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Complaint Investigation

Villa At Pine Place

August 21, 2025 · Clarkston, MI · 4800 Clintonville Rd
Citations 13
CMS Rating 1/5
Beds 120
Provider ID 235461
Healthcare Facility
Villa At Pine Place
Clarkston, MI  ·  View full profile →
Inspection Summary

Villa at Pine Place in Clarkston, MI — inspection on August 21, 2025.

Found 13 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0550
Resident Rights Deficiencies
Potential for More Than Minimal Harm

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

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/21/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Mission Point Nursing & Physical Rehabilitation Ce

4800 Clintonville Rd Clarkston, MI 48346

SUMMARY STATEMENT OF DEFICIENCIES

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Administrator was requested to review their smoking policy and acknowledged the one they referenced was an outdated policy and the current policy (referenced above) was the current policy and did not include punitive measures.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 R49 was disciplined based on the former smoking policy (prior to 2/2025).

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/21/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Mission Point Nursing & Physical Rehabilitation Ce

4800 Clintonville Rd Clarkston, MI 48346

SUMMARY STATEMENT OF DEFICIENCIES

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 (R60) of one resident reviewed for accommodation of needs.

Findings include:On 8/19/25 at 9:58 AM, 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, R60 discussed several concerns including the light above their bed.

When asked to explain further, 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 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.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/21/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Mission Point Nursing & Physical Rehabilitation Ce

4800 Clintonville Rd Clarkston, MI 48346

SUMMARY STATEMENT OF DEFICIENCIES

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.

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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.

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 .

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/21/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Mission Point Nursing & Physical Rehabilitation Ce

4800 Clintonville Rd Clarkston, MI 48346

SUMMARY STATEMENT OF DEFICIENCIES

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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.

According to the Minimum Data Set (MDS) assessment dated [DATE], R54 was cognitively intact.

The MDS assessment also indicated R54 was dependent on staff for eating.Review of R54's weights revealed the most recent weight dated 8/7/25 was 77.4 pounds.Review of 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 R54 with breakfast revealed 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 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. R54 was not on the list. On 8/21/25 at 10:05 AM, Registered Dietician (RD) K was interviewed and asked why R54 was not provided evening snacks. RD K explained R54 had never asked for evening snacks. RD K was asked why evening snacks were not included in R54's nutritional interventions due to her only weighing 77.4 pounds. RD K acknowledged the concern and explained he would add 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 R54 not receiving evening snacks.

The DON explained R54 had never asked for evening snacks, but thought it would be a good idea since 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.

Facility ID:

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.

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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.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Clarkston, MI, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Villa at Pine Place or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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