Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Mission Point Nursing & Physical Rehabilitation Ce
Holly, MI · 66 certified beds · Last Life Safety survey April 1, 2026
CMS Certification Number 235722 · first certified June 2017
Ownership
Operated by MISSION POINT HEALTHCARE SERVICES · For profit - Individual
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within MI
27 citations — more than 86% of the 422 certified nursing homes in MI. Compared within MI rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 5 citations; the earlier surveys in the window averaged 11. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens March 2027 — about 6 months from now. This facility’s last Life Safety survey was April 2026. Facilities in MI are typically surveyed 12–14 months after the last one (median 13), measured over 723 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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4 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
3 of the 27 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
11 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 27 Life Safety citations above. The Physical Environment Index
- F-0584 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.
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- F-0880 Provide and implement an infection prevention and control program.
- F-0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
- F-0908 Keep all essential equipment working safely.
How that compares
Compared with the median facility in MI, and nationally. Surveyors differ markedly between states, so the MI figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 27 |
| Median facility in MI | 14 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| January 23, 2024 | 13 |
| February 5, 2025 | 9 |
| April 1, 2026 | 5 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2026-04-01 |
| K-0324 | Provide properly protected cooking facilities. | 2 | 2025-02-05 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 2 | 2025-02-05 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 2 | 2025-02-05 |
| K-0920 | Ensure proper usage of power strips and extension cords. | 2 | 2025-02-05 |
| K-0925 | Ensure that sources of ignition are removed from patients receiving respiratory therapy. | 1 | 2024-01-23 |
| E-0041 | Implement emergency and standby power systems. | 1 | 2026-04-01 |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | 1 | 2024-01-23 |
What the citations cover
- Smoke Deficiencies 9
- Gas, Vacuum, and Electrical Systems Deficiencies 6
- Emergency Preparedness Deficiencies 3
- Egress Deficiencies 3
- Other 6
| Category | Citations |
|---|---|
| Smoke Deficiencies | 9 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 6 |
| Emergency Preparedness Deficiencies | 3 |
| Egress Deficiencies | 3 |
| Services Deficiencies | 3 |
| Miscellaneous Deficiencies | 3 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
April 1, 2026 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0041 | Implement emergency and standby power systems. | Deficient, Provider has date of correction (April 17, 2026) |
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Deficient, Provider has date of correction (April 17, 2026) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (April 17, 2026) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (April 17, 2026) |
| K-0781 | Have restrictions on the use of portable space heaters. | Deficient, Provider has date of correction (April 17, 2026) |
February 5, 2025 — 9 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (February 28, 2025) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (February 28, 2025) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (February 28, 2025) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (February 28, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (February 28, 2025) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (February 28, 2025) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (February 28, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (February 28, 2025) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (February 28, 2025) |
January 23, 2024 — 13 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (February 19, 2024) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (February 19, 2024) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (February 19, 2024) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (February 19, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (February 21, 2024) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (February 19, 2024) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (February 19, 2024) |
| K-0522 | Have an externally vented heating system. | Deficient, Provider has date of correction (February 19, 2024) |
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (February 19, 2024) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (February 19, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (February 19, 2024) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (February 19, 2024) |
| K-0925 | Ensure that sources of ignition are removed from patients receiving respiratory therapy. | Deficient, Provider has date of correction (February 19, 2024) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.