54 with breakfast revealed Resident R54 was not able to open items on the tray and required the assistance of staff to eat.On 8/21/25 at 9:01 AM, the Dietary Manager (DM) was interviewed and asked how evening snacks were distributed. The DM explained there was a list of residents that they would prepare a snack for and their name would be put on the snack and it was distributed to the resident in the evening. The DM was asked if Resident R54 was on the list for evening snacks. The DM explained he would check to see.On 8/21/25 at 9:15 AM, the DM provided a list of 45 residents who were provided evening snacks. Resident R54 was not on the list. On 8/21/25 at 10:05 AM, Registered Dietician (RD) K was interviewed and asked why Resident R54 was not provided evening snacks. RD K explained Resident R54 had never asked for evening snacks. RD K was asked why evening snacks were not included in Resident R54's nutritional interventions due to her only weighing 77.4 pounds. RD K acknowledged the concern and explained he would add Resident R54 to the list for evening snacks.On 8/21/25 at 2:10 PM, the Director of Nursing (DON) was interviewed and asked about Resident R54 not receiving evening snacks. The DON explained Resident R54 had never asked for evening snacks, but thought it would be a good idea since Resident R54 only weighed 77.4 pounds.Review of a facility policy titled, Weight Monitoring revised 1/2024 read in part, .Interventions will be identified, implemented, monitored and modified (as appropriate), consistent with the resident's assessed needs, choices, preferences, goals and current professional standards to maintain acceptable parameters of nutritional status.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Federal health inspectors cited Mission Point Nursing & Physical Rehabilitation Ce in Clarkston, MI for a deficiency under regulatory tag F-F0800 during a standard health inspection conducted on 2025-08-21.

Category: Nutrition and Dietary Deficiencies

The facility was found deficient in the following area: Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 13 deficiencies cited during this inspection of Mission Point Nursing & Physical Rehabilitation Ce.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-09.

Federal health inspectors cited Mission Point Nursing & Physical Rehabilitation Ce in Clarkston, MI for a deficiency under regulatory tag F-F0812 during a standard health inspection conducted on 2025-08-21.

Category: Nutrition and Dietary Deficiencies

The facility was found deficient in the following area: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 13 deficiencies cited during this inspection of Mission Point Nursing & Physical Rehabilitation Ce.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-09.

Federal health inspectors cited Mission Point Nursing & Physical Rehabilitation Ce in Clarkston, MI for a deficiency under regulatory tag F-F0880 during a standard health inspection conducted on 2025-08-21.

Category: Infection Control Deficiencies

The facility was found deficient in the following area: Provide and implement an infection prevention and control program.

Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 13 deficiencies cited during this inspection of Mission Point Nursing & Physical Rehabilitation Ce.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-09.