Cycle 1
Health 2025-05-08 · Fire 2025-05-08
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Traverse City, MI
The Villa at Traverse Point
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
2828 Concord Street, Traverse City, MI
(231) 941-1200
Overall
5 / 5
CMS overall stars
Health inspections
4 / 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
96
Certified beds
Average residents
78
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Villa Healthcare
Operator or chain grouping
Approved since
1981-08-25
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
0.88
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.34
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
2.11
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
3.33
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
2.66
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.65
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
1.07
CMS adjusted RN staffing hours
Adjusted total hours
4.06
CMS adjusted total nurse staffing hours
Case-mix index
1.12
Higher values indicate more complex resident acuity
RN turnover
27%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
64%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,210
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
17.67
Composite VBP score used to determine payment impact.
Payment multiplier
0.9818
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.63
Baseline 17.61% · Performance 21.14% · Measure score 0.63 · Achievement 0.63 · Improvement 0
Healthcare-associated infections
2.59
Baseline 4.88% · Performance 7.06% · Measure score 2.59 · Achievement 2.59 · Improvement 0
Total nurse turnover
0.99
Baseline 67.74% · Performance 61.33% · Measure score 0.99 · Achievement 0.57 · Improvement 0.99
Adjusted total nurse staffing
2.86
Baseline 3.26 hours · Performance 3.89 hours · Measure score 2.86 · Achievement 2.86 · Improvement 2.01
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.01% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 96 · Observed rate 7.29% · Lower 95% interval 6.8% |
| Discharge to community | 51.53% |
50.57%
1 pts better
|
No Different than the National Rate · Eligible stays 82 · Observed rate 48.78% · Lower 95% interval 42.05% |
| 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 68 · Denominator 68 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 68 |
| Discharge self-care score | 50% |
53.69%
3.7 pts worse
|
Numerator 25 · Denominator 50 |
| Discharge mobility score | 40% |
50.94%
10.9 pts worse
|
Numerator 20 · Denominator 50 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 68 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.06% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 52 · Observed rate 5.77% · Lower 95% interval 4.37% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 81 |
| Staff flu vaccination coverage | 35.92% |
42%
6.1 pts worse
|
Numerator 51 · Denominator 142 |
| Discharge function score | 56% |
56.45%
0.5 pts worse
|
Numerator 28 · Denominator 50 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 97.14% |
96.28%
0.9 pts better
|
Numerator 34 · Denominator 35 |
| Resident COVID-19 vaccinations up to date | 35% |
25.2%
9.8 pts better
|
Numerator 14 · Denominator 40 |
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 1.8 · Expected 2.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
1.5
0.9 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.7 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
95.0%
5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.4% |
95.0%
3.4 pts better
|
95.5%
2.9 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.9% |
3.1%
2.2 pts better
|
3.3%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.7% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 26.9% |
4.1%
22.8 pts worse
|
11.4%
15.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.8% · Q2 33.3% · Q3 22.4% · Q4 19.6% · 4Q avg 26.9% |
| Percentage of long-stay residents who lose too much weight | 1.6% |
5.5%
3.9 pts better
|
5.4%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.0% · Q3 2.2% · Q4 2.2% · 4Q avg 1.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.7% |
19.6%
0.1 pts worse
|
19.6%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.8% · Q2 17.3% · Q3 21.3% · Q4 19.6% · 4Q avg 19.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.7% |
16.5%
5.8 pts better
|
16.7%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 13.5% · Q3 9.1% · Q4 8.8% · 4Q avg 10.7% · 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 | 6.4% |
13.9%
7.5 pts better
|
16.3%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 20.2% · Q3 0.0% · Q4 0.0% · 4Q avg 6.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.2% |
11.7%
7.5 pts better
|
14.9%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 2.0% · Q3 6.5% · Q4 2.2% · 4Q avg 4.2% · 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 | 0.9% |
1.7%
0.8 pts better
|
1.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.7% |
20.4%
1.7 pts better
|
19.8%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.4% · Q2 21.7% · Q3 19.8% · Q4 15.3% · 4Q avg 18.7% |
| Percentage of long-stay residents with pressure ulcers | 7.3% |
5.6%
1.7 pts worse
|
5.1%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 12.4% · Q3 7.8% · Q4 3.6% · 4Q avg 7.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 90.2% |
82.8%
7.4 pts better
|
81.7%
8.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 90.4% · Q2 86.8% · Q3 92.1% · Q4 90.7% · 4Q avg 90.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.0% |
11.5%
1.5 pts worse
|
12.0%
1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.0% · Observed 12.2% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.0% |
1.3%
0.7 pts worse
|
1.6%
0.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 1.2% · Q3 0.0% · Q4 1.1% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.6% |
79.5%
11.1 pts better
|
79.7%
10.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.8% |
24.2%
4.4 pts better
|
23.9%
4.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.8% · Observed 16.2% · Expected 19.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-11 · Fire 2024-06-11
2 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-08-24 · Fire 2023-08-24
11 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-05-08
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 2025-05-23
E · Potential for more than minimal harm
2025-05-08
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-05-23
E · Potential for more than minimal harm
2025-05-08
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-05-23
F · Potential for more than minimal harm
2024-06-11
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-07-03
E · Potential for more than minimal harm
2024-06-11
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 2024-07-03
D · Potential for more than minimal harm
2024-06-11
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2024-07-03
F · Potential for more than minimal harm
2023-08-24
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-09-22
D · Potential for more than minimal harm
2023-08-24
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 2023-09-22
D · Potential for more than minimal harm
2023-08-24
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-09-22
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-05-08
F808 · Nutrition and Dietary Deficiencies
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2025-05-23
D · Potential for more than minimal harm
2025-05-08
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-05-23
F · Potential for more than minimal harm
2024-06-11
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-07-03
F · Potential for more than minimal harm
2024-06-11
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 2024-07-03
D · Potential for more than minimal harm
2023-12-05
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-12-22
F · Potential for more than minimal harm
2023-08-24
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 2023-09-22
F · Potential for more than minimal harm
2023-08-24
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 2023-09-22
F · Potential for more than minimal harm
2023-08-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-22
E · Potential for more than minimal harm
2023-08-24
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 2023-09-22
E · Potential for more than minimal harm
2023-08-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-09-22
E · Potential for more than minimal harm
2023-08-24
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2023-09-22
D · Potential for more than minimal harm
2023-08-24
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-09-22
D · Potential for more than minimal harm
2023-08-24
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-09-22
D · Potential for more than minimal harm
2023-08-24
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-09-22
D · Potential for more than minimal harm
2023-06-23
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 2023-07-07
Penalties and ownership
What sits behind the stars
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
Link, Eric
Operational/Managerial Control · Individual
Singerman, Joseph
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
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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
Medilodge of Traverse City
Traverse City, MI
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
#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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