Mission Point Nursing & Physical Rehabilitation Ce

F 0600

psychosocial harm during and after the investigation. Reporting of all alleged violations to the Administrator, state agency. law enforcement when applicable.

Level of Harm - Minimal harm or potential for actual harm 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

08/14/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Mission Point Nursing & Physical Rehabilitation Ce

313 Sherwood Street Holly, MI 48442

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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

CNA that was assigned to Resident R302 from 3PM (when the dayshift CNA went off duty) to 7 PM (when CNA E came on duty). The Administrator did not provide a response. On 8/14/25 at 2:49 PM, the Administrator was interviewed and confirmed they were the Abuse Coordinator for the facility and had conducted Resident R302's elopement investigation. The Administrator was asked about the discrepancy of the duration of time the resident had eloped from the facility. The Administrator denied to have been informed by the multiple staff members of the neighbors observation to have seen the resident outside of their home since 4 PM. The Administrator was asked if they had interviewed the neighbor during their investigation and the Administrator stated they did not. The multiple discrepancies with their investigation was discussed and compared with what was submitted to the SA. When asked why a statement had not been obtained by the assigned nurse to Resident R302 for the day shift of 7/25/25, the Administrator stated he did not have an answer for that. No further explanation or documentation was provided by the end of the survey.

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

08/14/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Mission Point Nursing & Physical Rehabilitation Ce

313 Sherwood Street Holly, MI 48442

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 0635

Provide doctor's orders for the resident's immediate care at the time the resident was admitted.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure all admission orders were reported and reconciled with the Physician for one (Resident R302) of one resident reviewed for an elopement. Findings include: A review of

the medical record revealed Resident R302 was admitted to the facility on [DATE REDACTED] with a primary admitting diagnosis of alcohol dependence with withdrawal and was documented to have intact cognition. A review of Resident R302's hospital discharge medications revealed the following:Lorazepam tablet sliding scale. If CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol) is 0-7: No Benzodiazepine dose indicated. 1 mg (milligram) if CIWA-AR Mild - MOD 8 -15. 2 mg if CIWA - AR Mild - MOD 16-67. Greater than 35, Notify Provider. PO (by mouth), every 2 hours PRN (as needed) for Per CIWA Scale. If CIWA-Ar is 0-7: No Benzodiazepine dose indicated. If CIWA-Ar is 8-15, give 1mg then reassess 2hrs after dose given. If CIWA-Ar >15, give 2mg then reassess 1 hr after dose given (Maximum dose 12mg/day). If score > 35 give dose indicated and notify provider; IV (intravenous) if unable to take PO. A review of the medical record and Physician orders revealed the as needed CIWA protocol was not reconciled or implemented like the rest of the medications documented on the hospital discharge medication report. On 8/14/25 at approximately 9:10 AM, the Director of Nursing (DON) was interviewed and asked why the CIWA alcohol withdrawal protocol was not implemented like the rest of the medications on the hospital discharge document. The DON stated they would look into it and follow back up. At 10:44 AM, the DON returned with Physician F (the assigned Physician to Resident R302). Physician F was asked if they were informed of the as needed CIWA protocol that was

on the discharge medication list from the hospital and Physician F stated they were not informed. The DON stated they were also unaware of the hospital discharge medication list that noted the CIWA protocol. The DON and Physician F stated they would start education with their staff. No further explanation or documentation was provided by the end of the survey.

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

08/14/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Mission Point Nursing & Physical Rehabilitation Ce

313 Sherwood Street Holly, MI 48442

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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

confirmed the loss of the top layer of the skin for the wound. The facility wound nurse was not present for

the duration of the survey and was not interviewed. On 8/13/25 at 1:41 PM, the Director of Nursing (DON) was interviewed and questioned about the accuracy of the wound assessments for Resident R301 on 7/2/25, 7/9/25 and 7/16/25. The review of the hospital diagnosis of the wound on the same day the resident was last assessed in the facility on 7/16/25, was reviewed. The DON stated they would look into it and follow back up. On 8/13/25 at 3:34 PM, the DON returned with the Wound Physician (WP) B on the phone for an interview. The connection of the call was bad and the interview was not conducted at that time. On 8/14/25 at 3:14 PM, a telephone interview was conducted with WP B the concern of the accuracy of the staging of

the wound compared to the documented assessment of the wound was discussed. WP B acknowledged

the wound initially started as MASD. WP B stated they could have changed the documentation of the staging of the wound as it worsened. WP B stated their assessment noted the exact description of the wound, however acknowledged the wound staging documentation should have been updated. No further information or documentation was provided before the end of the survey.

