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

Compare this facility

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

Staffing

Hours and turnover

RN hours / resident day

0.88

Registered nurse staffing

LPN hours / resident day

0.34

Licensed practical nurse staffing

Aide hours / resident day

2.11

Nurse aide staffing

Weekend hours

2.66

Weekend nurse staffing

RN turnover

27%

Annual RN turnover

Total nurse turnover

64%

Annual nurse turnover

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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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

Survey summary

Recent inspection cycles

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)

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

100% 14 facilities 2023-07-01

Aaron, Jonathan