Cycle 1
Health 2025-05-02 · Fire 2025-05-02
7 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Traverse City, MI
Medilodge of Traverse City
4-star overall rating with 3-star inspections with $13,845 in total fines with 7 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
2585 South LaFranier Road, Traverse City, MI
(231) 947-9511
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
84
Certified beds
Average residents
78
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Medilodge
Operator or chain grouping
Approved since
1977-09-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
50 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
0.96
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.28
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
2.17
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
3.40
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
1.24
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
2.86
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.77
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
1.07
CMS adjusted RN staffing hours
Adjusted total hours
3.83
CMS adjusted total nurse staffing hours
Case-mix index
1.22
Higher values indicate more complex resident acuity
RN turnover
38%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
40%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,092
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
24.76
Composite VBP score used to determine payment impact.
Payment multiplier
0.9836
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.44
Baseline 17.64% · Performance 19.84% · Measure score 3.44 · Achievement 3.44 · Improvement 0
Healthcare-associated infections
0.88
Baseline 6.64% · Performance 7.57% · Measure score 0.88 · Achievement 0.88 · Improvement 0
Total nurse turnover
2.41
Baseline 43.33% · Performance 53.85% · Measure score 2.41 · Achievement 2.41 · Improvement 0
Adjusted total nurse staffing
3.17
Baseline 4.12 hours · Performance 3.98 hours · Measure score 3.17 · Achievement 3.17 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.9% |
10.72%
1.8 pts better
|
No Different than the National Rate · Eligible stays 82 · Observed rate 3.66% · Lower 95% interval 5.61% |
| Discharge to community | 56.27% |
50.57%
5.7 pts better
|
No Different than the National Rate · Eligible stays 66 · Observed rate 53.03% · Lower 95% interval 45.94% |
| Medicare spending per beneficiary | 0.96 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 97.01% |
95.27%
1.7 pts better
|
Numerator 65 · Denominator 67 |
| Falls with major injury | 1.49% |
0.77%
0.7 pts worse
|
Numerator 1 · Denominator 67 |
| Discharge self-care score | 68.89% |
53.69%
15.2 pts better
|
Numerator 31 · Denominator 45 |
| Discharge mobility score | 66.67% |
50.94%
15.7 pts better
|
Numerator 30 · Denominator 45 |
| Pressure ulcers or injuries, new or worsened | 2.99% |
2.29%
0.7 pts worse
|
Numerator 2 · Denominator 67 · Adjusted rate 3.17% |
| Healthcare-associated infections requiring hospitalization | 7.57% |
7.12%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 57 · Observed rate 8.77% · Lower 95% interval 4.2% |
| Staff COVID-19 vaccination coverage | 0.83% |
8.2%
7.4 pts worse
|
Numerator 1 · Denominator 120 |
| Staff flu vaccination coverage | 10.66% |
42%
31.3 pts worse
|
Numerator 13 · Denominator 122 |
| Discharge function score | 75.56% |
56.45%
19.1 pts better
|
Numerator 34 · Denominator 45 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 32 · Denominator 32 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 33.33% |
25.2%
8.1 pts better
|
Numerator 12 · Denominator 36 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
1.7
0.2 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.3 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
1.5
0.4 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.0 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.7% |
95.0%
3.7 pts better
|
93.4%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.1% · Q2 98.3% · Q3 100.0% · Q4 98.3% · 4Q avg 98.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.0%
5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.3% |
3.1%
1.2 pts worse
|
3.3%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 3.4% · Q3 4.8% · Q4 5.1% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.8% |
4.1%
2.3 pts better
|
11.4%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.3% · Q4 3.5% · 4Q avg 1.8% |
| Percentage of long-stay residents who lose too much weight | 7.6% |
5.5%
2.1 pts worse
|
5.4%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 12.2% · Q3 5.4% · Q4 4.3% · 4Q avg 7.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 32.0% |
19.6%
12.4 pts worse
|
19.6%
12.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.3% · Q2 32.0% · Q3 39.3% · Q4 27.1% · 4Q avg 32.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 23.2% |
16.5%
6.7 pts worse
|
16.7%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.5% · Q2 23.1% · Q3 23.9% · Q4 17.9% · 4Q avg 23.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.4% |
0.1%
0.3 pts worse
|
0.1%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.6% · Q4 0.0% · 4Q avg 0.4% |
| Percentage of long-stay residents whose ability to walk independently worsened | 4.4% |
13.9%
9.5 pts better
|
16.3%
11.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 3.9% · Q3 9.1% · Q4 2.9% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.4% |
11.7%
6.3 pts better
|
14.9%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 6.5% · Q3 9.8% · Q4 2.2% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.2% |
0.9%
0.3 pts worse
|
1.0%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.6% · Q3 1.4% · Q4 1.5% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
1.7%
1.3 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.7% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.3% |
20.4%
3.9 pts worse
|
19.8%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.1% · Q2 18.6% · Q3 13.7% · Q4 40.2% · 4Q avg 24.3% |
| Percentage of long-stay residents with pressure ulcers | 4.3% |
5.6%
1.3 pts better
|
5.1%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 5.9% · Q3 6.6% · Q4 1.7% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.5% |
82.8%
8.7 pts better
|
81.7%
9.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.8% · Q2 91.5% · Q3 91.8% · Q4 90.4% · 4Q avg 91.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 0.0% |
11.5%
11.5 pts better
|
12.0%
12 pts better
|
Short Stay · 20240701-20250630 · Adjusted 0.0% · Observed 0.0% · Expected 11.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.5% |
1.3%
1.2 pts worse
|
1.6%
0.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 4.0% · Q3 0.0% · Q4 2.5% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 84.1% |
79.5%
4.6 pts better
|
79.7%
4.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 84.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.9% |
24.2%
1.3 pts better
|
23.9%
1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.9% · Observed 18.5% · Expected 19.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-20 · Fire 2024-03-20
10 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cycle 3
Health 2023-04-03 · Fire 2023-04-03
12 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-02
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-06-10
F · Potential for more than minimal harm
2025-05-02
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2025-06-10
F · Potential for more than minimal harm
2025-05-02
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-06-10
E · Potential for more than minimal harm
2025-05-02
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 2025-06-10
E · Potential for more than minimal harm
2025-05-02
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-06-10
D · Potential for more than minimal harm
2025-05-02
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-06-10
D · Potential for more than minimal harm
2025-05-02
K925 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that sources of ignition are removed from patients receiving respiratory therapy.
