Hamtramck, MI

St. Joseph's, A Villa Center

5-star overall rating with 4-star inspections with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle

9400 Conant Street, Hamtramck, MI

(313) 874-4500

Compare this facility

Overall

5 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

169

Certified beds

Average residents

141

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Villa Healthcare

Operator or chain grouping

Approved since

1978-11-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

18 facilities

Chain averages 3 overall / 2 health / 3 staffing / 5 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

0.19

Registered nurse staffing · state 0.77 · national 0.68

LPN hours / resident day

1.03

Licensed practical nurse staffing · state 0.88 · national 0.87

Aide hours / resident day

2.14

Nurse aide staffing · state 2.38 · national 2.35

Total nurse hours

3.36

All reported nurse hours · state 4.03 · national 3.89

Licensed hours

1.22

RN + LPN hours · state 1.65 · national 1.54

Weekend hours

3.15

Weekend nurse staffing · state 3.52 · national 3.43

Weekend RN hours

0.12

Weekend registered nurse coverage · state 0.49 · national 0.47

Physical therapist

0.02

Reported PT staffing · state 0.07 · national 0.07

Adjusted RN hours

0.22

CMS adjusted RN staffing hours

Adjusted total hours

3.90

CMS adjusted total nurse staffing hours

Case-mix index

1.18

Higher values indicate more complex resident acuity

RN turnover

20%

Annual RN turnover · state 41% · national 45%

Total nurse turnover

32%

Annual nurse turnover · state 44% · national 46%

SNF VBP

Value-based purchasing

Program rank

4,075

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

41.42

Composite VBP score used to determine payment impact.

Payment multiplier

0.9943

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

1.28

Baseline 21.92% · Performance 21.05% · Measure score 1.28 · Achievement 0.83 · Improvement 1.28

Healthcare-associated infections

5.28

Baseline 9.12% · Performance 6.74% · Measure score 5.28 · Achievement 3.67 · Improvement 5.28

Total nurse turnover

7.13

Baseline 38.20% · Performance 34.54% · Measure score 7.13 · Achievement 7.13 · Improvement 2.24

Adjusted total nurse staffing

2.87

Baseline 3.56 hours · Performance 3.89 hours · Measure score 2.87 · Achievement 2.87 · Improvement 1.01

