Cycle 1
Health 2025-01-08 · Fire 2025-01-08
4 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Warren, MI
The Villa at City Center
4-star overall rating with 3-star inspections with $8,454 in total fines with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
11700 East Ten Mile Road, Warren, MI
(586) 759-5960
Overall
4 / 5
CMS overall stars
Health inspections
3 / 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
152
Certified beds
Average residents
140
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Villa Healthcare
Operator or chain grouping
Approved since
1979-01-25
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
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.31
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
1.25
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
2.03
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
3.59
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
1.56
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
3.14
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.20
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.33
CMS adjusted RN staffing hours
Adjusted total hours
3.84
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
36%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
33%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,518
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29.53
Composite VBP score used to determine payment impact.
Payment multiplier
0.9855
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.71
Baseline 22.55% · Performance 21.33% · Measure score 1.71 · Achievement 0 · Improvement 1.71
Healthcare-associated infections
3.88
Baseline 7.60% · Performance 6.67% · Measure score 3.88 · Achievement 3.88 · Improvement 3.05
Total nurse turnover
4.23
Baseline 65.39% · Performance 46.41% · Measure score 4.23 · Achievement 4.23 · Improvement 4.18
Adjusted total nurse staffing
1.99
Baseline 3.66 hours · Performance 3.65 hours · Measure score 1.99 · Achievement 1.99 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.43% |
10.72%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 108 · Observed rate 14.81% · Lower 95% interval 8.62% |
| Discharge to community | 46.74% |
50.57%
3.8 pts worse
|
No Different than the National Rate · Eligible stays 100 · Observed rate 39% · Lower 95% interval 37.61% |
| Medicare spending per beneficiary | 1.08 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 90.24% |
95.27%
5 pts worse
|
Numerator 74 · Denominator 82 |
| Falls with major injury | 1.22% |
0.77%
0.4 pts worse
|
Numerator 1 · Denominator 82 |
| Discharge self-care score | 42.31% |
53.69%
11.4 pts worse
|
Numerator 22 · Denominator 52 |
| Discharge mobility score | 53.85% |
50.94%
2.9 pts better
|
Numerator 28 · Denominator 52 |
| Pressure ulcers or injuries, new or worsened | 2.44% |
2.29%
0.1 pts worse
|
Numerator 2 · Denominator 82 · Adjusted rate 2.06% |
| Healthcare-associated infections requiring hospitalization | 6.67% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 54 · Observed rate 5.56% · Lower 95% interval 3.9% |
| Staff COVID-19 vaccination coverage | 100% |
8.2%
91.8 pts better
|
Numerator 5 · Denominator 5 |
| Staff flu vaccination coverage | 1.03% |
42%
41 pts worse
|
Numerator 2 · Denominator 195 |
| Discharge function score | 61.54% |
56.45%
5.1 pts better
|
Numerator 32 · Denominator 52 |
| Transfer of health information to provider | 95.65% |
95.95%
0.3 pts worse
|
Numerator 22 · Denominator 23 |
| Transfer of health information to patient | 94.87% |
96.28%
1.4 pts worse
|
Numerator 37 · Denominator 39 |
| Resident COVID-19 vaccinations up to date | 23.53% |
25.2%
1.7 pts worse
|
Numerator 12 · Denominator 51 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.8% |
95.0%
1.8 pts better
|
93.4%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 92.5% · Q2 98.3% · Q3 97.3% · Q4 99.1% · 4Q avg 96.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.9% |
95.0%
1.9 pts better
|
95.5%
1.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.7% |
3.1%
1.4 pts better
|
3.3%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 2.5% · Q3 1.8% · Q4 1.7% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.3% |
4.1%
3.2 pts worse
|
11.4%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 13.6% · Q3 2.9% · Q4 7.7% · 4Q avg 7.3% |
| Percentage of long-stay residents who lose too much weight | 2.3% |
5.5%
3.2 pts better
|
5.4%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 0.9% · Q3 2.8% · Q4 2.9% · 4Q avg 2.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.2% |
19.6%
1.4 pts better
|
19.6%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.7% · Q2 20.0% · Q3 20.8% · Q4 16.3% · 4Q avg 18.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 23.4% |
16.5%
6.9 pts worse
|
16.7%
6.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.0% · Q2 23.3% · Q3 25.0% · Q4 19.3% · 4Q avg 23.4% · 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 | 10.6% |
13.9%
3.3 pts better
|
16.3%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 13.3% · Q3 8.3% · Q4 17.4% · 4Q avg 10.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.0% |
11.7%
7.7 pts better
|
14.9%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 3.7% · Q3 4.8% · Q4 4.9% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
0.9%
0.1 pts better
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 1.6% · Q3 0.0% · Q4 0.7% · 4Q avg 0.8% · 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 | 12.7% |
20.4%
7.7 pts better
|
19.8%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.2% · Q2 11.8% · Q3 8.9% · Q4 18.0% · 4Q avg 12.7% |
| Percentage of long-stay residents with pressure ulcers | 3.9% |
5.6%
1.7 pts better
|
5.1%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 4.8% · Q3 2.6% · Q4 4.7% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 79.2% |
82.8%
3.6 pts worse
|
81.7%
2.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 70.4% · Q2 83.2% · Q3 84.1% · Q4 78.0% · 4Q avg 79.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.6% |
11.5%
2.9 pts better
|
12.0%
3.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.6% · Observed 9.2% · Expected 11.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.3% |
1.3%
1 pts better
|
1.6%
1.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.8% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 81.9% |
79.5%
2.4 pts better
|
79.7%
