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Complaint Investigation

Mission Point Nursing & Physical Rehabilitation Ce

Inspection Date: August 22, 2025
Total Violations 1
Facility ID 235290
Location Greenville, MI
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Inspection Findings

F-Tag F0689

Quality of Life and Care Deficiencies
Harm Level: Potential for More Than Minimal Harm

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

reported Resident R101 had a phone with him but that the phone was not functioning. CNA D reported the Resident's walker was retrieved and he stood by while staff pushed his power wheelchair out of the mud.

Review of the EMR Progress Notes for Resident R101 reflected an entry dated 7/29/2025 at 4:15 AM by LPN H. The entry reflected, resident (Resident R101) was found in the courtyard stuck in his electric wheelchair in the mud, he had been out watering the garden and tried to shut off the water when he got stuck, no injuries.During an

interview conducted 8/22/2025 at 7:30 AM, Unit Manager (UM) J reported if a resident leaves the building,

they or their guardian are required to sign out in the books that are on the unit or at the front door. UM J reported staff do hourly rounds on residents and can check the books to see if a resident had left the facility.During an interview conducted 8/22/2025 at 7:21 AM Registered Nurse (RN) B reported that residents are coded out of the building by staff. RN B reported that if a resident cannot be accounted for the Elopement protocol is initiated and a head count is conducted. RN B once all residents are accounted for

an all clear is announced overhead.Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, Health care agencies have instituted purposeful hourly rounds to improve nurse responsiveness and patient satisfaction. Purposeful rounds include the 4 Ps (i.e., pain, potty, positioning, and periphery).

Nursing staff usually conduct hourly rounds and ask patients about their pain and whether they need to toilet; then the patients are positioned for comfort, and an environmental check is done. The implementation of purposeful rounding improves patient safety by decreasing the occurrence of patient preventable events and proactively addresses problems before they occur (Zadvinskis et al., 2019). [NAME], [NAME] A.; [NAME], [NAME] G.; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 1448).

Elsevier Health Sciences. Kindle Edition.

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📋 Inspection Summary

Mission Point Nursing & Physical Rehabilitation Ce in Greenville, MI inspection on recent inspection.

Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.

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

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 Greenville, 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 Mission Point Nursing & Physical Rehabilitation Ce or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.
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