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
Chain footprint
20 facilities
Chain averages 3 overall / 3 health / 4 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.52
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
1.58
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
2.15
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
4.25
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
2.10
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
3.76
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.18
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.16
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.55
CMS adjusted RN staffing hours
Adjusted total hours
4.55
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
44%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
34%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,001
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
37.81
Composite VBP score used to determine payment impact.
Payment multiplier
0.9910
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.51% · Performance 22.16% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
3.54
Baseline 4.43% · Performance 6.78% · Measure score 3.54 · Achievement 3.54 · Improvement 0
Total nurse turnover
6.87
Baseline 45.24% · Performance 35.61% · Measure score 6.87 · Achievement 6.87 · Improvement 4.22
Adjusted total nurse staffing
4.71
Baseline 3.96 hours · Performance 4.42 hours · Measure score 4.71 · Achievement 4.71 · Improvement 2.03
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.68% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 662 · Observed rate 9.97% · Lower 95% interval 9.23% |
| Discharge to community | 69% |
50.57%
18.4 pts better
|
Better than the National Rate · Eligible stays 668 · Observed rate 65.27% · Lower 95% interval 65.19% |
| Medicare spending per beneficiary | 0.89 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 99.51% |
95.27%
4.2 pts better
|
Numerator 407 · Denominator 409 |
| Falls with major injury | 0.49% |
0.77%
0.3 pts better
|
Numerator 2 · Denominator 409 |
| Discharge self-care score | 53.61% |
53.69%
0.1 pts worse
|
Numerator 171 · Denominator 319 |
| Discharge mobility score | 41.69% |
50.94%
9.2 pts worse
|
Numerator 133 · Denominator 319 |
| Pressure ulcers or injuries, new or worsened | 0.73% |
2.29%
1.6 pts better
|
Numerator 3 · Denominator 409 · Adjusted rate 0.77% |
| Healthcare-associated infections requiring hospitalization | 6.78% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 374 · Observed rate 5.88% · Lower 95% interval 4.58% |
| Staff COVID-19 vaccination coverage | 8.94% |
8.2%
0.7 pts better
|
Numerator 16 · Denominator 179 |
| Staff flu vaccination coverage | 20.66% |
42%
21.3 pts worse
|
Numerator 50 · Denominator 242 |
| Discharge function score | 47.96% |
56.45%
8.5 pts worse
|
Numerator 153 · Denominator 319 |
| Transfer of health information to provider | 99.11% |
95.95%
3.2 pts better
|
Numerator 334 · Denominator 337 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 43 · Denominator 43 |
| Resident COVID-19 vaccinations up to date | 28.71% |
25.2%
3.5 pts better
|
Numerator 60 · Denominator 209 |
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 · Adjusted 1.9 · Observed 1.8 · Expected 1.8 · Used in QM five-star |
| 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 · Adjusted 0.7 · Observed 0.7 · Expected 1.6 · Used in QM five-star |
| 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 · Q1 96.2% · Q2 98.0% · Q3 98.0% · Q4 98.0% · 4Q avg 97.5% |
| 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 · 4Q avg 83.3% |
| 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 · Q1 3.8% · Q2 6.1% · Q3 6.0% · Q4 2.0% · 4Q avg 4.5% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 4.4% · Q3 6.4% · Q4 2.3% · 4Q avg 3.3% |
| 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 · Q1 5.0% · Q2 2.3% · Q3 4.3% · Q4 8.5% · 4Q avg 5.1% |
| 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 · Q1 10.6% · Q2 6.5% · Q3 8.3% · Q4 14.3% · 4Q avg 10.0% |
| 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 · Q1 8.6% · Q2 7.7% · Q3 8.9% · Q4 7.3% · 4Q avg 8.1% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| 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 · 4Q avg 21.6% · Used in QM five-star |
| 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 · Q1 28.3% · Q2 15.2% · Q3 10.4% · Q4 12.2% · 4Q avg 16.4% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 1.6% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| 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 · Q1 11.1% · Q2 2.1% · Q3 2.1% · Q4 0.0% · 4Q avg 3.7% · Used in QM five-star |
| 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 · Q1 31.4% · Q2 31.2% · Q3 26.0% · Q4 18.1% · 4Q avg 26.4% |
| 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 · Q1 7.7% · Q2 6.8% · Q3 12.8% · Q4 6.8% · 4Q avg 8.6% · Used in QM five-star |
| 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 · Q1 96.3% · Q2 96.2% · Q3 95.9% · Q4 96.2% · 4Q avg 96.1% |
| 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 · Adjusted 8.2% · Observed 7.4% · Expected 10.1% · Used in QM five-star |
| 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 · Q1 1.6% · Q2 0.9% · Q3 0.9% · Q4 0.6% · 4Q avg 1.0% · Used in QM five-star |
| 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 · 4Q avg 88.0% |
| 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 · Adjusted 22.4% · Observed 20.7% · Expected 22.0% · Used in QM five-star |
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
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#2
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#3
Mission Point Nursing & Physical Rehabilitation Ce
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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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