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

08/14/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Mission Point Nursing & Physical Rehabilitation Ce

313 Sherwood Street Holly, MI 48442

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

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

good space when I was there.Resident R302 also confirmed that staff came to the neighbor's house and talked them into going back to the facility. On 8/14/25 at 2:05 PM, the Administrator was asked to provide the name of

the CNA that was assigned to Resident R302 from 3PM (when the dayshift CNA went off duty) to 7 PM (when CNA E came on duty). The Administrator did not provide a response. It was identified that the staff were unaware of the resident's departure and/or whereabouts from approximately 4 PM until approximately 9:15 PM (the approximate time RN C received the phone call from the reporting neighbor), more than five hours. The facility failed to develop and implement a substance use disorder plan of care and/or care plan for Resident R302's alcohol dependence, resulting in the Resident R302 to have eloped from the facility undetected for several hours in attempts to satisfy their addiction to alcohol. A review of the facility policy titled Behavioral Health Services dated 6/1/23, documented in part . Substance use disorder (SUD) is defined as recurrent use of alcohol and/or drugs that causes clinically and functionally significant impairment, such as health problems, disability, and failure to meet major responsibilities at work, school, or home. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders. The facility utilizes the comprehensive assessment process for identifying and assessing a resident's mental and psychosocial status and providing person-centered care. The assessment and care plan will include goals that are person-centered and individualized to reflect and maximize the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety. Facility efforts to help residents with. SUD , such as individual counseling services, access to group counseling or access to a Medication Assisted Treatment program.On 8/13/25 at 3:50 PM, Social Worker (SW) H was interviewed and asked their involvement in the implementation of a plan of care and/or care plan for Resident R302's substance use disorder for alcohol dependence. SW H explained

they typically have not created a care plan for substance use disorder. SW H stated they would review the facility policy and talk with the Administrator. SW H stated . I honestly didn't know we had that policy.On 8/14/25 at approximately 8:30 AM, the Administrator was interviewed and asked about the failure to implement a care plan and/or interventions for Resident R302, a resident with a primary admitting diagnosis of alcohol dependence and withdrawal. The Administrator acknowledged the concern. The concern was discussed regarding the lack of a plan of care for the resident substance use disorder (alcohol) that ultimately resulted in the resident to have eloped from the facility undetected for hours to satisfy their addiction. The Administrator stated the facility staff had been re-educated on the elopement policy. The Administration team failed to re-educate the facility staff on the substance use disorder policy. On 8/14/25 at approximately 9:10 AM, the Director of Nursing (DON) was interviewed and asked why a substance use disorder plan or care and/or care plan was not implemented for Resident R302's alcohol addiction. The DON stated usually the social worker completed those types of care plans, however, would look into it. Shortly after the DON confirmed they could not find anything implemented for Resident R302's substance use disorder. The DON stated they would start education with their staff. No further explanation or documentation was provided by

the end of the survey.

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

08/14/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Mission Point Nursing & Physical Rehabilitation Ce

313 Sherwood Street Holly, MI 48442

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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake: 2570372.Based on interview and record reviews the facility staff failed to follow the recommendation of the psych nurse practitioner (NP) and failed to identify a change of condition (urinary tract infection - uti) as the cause of a mental status/behavioral changes for one (Resident R301) of two residents' reviewed for neglect/abuse. Findings include:A review of the medical record revealed Resident R301 was admitted to

the facility on [DATE REDACTED] with a primary diagnosis of dementia and required staff assistance with all Activities of Daily Living (ADLs). A Social Service Progress Note dated 6/26/25 at 8:03 AM, recapped the recommendations from a psych consultation which documented the following . Seen 6/25/25 by (psych clinician name), NP (nurse practitioner) with psych services. Consult states the following. Patient presents with increased anxiety, agitation, and aggression. Emphasis should be placed on ruling out underlying medical or environmental contributors. Patient has a known and established history of significant agitation

