Cycle 1
Health 2025-05-22 · Fire 2025-05-22
18 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Petoskey, MI
The Villa at the Bay
1-star overall rating with 1-star inspections with $241,488 in total fines with 18 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
1500 Spring Street, Petoskey, MI
(231) 347-5500
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
110
Certified beds
Average residents
73
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Villa Healthcare
Operator or chain grouping
Approved since
1983-03-25
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
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.48
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
1.12
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
3.63
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
1.60
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
3.10
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.28
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.54
CMS adjusted RN staffing hours
Adjusted total hours
4.05
CMS adjusted total nurse staffing hours
Case-mix index
1.23
Higher values indicate more complex resident acuity
RN turnover
59%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
71%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,130
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
24.67
Composite VBP score used to determine payment impact.
Payment multiplier
0.9835
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.89
Baseline 20.31% · Performance 20.56% · Measure score 1.89 · Achievement 1.89 · Improvement 0
Healthcare-associated infections
4.91
Baseline 5.20% · Performance 6.37% · Measure score 4.91 · Achievement 4.91 · Improvement 0
Total nurse turnover
1.50
Baseline 54.24% · Performance 57.53% · Measure score 1.50 · Achievement 1.50 · Improvement 0
Adjusted total nurse staffing
1.57
Baseline 3.08 hours · Performance 3.52 hours · Measure score 1.57 · Achievement 1.57 · Improvement 1.13
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.17% |
10.72%
1.6 pts better
|
No Different than the National Rate · Eligible stays 94 · Observed rate 5.32% · Lower 95% interval 6.29% |
| Discharge to community | 44.14% |
50.57%
6.4 pts worse
|
No Different than the National Rate · Eligible stays 69 · Observed rate 37.68% · Lower 95% interval 35.53% |
| Medicare spending per beneficiary | 0.75 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 97.92% |
95.27%
2.7 pts better
|
Numerator 47 · Denominator 48 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 48 |
| Discharge self-care score | 48.72% |
53.69%
5 pts worse
|
Numerator 19 · Denominator 39 |
| Discharge mobility score | 61.54% |
50.94%
10.6 pts better
|
Numerator 24 · Denominator 39 |
| Pressure ulcers or injuries, new or worsened | 6.25% |
2.29%
4 pts worse
|
Numerator 3 · Denominator 48 · Adjusted rate 6.24% |
| Healthcare-associated infections requiring hospitalization | 6.37% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 52 · Observed rate 3.85% · Lower 95% interval 3.32% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 64 |
| Staff flu vaccination coverage | 1.12% |
42%
40.9 pts worse
|
Numerator 1 · Denominator 89 |
| Discharge function score | 64.1% |
56.45%
7.6 pts better
|
Numerator 25 · Denominator 39 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 95.24% |
96.28%
1 pts worse
|
Numerator 20 · Denominator 21 |
| Resident COVID-19 vaccinations up to date | 26.09% |
25.2%
0.9 pts better
|
Numerator 6 · Denominator 23 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.7
0.4 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.1 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
1.5
0.5 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.8 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.9% |
95.0%
1.9 pts better
|
93.4%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.3% · Q2 91.7% · Q3 100.0% · Q4 100.0% · 4Q avg 96.9% |
| 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 | 5.4% |
3.1%
2.3 pts worse
|
3.3%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 5.0% · Q3 4.5% · Q4 5.9% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 21.4% |
4.1%
17.3 pts worse
|
11.4%
10 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.3% · Q2 32.7% · Q3 26.2% · Q4 8.6% · 4Q avg 21.4% |
| 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 7.0% · Q2 3.7% · Q3 5.0% · Q4 6.6% · 4Q avg 5.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.2% |
19.6%
3.4 pts better
|
19.6%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.7% · Q2 18.5% · Q3 13.1% · Q4 13.1% · 4Q avg 16.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.5% |
16.5%
About the same
|