2.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 81.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.2% |
24.2%
5 pts worse
|
23.9%
5.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.2% · Observed 32.9% · Expected 26.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-25 · Fire 2023-10-25
15 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-08-31 · Fire 2022-08-31
25 health deficiencies
Top issue: Quality of Life and Care (9 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-01-08
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-02-07
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-01-08
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 2025-02-07
E · Potential for more than minimal harm
2025-01-08
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-02-07
D · Potential for more than minimal harm
2025-01-08
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2025-02-07
D · Potential for more than minimal harm
2025-01-08
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 2025-02-07
D · Potential for more than minimal harm
2024-08-15
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-09-06
D · Potential for more than minimal harm
2024-08-15
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-09-06
D · Potential for more than minimal harm
2024-01-31
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-21
F · Potential for more than minimal harm
2023-10-25
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 2023-11-30
E · Potential for more than minimal harm
2023-10-25
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 2023-11-30
D · Potential for more than minimal harm
2023-10-25
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 2023-11-30
D · Potential for more than minimal harm
2023-10-25
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-10-25
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-10-25
F626 · Resident Rights Deficiencies
Health
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-10-25
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 2023-11-30
D · Potential for more than minimal harm
2023-10-25
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 2023-11-30
D · Potential for more than minimal harm
2023-10-25
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-10-25
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-10-25
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-10-25
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-10-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-05-23
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2023-05-31
G · Actual harm
2023-03-02
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 2023-03-21
K · Immediate jeopardy
2022-08-31
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 2022-10-05
J · Immediate jeopardy
2022-08-31
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2022-10-05
G · Actual harm
2022-08-31
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-10-05
F · Potential for more than minimal harm
2022-08-31
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
2022-08-31
F574 · Resident Rights Deficiencies
Health
The resident has the right to receive notices in a format and a language he or she understands.
Corrected 2022-10-05
E · Potential for more than minimal harm
2022-08-31
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2022-10-05
E · Potential for more than minimal harm
2022-08-31
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 2022-10-05
E · Potential for more than minimal harm
2022-08-31
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 2022-10-05
E · Potential for more than minimal harm
2022-08-31
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-10-05
E · Potential for more than minimal harm
2022-08-31
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 2022-10-05
E · Potential for more than minimal harm
2022-08-31
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 2022-10-05
D · Potential for more than minimal harm
2022-08-31
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2022-10-05
D · Potential for more than minimal harm
2022-08-31
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 2022-10-05
D · Potential for more than minimal harm
2022-08-31
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2022-10-05
D · Potential for more than minimal harm
2022-08-31
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2022-10-05
D · Potential for more than minimal harm
2022-08-31
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-10-05
D · Potential for more than minimal harm
2022-08-31
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 2022-10-05
D · Potential for more than minimal harm
2022-08-31
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2022-10-05
D · Potential for more than minimal harm
2022-08-31
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2022-10-05
D · Potential for more than minimal harm
2022-08-31
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-10-05
D · Potential for more than minimal harm
2022-08-31
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2022-10-05
D · Potential for more than minimal harm
2022-08-31
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2022-10-05
Penalties and ownership
What sits behind the stars
$2,117
2023-11-20
Fine
Fine · fine $2,117
Fine
$1,764
2023-11-13
Fine
Fine · fine $1,764
Fine
$1,411
2023-11-06
Fine
Fine · fine $1,411
Fine
$1,764
2023-10-30
Fine
Fine · fine $1,764
Fine
$1,398
2023-10-10
Fine
Fine · fine $1,398
Fine
Ownership
Omnia Opco Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Aaron, Jonathan
Operational/Managerial Control · Individual
Aaron, Jonathan
Corporate Officer · Individual
Baumol, Yehoshua
Operational/Managerial Control · Individual
Graf, Marcella
Operational/Managerial Control · Individual
Owusu-Ansah, Kwadwo
Operational/Managerial Control · Individual
Singerman, Joseph
Operational/Managerial Control · Individual
Nearby options
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#2
Father Murray, A Villa Center
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2-star overall rating with 2-star inspections with abuse icon flag with 13 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#3
Autumn Woods Residential Health
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2-star overall rating with 2-star inspections with abuse icon flag with 14 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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