Cycle 1
Health 2025-01-15 · Fire 2025-01-15
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fraser, MI
Fraser Villa
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
33300 Utica Road, Fraser, MI
(586) 293-3300
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
111
Certified beds
Average residents
106
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Trinity Health
Operator or chain grouping
Approved since
1986-03-06
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.52
Registered nurse staffing
LPN hours / resident day
1.58
Licensed practical nurse staffing
Aide hours / resident day
2.15
Nurse aide staffing
Weekend hours
3.76
Weekend nurse staffing
RN turnover
44%
Annual RN turnover
Total nurse turnover
34%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
1.7
0.2 pts worse
|
1.9
About the same
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
1.5
0.8 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.5% |
95.0%
2.5 pts better
|
93.4%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 83.3% |
95.0%
11.7 pts worse
|
95.5%
12.2 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.5% |
3.1%
1.4 pts worse
|
3.3%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 3.3% |
4.1%
0.8 pts better
|
11.4%
8.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 5.1% |
5.5%
0.4 pts better
|
5.4%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.0% |
19.6%
9.6 pts better
|
19.6%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 8.1% |
16.5%
8.4 pts better
|
16.7%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 21.6% |
13.9%
7.7 pts worse
|
16.3%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.4% |
11.7%
4.7 pts worse
|
14.9%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.9%
0.5 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 3.7% |
1.7%
2 pts worse
|
1.7%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.4% |
20.4%
6 pts worse
|
19.8%
6.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 8.6% |
5.6%
3 pts worse
|
5.1%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.1% |
82.8%
13.3 pts better
|
81.7%
14.4 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.2% |
11.5%
3.3 pts better
|
12.0%
3.8 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
1.3%
0.3 pts better
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.0% |
79.5%
8.5 pts better
|
79.7%
8.3 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.4% |
24.2%
1.8 pts better
|
23.9%
1.5 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-11 · Fire 2024-01-11
3 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2022-10-06 · Fire 2022-10-06
0 health deficiencies
No concentrated health issue counts in this cycle.
11 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-15
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-02-03
F · Potential for more than minimal harm
2025-01-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-03
F · Potential for more than minimal harm
2025-01-15
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-02-03
F · Potential for more than minimal harm
2025-01-15
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-02-03
F · Potential for more than minimal harm
2025-01-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-02-03
E · Potential for more than minimal harm
2025-01-15
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-02-03
E · Potential for more than minimal harm
2025-01-15
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-02-03
E · Potential for more than minimal harm
2025-01-15
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2025-02-03
E · Potential for more than minimal harm
2024-01-11
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-02-07
F · Potential for more than minimal harm
2022-10-06
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2022-11-12
F · Potential for more than minimal harm
2022-10-06
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-11-12
F · Potential for more than minimal harm
2022-10-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-11-12
F · Potential for more than minimal harm
2022-10-06
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-11-12
F · Potential for more than minimal harm
2022-10-06
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2022-11-12
F · Potential for more than minimal harm
2022-10-06
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-11-12
E · Potential for more than minimal harm
2022-10-06
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-11-12
E · Potential for more than minimal harm
2022-10-06
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-11-12
D · Potential for more than minimal harm
2022-10-06
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-11-12
D · Potential for more than minimal harm
2022-10-06
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2022-11-12
D · Potential for more than minimal harm
2022-10-06
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-11-12
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-02-04
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-02-18
F · Potential for more than minimal harm
2025-01-15
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-01-31
D · Potential for more than minimal harm
2025-01-15
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-01-31
D · Potential for more than minimal harm
2024-01-11
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-02-07
D · Potential for more than minimal harm
2024-01-11
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-02-07
Penalties and ownership
What sits behind the stars
Ownership
Trinity Continuing Care Services
5% Or Greater Direct Ownership Interest · Organization
Trinity Health Corporation
5% Or Greater Indirect Ownership Interest · Organization
Bowens, Marcus
Corporate Director · Individual
Bowens, Marcus
Corporate Officer · Individual
Defrain, David
Corporate Director · Individual
Handy, Joanne
Corporate Director · Individual
Henkel, Arthur
Corporate Director · Individual
Jones, Beverly
Corporate Director · Individual
Latovick, Pamela
W-2 Managing Employee · Individual
Minnix, William
Corporate Director · Individual
Murray, Mandi
Corporate Director · Individual
Murray, Mandi
Corporate Officer · Individual
Pachla, Jennifer
Operational/Managerial Control · Individual
Poole, Lejon
Corporate Director · Individual
Tag, Anna Marie
Corporate Director · Individual
Tapia, Marjorie
Corporate Director · Individual
Villarruel, Antonia
Corporate Director · Individual
Wells, Dewayne
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Medilodge of Sterling Heights
Sterling Heights, MI
2-star overall rating with 2-star inspections with 14 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#2
Optalis Health and Rehabilitation of Sterling Heig
Sterling Heights, MI
3-star overall rating with 2-star inspections with $4,233 in total fines with 16 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Mission Point Nursing & Physical Rehabilitation Ce
Clinton Township, MI
2-star overall rating with 2-star inspections with abuse icon flag with 13 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
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