16.7%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 15.8% · Q3 16.7% · Q4 14.3% · 4Q avg 16.5% · 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 | 14.2% |
13.9%
0.3 pts worse
|
16.3%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 22.4% · Q2 3.7% · Q3 18.4% · Q4 10.9% · 4Q avg 14.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.6% |
11.7%
3.1 pts better
|
14.9%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.5% · Q2 6.4% · Q3 7.3% · Q4 7.1% · 4Q avg 8.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
1.7%
0.5 pts better
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.0% · Q3 1.5% · Q4 1.5% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.7% |
20.4%
6.3 pts worse
|
19.8%
6.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.9% · Q2 24.8% · Q3 34.6% · Q4 28.0% · 4Q avg 26.7% |
| Percentage of long-stay residents with pressure ulcers | 6.3% |
5.6%
0.7 pts worse
|
5.1%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 5.5% · Q3 10.5% · Q4 1.6% · 4Q avg 6.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.0% |
82.8%
14.2 pts better
|
81.7%
15.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.4% · Q2 95.5% · Q3 97.4% · Q4 98.3% · 4Q avg 97.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.7% |
11.5%
0.2 pts worse
|
12.0%
0.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.7% · Observed 13.2% · Expected 12.6% · 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 | 81.4% |
79.5%
1.9 pts better
|
79.7%
1.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 81.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.9% |
24.2%
6.3 pts better
|
23.9%
6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.9% · Observed 21.1% · Expected 28.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-17 · Fire 2024-07-17
17 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-09-20 · Fire 2023-09-20
25 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
5 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-22
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2025-06-16
F · Potential for more than minimal harm
2025-05-22
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2025-07-09
F · Potential for more than minimal harm
2025-05-22
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-06-16
E · Potential for more than minimal harm
2025-05-22
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 2025-06-16
E · Potential for more than minimal harm
2025-05-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-16
E · Potential for more than minimal harm
2025-05-22
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-06-16
D · Potential for more than minimal harm
2025-05-22
K241 · Egress Deficiencies
Fire Safety
Have correct number of accessible exits for each story.
Corrected 2025-07-07
D · Potential for more than minimal harm
2025-05-22
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-06-16
F · Potential for more than minimal harm
2024-07-17
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-08-13
E · Potential for more than minimal harm
2024-07-17
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2024-08-13
E · Potential for more than minimal harm
2024-07-17
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-08-13
F · Potential for more than minimal harm
2023-09-20
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-10-13
F · Potential for more than minimal harm
2023-09-20
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-10-13
E · Potential for more than minimal harm
2023-09-20
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-10-13
D · Potential for more than minimal harm
2023-09-20
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-10-13
D · Potential for more than minimal harm
2023-09-20
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-10-13
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-26
F603 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Corrected 2025-12-02
G · Actual harm
2025-05-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-25
G · Actual harm
2025-05-22
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-06-25
F · Potential for more than minimal harm
2025-05-22
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-06-25
F · Potential for more than minimal harm
2025-05-22
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2025-06-25
F · Potential for more than minimal harm
2025-05-22
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2025-07-18
F · Potential for more than minimal harm
2025-05-22
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 2025-07-18
F · Potential for more than minimal harm
2025-05-22
F906 · Environmental Deficiencies
Health
Provide enough power supply for lighting all entrances and exits; equipment for fire detection and alarm systems, and extinguishers.