Corrected 2025-06-10
F · Potential for more than minimal harm
2024-03-20
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-04-05
E · Potential for more than minimal harm
2023-12-01
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-12-12
F · Potential for more than minimal harm
2023-04-03
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2023-04-10
F · Potential for more than minimal harm
2023-04-03
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2023-04-10
E · Potential for more than minimal harm
2023-04-03
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-04-10
E · Potential for more than minimal harm
2023-04-03
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-04-10
E · Potential for more than minimal harm
2023-04-03
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2023-04-10
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-05-02
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-06-10
E · Potential for more than minimal harm
2025-05-02
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-06-10
E · Potential for more than minimal harm
2025-05-02
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-06-10
E · Potential for more than minimal harm
2025-05-02
F923 · Environmental Deficiencies
Health
Have enough outside ventilation via a window or mechanical ventilation, or both.
Corrected 2025-06-10
D · Potential for more than minimal harm
2025-05-02
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-06-10
D · Potential for more than minimal harm
2025-05-02
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2025-04-30
D · Potential for more than minimal harm
2025-05-02
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 2025-06-10
D · Potential for more than minimal harm
2024-10-15
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-11-05
D · Potential for more than minimal harm
2024-10-15
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-11-05
D · Potential for more than minimal harm
2024-06-26
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-06-18
G · Actual harm
2024-03-20
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 2023-11-20
F · Potential for more than minimal harm
2024-03-20
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 2024-04-18
E · Potential for more than minimal harm
2024-03-20
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-04-18
E · Potential for more than minimal harm
2024-03-20
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-04-18
D · Potential for more than minimal harm
2024-03-20
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-04-18
D · Potential for more than minimal harm
2024-03-20
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-04-18
C · Minimal harm
2024-03-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-18
F · Potential for more than minimal harm
2023-12-20
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-01-09
G · Actual harm
2023-04-03
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-04-27
F · Potential for more than minimal harm
2023-04-03
F680 · Quality of Life and Care Deficiencies
Health
Ensure the activities program is directed by a qualified professional.
Corrected 2023-04-27
F · Potential for more than minimal harm
2023-04-03
F801 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2023-04-27
D · Potential for more than minimal harm
2023-04-03
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-04-27
D · Potential for more than minimal harm
2023-04-03
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-04-27
D · Potential for more than minimal harm
2023-04-03
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-04-27
D · Potential for more than minimal harm
2023-04-03
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-04-27
D · Potential for more than minimal harm
2023-04-03
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-04-27
G · Actual harm
2023-03-17
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 2023-04-10
D · Potential for more than minimal harm
2023-03-17
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-04-10
D · Potential for more than minimal harm
2023-03-17
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-04-10
Penalties and ownership
What sits behind the stars
$13,845
2023-03-17
Fine
Fine · fine $13,845
Fine
$0
2023-03-17
Payment Denial
Payment Denial · denial start 2023-04-11 · 16 days
16 day denial
Ownership
Everest Opco Group LLC
5% Or Greater Direct Ownership Interest · Organization
B&Y Healthcare S Corp
5% Or Greater Indirect Ownership Interest · Organization
B&Y Trust
5% Or Greater Indirect Ownership Interest · Organization
Blossom Healthcare Management LLC
Operational/Managerial Control · Organization
Cody Healthcare S Corp
5% Or Greater Indirect Ownership Interest · Organization
Craig Flashner 2007 Trust
5% Or Greater Indirect Ownership Interest · Organization
Flashner, Craig
Operational/Managerial Control · Individual
Flashner, Craig
Corporate Director · Individual
Kirk, Kristine
W-2 Managing Employee · Individual
Norcross, Robert
Contracted Managing Employee · Individual
Perlstein, Yitzchok
Operational/Managerial Control · Individual
Perlstein, Yitzchok
Corporate Director · Individual
Prestige Administrative Services, LLC
Operational/Managerial Control · Organization
Rogers, Stacey
Contracted Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Medilodge of GTC
Traverse City, MI
2-star overall rating with 1-star inspections with $69,430 in total fines with 11 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
The Villa at Traverse Point
Traverse City, MI
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Grand Traverse Pavilions
Traverse City, MI
2-star overall rating with 1-star inspections with abuse icon flag with $148,763 in total fines with 23 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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