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Inspection visit

Inspection

Mission Point Nursing & Physical Rehabilitation CeCMS #23555225 citations on this visit
25 citations recorded

Citations

25 citations recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0363GeneralS&S Fpotential for harm

    Install corridor and hallway doors that block smoke.

  • 0881GeneralS&S Fpotential for harm

    F881 - Infection prevention and control program

    Implement a program that monitors antibiotic use.

  • 0039GeneralS&S Fpotential for harm

    Conduct testing and exercise requirements.

  • 0321GeneralS&S Fpotential for harm

    Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

  • 0345GeneralS&S Fpotential for harm

    Have approved installation, maintenance and testing program for fire alarm systems.

  • 0355GeneralS&S Fpotential for harm

    Properly select, install, inspect, or maintain portable fire extinguishes.

  • 0374GeneralS&S Epotential for harm

    Install smoke barrier doors that can resist smoke for at least 20 minutes.

  • 0711GeneralS&S Fpotential for harm

    F711 - Physician Visits

    Provide a written emergency evacuation plan.

  • 0712GeneralS&S Fpotential for harm

    F712 - Frequency of physician visits

    Have simulated fire drills held at unexpected times.

  • 0741GeneralS&S Fpotential for harm

    F741 - The facility must have sufficient staff who provide direct services to

    Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

  • 0918GeneralS&S Fpotential for harm

    F918 - Bathroom Facilities

    Have generator or other power source capable of supplying service within 10 seconds.

  • 0656GeneralS&S Fpotential for harm

    F656 - Comprehensive Care Plans

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  • 0657GeneralS&S Dpotential for harm

    F657 - Comprehensive Care Plans

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

  • 0676GeneralS&S Dpotential for harm

    F676 - Based on the comprehensive assessment of a resident and consistent with

    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

  • 0695GeneralS&S Dpotential for harm

    F695 - Respiratory care, including tracheostomy care and tracheal suctioning

    Provide safe and appropriate respiratory care for a resident when needed.

  • 0759GeneralS&S Dpotential for harm

    F759 - Medication Errors

    Ensure medication error rates are not 5 percent or greater.

  • 0801GeneralS&S Fpotential for harm

    F801 - Staffing

    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

  • 0802GeneralS&S Fpotential for harm

    F802 - Staffing

    Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

  • 0812GeneralS&S Fpotential for harm

    F812 - Food safety requirements

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  • 0835GeneralS&S Fpotential for harm

    F835 - Administration

    Administer the facility in a manner that enables it to use its resources effectively and efficiently.

  • 0847GeneralS&S Dpotential for harm

    F847 - Entering Into Binding Arbitration Agreements

    Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

  • 0865GeneralS&S Fpotential for harm

    F865 - Quality assurance and performance improvement (QAPI) program

    Have a plan that describes the process for conducting QAPI and QAA activities.

  • 0867GeneralS&S Fpotential for harm

    F867 - Program feedback, data systems and monitoring

    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

  • 0868GeneralS&S Fpotential for harm

    F868 - Quality assessment and assurance

    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

  • 0882GeneralS&S Fpotential for harm

    F882 - Infection preventionist

    Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

FAQ · About this visit

Common questions about this visit

What happened during the July 25, 2025 survey of Mission Point Nursing & Physical Rehabilitation Ce?

This was a inspection survey of Mission Point Nursing & Physical Rehabilitation Ce on July 25, 2025. The surveyor cited 25 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at Mission Point Nursing & Physical Rehabilitation Ce on July 25, 2025?

Yes, 25 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Install corridor and hallway doors that block smoke."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

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Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.