Corrected 2025-06-25
F · Potential for more than minimal harm
2025-05-22
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-06-25
E · Potential for more than minimal harm
2025-05-22
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 2025-06-25
E · Potential for more than minimal harm
2025-05-22
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 2025-06-25
D · Potential for more than minimal harm
2025-05-22
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-06-25
D · Potential for more than minimal harm
2025-05-22
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2025-07-09
D · Potential for more than minimal harm
2025-05-22
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 2025-07-09
D · Potential for more than minimal harm
2025-05-22
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 2025-06-25
D · Potential for more than minimal harm
2025-05-22
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 2025-06-25
D · Potential for more than minimal harm
2025-05-22
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-07-18
D · Potential for more than minimal harm
2025-05-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-18
G · Actual harm
2025-02-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-08
D · Potential for more than minimal harm
2025-02-20
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 2025-03-14
D · Potential for more than minimal harm
2025-02-20
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 2025-03-14
D · Potential for more than minimal harm
2025-02-20
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 2025-03-14
D · Potential for more than minimal harm
2025-02-20
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-03-14
G · Actual harm
2024-07-17
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-08-13
F · Potential for more than minimal harm
2024-07-17
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 2024-08-30
F · Potential for more than minimal harm
2024-07-17
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2024-08-13
F · Potential for more than minimal harm
2024-07-17
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 2024-08-22
E · Potential for more than minimal harm
2024-07-17
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2024-08-13
D · Potential for more than minimal harm
2024-07-17
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 2024-07-14
D · Potential for more than minimal harm
2024-07-17
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-08-22
D · Potential for more than minimal harm
2024-07-17
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2024-08-13
D · Potential for more than minimal harm
2024-07-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-22
E · Potential for more than minimal harm
2024-05-08
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-06-05
E · Potential for more than minimal harm
2024-05-08
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 2024-06-05
D · Potential for more than minimal harm
2024-05-08
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 2024-06-05
D · Potential for more than minimal harm
2023-12-20
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 2024-01-05
F · Potential for more than minimal harm
2023-09-20
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 2023-10-13
E · Potential for more than minimal harm
2023-09-20
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 2023-10-13
E · Potential for more than minimal harm
2023-09-20
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 2023-10-13
E · Potential for more than minimal harm
2023-09-20
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 2023-10-13
D · Potential for more than minimal harm
2023-09-20
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 2023-10-13
D · Potential for more than minimal harm
2023-09-20
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2023-10-13
D · Potential for more than minimal harm
2023-09-20
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 2023-10-13
D · Potential for more than minimal harm
2023-09-20
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-10-13
D · Potential for more than minimal harm
2023-09-20
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2023-10-13
D · Potential for more than minimal harm
2023-09-20
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-10-13
D · Potential for more than minimal harm
2023-09-20
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2023-10-13
D · Potential for more than minimal harm
2023-09-20
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 2023-10-13
D · Potential for more than minimal harm
2023-09-20
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-10-13
D · Potential for more than minimal harm
2023-09-20
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 2023-10-13
D · Potential for more than minimal harm
2023-09-20
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 2023-10-13
D · Potential for more than minimal harm
2023-09-20
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-10-13
D · Potential for more than minimal harm
2023-09-20
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-10-13
D · Potential for more than minimal harm
2023-09-20
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2023-10-13
D · Potential for more than minimal harm
2023-09-20
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-10-13
D · Potential for more than minimal harm
2023-09-20
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2023-10-13
D · Potential for more than minimal harm
2023-09-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-13
D · Potential for more than minimal harm
2023-05-25
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 2023-06-14
D · Potential for more than minimal harm
2023-03-30
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 2023-04-18
D · Potential for more than minimal harm
2023-03-30
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 2023-04-18
Penalties and ownership
What sits behind the stars
$110,448
2025-05-22
Fine
Fine · fine $110,448
Fine
$0
2025-05-22
Payment Denial
Payment Denial · denial start 2025-06-19 · 29 days
29 day denial
$131,040
2025-02-20
Fine
Fine · fine $131,040
Fine
$0
2025-02-20
Payment Denial
Payment Denial · denial start 2025-03-21 · 18 days
18 day denial
$0
2024-07-17
Payment Denial
Payment Denial · denial start 2024-08-15 · 26 days
26 day denial
Ownership
Omnia Opco Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Aaron, Jonathan
Corporate Officer · Individual
Baumol, Yehoshua
Operational/Managerial Control · Individual
Graf, Marcella
Operational/Managerial Control · Individual
Mclenna, Ashley
Operational/Managerial Control · Individual
Singerman, Joseph
Operational/Managerial Control · Individual
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#3
Boulder Park Terrace
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