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.34%	10.72% 0.6 pts worse	No Different than the National Rate · Eligible stays 60 · Observed rate 15% · Lower 95% interval 6.43%
Discharge to community	41.96%	50.57% 8.6 pts worse	No Different than the National Rate · Eligible stays 64 · Observed rate 29.69% · Lower 95% interval 30.48%
Medicare spending per beneficiary	0.8	1.02 0.2 pts better
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 34 · Denominator 34
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 34
Discharge self-care score	75%	53.69% 21.3 pts better	Numerator 15 · Denominator 20
Discharge mobility score	65%	50.94% 14.1 pts better	Numerator 13 · Denominator 20
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 34 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	6.74%	7.12% 0.4 pts better	No Different than the National Rate · Eligible stays 36 · Observed rate 5.56% · Lower 95% interval 3.64%
Staff COVID-19 vaccination coverage	65.12%	8.2% 56.9 pts better	Numerator 84 · Denominator 129
Staff flu vaccination coverage	17.91%	42% 24.1 pts worse	Numerator 24 · Denominator 134
Discharge function score	50%	56.45% 6.5 pts worse	Numerator 10 · Denominator 20
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	98.5%	95.0% 3.5 pts better	93.4% 5.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 96.9% · Q2 99.3% · Q3 99.2% · Q4 98.4% · 4Q avg 98.5%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	98.6%	95.0% 3.6 pts better	95.5% 3.1 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 98.6%
Percentage of long-stay residents experiencing one or more falls with major injury	1.0%	3.1% 2.1 pts better	3.3% 2.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.7% · Q3 1.5% · Q4 0.8% · 4Q avg 1.0% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	0.4%	4.1% 3.7 pts better	11.4% 11 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.7% · 4Q avg 0.4%
Percentage of long-stay residents who lose too much weight	5.6%	5.5% 0.1 pts worse	5.4% 0.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 8.6% · Q3 3.1% · Q4 4.9% · 4Q avg 5.6%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	6.1%	19.6% 13.5 pts better	19.6% 13.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 5.4% · Q3 7.1% · Q4 5.6% · 4Q avg 6.1%
Percentage of long-stay residents who received an antipsychotic medication	9.5%	16.5% 7 pts better	16.7% 7.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 12.0% · Q2 5.9% · Q3 6.8% · Q4 12.6% · 4Q avg 9.5% · 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	7.7%	13.9% 6.2 pts better	16.3% 8.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 15.5% · Q3 8.1% · Q4 2.0% · 4Q avg 7.7% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	6.0%	11.7% 5.7 pts better	14.9% 8.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 5.0% · Q3 7.6% · Q4 6.9% · 4Q avg 6.0% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.2%	0.9% 0.7 pts better	1.0% 0.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.7% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.0%	1.7% 1.7 pts better	1.7% 1.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	14.2%	20.4% 6.2 pts better	19.8% 5.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 18.6% · Q2 13.1% · Q3 11.7% · Q4 13.4% · 4Q avg 14.2%
Percentage of long-stay residents with pressure ulcers	3.6%	5.6% 2 pts better	5.1% 1.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 4.9% · Q3 3.0% · Q4 2.3% · 4Q avg 3.6% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	89.1%	82.8% 6.3 pts better	81.7% 7.4 pts better	Short Stay · 2024Q4-2025Q3 · Q1 97.1% · Q2 97.4% · Q3 84.3% · Q4 81.0% · 4Q avg 89.1%
Percentage of short-stay residents who had an outpatient emergency department visit	13.6%	11.5% 2.1 pts worse	12.0% 1.6 pts worse	Short Stay · 20240701-20250630 · Adjusted 13.6% · Observed 17.2% · Expected 14.1% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.0%	1.3% 1.3 pts better	1.6% 1.6 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	97.4%	79.5% 17.9 pts better	79.7% 17.7 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 97.4%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	20.7%	24.2% 3.5 pts better	23.9% 3.2 pts better	Short Stay · 20240701-20250630 · Adjusted 20.7% · Observed 27.6% · Expected 31.8% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-02-05 · Fire 2025-02-05

5 health deficiencies

Top issue: Environmental (2 deficiencies)

2 fire-safety deficiencies

Top issue: Services (1 deficiency)

Cycle 2 Health 2023-11-29 · Fire 2023-11-29

4 health deficiencies

Top issue: Environmental (1 deficiency)

4 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 3 Health 2022-09-13 · Fire 2022-09-13

9 health deficiencies

Top issue: Nutrition and Dietary (2 deficiencies)

1 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2025-02-05

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-02-23

E · Potential for more than minimal harm 2025-02-05

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2025-02-23

F · Potential for more than minimal harm 2023-11-29

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

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

Corrected 2023-12-15

E · Potential for more than minimal harm 2023-11-29

K342 · Smoke Deficiencies

Fire Safety

Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.

Corrected 2023-12-15

E · Potential for more than minimal harm 2023-11-29

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-12-15

E · Potential for more than minimal harm 2023-11-29

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2023-12-15

E · Potential for more than minimal harm 2022-09-13

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2022-10-05

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-04-10

F742 · Quality of Life and Care Deficiencies

Health

Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.

Corrected 2025-05-05

F · Potential for more than minimal harm 2025-02-05

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 2025-02-23

D · Potential for more than minimal harm 2025-02-05

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2025-02-23

C · Minimal harm 2025-02-05

F912 · Environmental Deficiencies

Health

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

Corrected 2025-02-23

C · Minimal harm 2025-02-05

F921 · Environmental Deficiencies

Health

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Corrected 2025-02-23

D · Potential for more than minimal harm 2023-11-29

F584 · Resident Rights Deficiencies

Health

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.

Corrected 2023-12-15

D · Potential for more than minimal harm 2023-11-29

F711 · Nursing and Physician Services Deficiencies

Health

Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.

Corrected 2023-12-15

D · Potential for more than minimal harm 2023-11-29

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 2023-12-15

C · Minimal harm 2023-11-29

F912 · Environmental Deficiencies

Health

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

Corrected 2023-12-15

F · Potential for more than minimal harm 2022-09-13

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 2022-10-05

E · Potential for more than minimal harm 2022-09-13