in the presence of acute etiologies, particularly UTIs. If behavioral changes continue to persist, would advise consideration to repeat urine analysis.A Nursing progress note dated 7/16/25 at 4:31 PM, documented in part . This writer contacted the guardian because the patient was having a behavior with another resident. The resident was heard and seen calling the resident a whore hopper and a Bitch, The granddaughter asked to speak with her. The resident did speak with her. The writer was asked to take the phone and speak with (guardian name). she told me she was having a NP (nurse practitioner) look over the resident medications. And she will be here later to see (Resident R301's name).A Nursing progress note dated 7/16/25 at 5:28 PM, documented in part . the resident has been sitting at the nurse station for the past hour.

She has been singing and to <sic> talking with this writer and other staff. The resident mood back at baseline with no memory of the previous behavior.A review of the medical record revealed a repeat urinalysis was not considered, ordered or obtained, as the recommended documentation by the psych NP

on 6/26/25. A discharge emergent note dated 7/16/25 at 11:08 PM, documented the family of Resident R301 called emergency medical services to transport Resident R301 to the hospital regarding medical concerns with the resident. A review of the hospital documents revealed the following: . presenting from her living facility. per request of granddaughter who is patient's guardian for change in patient's mentation. Family is concerned that patient has a urinary tract infection due to her change from [NAME] <sic> (alert and oriented) to self and place to [NAME] to self. Patient was combative on July 16, 2025. Mentation was worsening from her baseline. Further review of the hospital documents revealed the identification of . Sepsis due to Enterobacter species (type of bacteria). Enterobacter cloacae complex bacteremia (presence of bacteria in

the bloodstream) secondary to a urinary tract infection. On IV (intravenous) cefepime (antibiotic) and plan a 14-day course of therapy. Urinary tract infection. ID (infectious disease) on case. present on admission.The facility staff failed in following the recommendation of the psych nurse practitioner and failed to identify Resident R301's urinary tract infection. On 8/13/25 at 1:41 PM, the Director of Nursing (DON) was asked about the mental and behavioral changes documented for Resident R301 and why follow-up testing to rule out a UTI was not completed as recommended by the psych NP. The DON stated they were unaware of the psych NP recommendation and would look into it and follow back up. On 8/14/25 at 9:05 AM, the DON returned and stated they had missed the repeat urinalysis recommendation. No further explanation or documentation was provided by the end of the survey.

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

08/14/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Mission Point Nursing & Physical Rehabilitation Ce

313 Sherwood Street Holly, MI 48442

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 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** This citation pertains to intake: 2570372.Based on interview and record reviews the facility failed to identify, follow up and follow the facility policy on weight loss for one (Resident R301) of one resident reviewed for weight loss. Findings include: A review of the medical record revealed Resident R301 was admitted to the facility on [DATE REDACTED] with a primary diagnosis of dementia and required staff assistance with all Activities of Daily Living (ADLs). A review of the resident Weight Summary documented the following: 7/3/25 at 1:25 PM- 134.4 lbs (pounds)6/5/25 at 3:04 PM- 150.8 lbs This indicates a -10.88 loss in less than a month. There was no recorded re-weight to confirm the weight loss documented. A record review of the Electronic Medical Record (EMR) and Nutrition assessments/notes were all reviewed, and none identified the clarification of the 7/3/25 recorded weight, notification to the dietician/physician, monitoring, interventions or modifications to the resident's nutrition plan of care. A review of the facility policy titled Weight Monitoring revised 01/21 documented in part .Weight Analysis: The newly recorded resident weight should be compared to the previous recorded weight to determine if a re-weight is necessary.On 8/13/25 at 1:41 PM, the Director of Nursing (DON) was interviewed and asked about the recorded weight loss on 7/3/25 and the lack of follow up. The DON replied

the staff should have notified them, and a re-weight should have been obtained. The DON confirmed they were not notified of the recorded weight loss. The DON stated they would look into it further and follow back up. On 8/14/25 at 9:05 AM, the DON returned and stated the therapy staff obtained both weights in June and July 2025, however failed to inform them of the recorded weight loss. The DON stated education will be conducted with the therapy staff. No further explanation or documentation was provided by the end of the survey.

Residents Affected - Few

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

Event ID:

Facility ID:

If continuation sheet