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.

27
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
5
Tags cited more than once
Across separate surveys
15
Inspection & testing records
Of the citations on file

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

Improvingfewer citations at the latest survey than at its earlier surveys in the window.

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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Which alerts

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

Citations on file over three years

Compared with the median facility in MI, and nationally. Surveyors differ markedly between states, so the MI figure is the meaningful one.

This facility27MI median14National median11
Citations on file over three years, compared
MeasureCitations
This facility27
Median facility in MI14
Median facility nationally11

Survey history

Citations at each Life Safety survey
132024-0192025-0252026-04
Citations at each Life Safety survey
Survey dateCitations
January 23, 202413
February 5, 20259
April 1, 20265

Most-cited tags

Most-cited tags at this facility
K-03533K-03242K-03452K-09182K-09202K-09251E-00411K-09141
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0353Inspect, test, and maintain automatic sprinkler systems.32026-04-01
K-0324Provide properly protected cooking facilities.22025-02-05
K-0345Have approved installation, maintenance and testing program for fire alarm systems.22025-02-05
K-0918Have generator or other power source capable of supplying service within 10 seconds.22025-02-05
K-0920Ensure proper usage of power strips and extension cords.22025-02-05
K-0925Ensure that sources of ignition are removed from patients receiving respiratory therapy.12024-01-23
E-0041Implement emergency and standby power systems.12026-04-01
K-0914Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.12024-01-23

What the citations cover

Citations by CMS category
  • Smoke Deficiencies 9
  • Gas, Vacuum, and Electrical Systems Deficiencies 6
  • Emergency Preparedness Deficiencies 3
  • Egress Deficiencies 3
  • Other 6
Citations by CMS category
CategoryCitations
Smoke Deficiencies9
Gas, Vacuum, and Electrical Systems Deficiencies6
Emergency Preparedness Deficiencies3
Egress Deficiencies3
Services Deficiencies3
Miscellaneous Deficiencies3

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

April 1, 2026 — 5 citations

Citations issued on April 1, 2026
TagWhat the surveyor checksStatus
E-0041Implement emergency and standby power systems.Deficient, Provider has date of correction (April 17, 2026)
K-0222Add 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-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (April 17, 2026)
K-0761To conduct inspection, testing and maintenance of fire doors by qualified individuals.Deficient, Provider has date of correction (April 17, 2026)
K-0781Have restrictions on the use of portable space heaters.Deficient, Provider has date of correction (April 17, 2026)

February 5, 2025 — 9 citations

Citations issued on February 5, 2025
TagWhat the surveyor checksStatus
K-0211Keep aisles, corridors, and exits free of obstruction in case of emergency.Deficient, Provider has date of correction (February 28, 2025)
K-0291Install emergency lighting that can last at least 1 1/2 hours.Deficient, Provider has date of correction (February 28, 2025)
K-0324Provide properly protected cooking facilities.Deficient, Provider has date of correction (February 28, 2025)
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has date of correction (February 28, 2025)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (February 28, 2025)
K-0372Ensure smoke barriers are constructed to a 1 hour fire resistance rating.Deficient, Provider has date of correction (February 28, 2025)
K-0521Ensure 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-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (February 28, 2025)
K-0920Ensure proper usage of power strips and extension cords.Deficient, Provider has date of correction (February 28, 2025)

January 23, 2024 — 13 citations

Citations issued on January 23, 2024
TagWhat the surveyor checksStatus
E-0004Develop and maintain an Emergency Preparedness Program (EP).Deficient, Provider has date of correction (February 19, 2024)
E-0039Conduct testing and exercise requirements.Deficient, Provider has date of correction (February 19, 2024)
K-0324Provide properly protected cooking facilities.Deficient, Provider has date of correction (February 19, 2024)
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has date of correction (February 19, 2024)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (February 21, 2024)
K-0355Properly select, install, inspect, or maintain portable fire extinguishes.Deficient, Provider has date of correction (February 19, 2024)
K-0511Have properly installed electrical wiring and gas equipment.Deficient, Provider has date of correction (February 19, 2024)
K-0522Have an externally vented heating system.Deficient, Provider has date of correction (February 19, 2024)
K-0711Provide a written emergency evacuation plan.Deficient, Provider has date of correction (February 19, 2024)
K-0914Ensure 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-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (February 19, 2024)
K-0920Ensure proper usage of power strips and extension cords.Deficient, Provider has date of correction (February 19, 2024)
K-0925Ensure 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.