Above average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Villa At Traverse Point during CMS and state inspections, most recent first.
The facility failed to obtain informed consent from the appropriate responsible party before starting an antipsychotic medication for a resident admitted with encephalopathy, traumatic brain injury, and mild neurocognitive disorder. Although a DPOAH had been activated and the admission note documented that the resident was incapable of making informed decisions, staff obtained verbal consent for Seroquel directly from the resident and initiated two daily dosing orders. The resident’s representative later reported she had not approved the drug and would never have consented to it, and an IDT note recorded the family’s concern about the resident being sedated and on Seroquel. The SSD, responsible for medication consent forms, stated that the responsible decision-maker should sign consents and suggested the failure to obtain consent from the DPOAH was likely a clerical error, despite facility policy requiring informed consent from the resident and/or responsible party for psychotropic medications.
Four residents with physician-ordered No Added Salt (NAS) diets received meal trays containing salt packets, despite clear diet orders and tray cards specifying NAS diets. Staff interviews and review of the facility's diet manual confirmed that salt should not have been provided to these residents, indicating a failure by the dietary department to follow prescribed therapeutic diets.
A resident with intact cognition and multiple diagnoses was administered Haloperidol for bipolar disorder without documented consent. The medication was given on several occasions, and both the Social Services Director and DON confirmed that the required consent was not completed, contrary to facility policy.
Surveyors observed that the delayed egress door locking system at the main entrance near nurse's station 1 did not enter an irreversible opening sequence when the panic bar was activated, as required by NFPA 101. This deficiency, confirmed by the Maintenance Director, could affect approximately 15 occupants in the event of a fire emergency.
A shelf was found protruding over stove top burners, creating a noncompliant installation per NFPA 96 and potentially obstructing the hood suppression system. This deficiency was confirmed by the Maintenance Director and could affect approximately six occupants in the event of a fire emergency.
A fire extinguisher in the laundry room was found mounted at 66 inches above the floor, exceeding the height limit set by NFPA 10. This noncompliance was confirmed by the Maintenance Director and could affect about six occupants during a fire emergency.
The facility failed to serve food at a palatable temperature, affecting 15 residents who reported dissatisfaction with cold meals. Observations showed overcooked Brussels sprouts held at 201°F for an hour before serving, leading to mushy texture and reduced nutritive value. The NHA acknowledged the issue, which was raised in resident council meetings.
The facility failed to maintain food safety and hygiene standards, with observations of improper food storage temperatures, expired and unidentified food items, and inadequate hand hygiene practices. These deficiencies violate the FDA Food Code 2017, posing a risk of foodborne illness.
Failure to Obtain Informed Consent for Antipsychotic Medication from Resident Representative
Penalty
Summary
The facility failed to obtain informed consent from the appropriate responsible party before initiating an antipsychotic medication for a resident. The resident was admitted with diagnoses including a fourth thoracic vertebra fracture, encephalopathy, traumatic subarachnoid hemorrhage, and mild neurocognitive disorder. An admission note documented that the resident had acute metabolic encephalopathy, possibly dementia with behavioral disturbance, and was incapable of making informed decisions. A Durable Power of Attorney for Healthcare (DPOAH) had been activated prior to admission, designating DPOAH B as the person responsible for healthcare decisions. Despite this, the facility obtained verbal consent for Seroquel from the resident rather than from DPOAH B. The Medication Administration Record showed that Seroquel 25 mg was initiated on the day of admission for acute metabolic encephalopathy, with two separate daily dosing orders. The DPOAH later reported she had not approved the use of Seroquel and stated she would never have consented to that medication. An interdisciplinary team note documented that the DPOAH and family were upset that they had not been informed of the resident’s continuity of care and questioned why the resident was on Seroquel, stating they wanted the resident off the medication completely. The Social Services Director, who was responsible for medication consent forms, acknowledged that the person responsible for medical decisions should sign the consent and indicated that the failure to obtain consent from the DPOAH was likely a clerical error. The facility’s psychotropic medication guideline required informed consent from the resident and/or responsible party when psychotropic medications are initiated or changed.
Failure to Adhere to No Added Salt Diet Orders for Multiple Residents
Penalty
Summary
The facility failed to ensure that therapeutic diets, specifically No Added Salt (NAS) diets, were properly implemented for four residents with various medical conditions, including Alzheimer's disease, hypertension, chronic kidney disease, diabetes mellitus, atrial fibrillation, chronic obstructive pulmonary disease, acute congestive heart disease, and acute respiratory failure. During meal observations, each of these residents received lunch trays that included salt packets, despite their physician-ordered NAS diets. Tray cards for these residents clearly indicated the NAS diet order, yet the presence of salt packets on their trays was noted by both surveyors and the facility's registered dietitian. Interviews with staff, including a registered dietitian, confirmed that the dietary department was not following the tray cards and that salt should not have been provided to residents on NAS diets. The facility's diet manual also specifies that salt packets should not be sent on meal trays for residents prescribed a NAS diet. These findings were based on direct observation, staff interviews, and review of physician orders and diet manuals.
Failure to Obtain Consent for Antipsychotic Medication
Penalty
Summary
The facility failed to obtain consent for an antipsychotic medication prior to its initiation for one resident. The resident, who had diagnoses including bipolar disorder, type 2 diabetes mellitus, and unsteadiness on feet, was admitted with intact cognition as evidenced by a perfect score on the BIMS assessment. Physician orders indicated the resident was to receive Haloperidol for bipolar disorder, and the Medication Administration Record confirmed the medication was administered on multiple occasions. Review of the electronic medical record revealed that no consent for the antipsychotic medication had been signed by the resident. Interviews with the Social Services Director and the Director of Nursing confirmed that the required consent was not present in the record and had not been completed, despite facility policy requiring education and consent for antipsychotic drug use.
Delayed Egress Door Locking System Not Maintained per NFPA Standards
Penalty
Summary
The facility failed to maintain the delayed egress door locking system at the main entrance door near nurse's station 1. During an observation on May 7, 2025, it was found that the delayed egress device did not enter an irreversible opening sequence when the panic bar was activated, as required by NFPA 101, 19.2.2.2.4 (2), 7.2.1.6.1. This deficiency was identified through direct observation and confirmed in an interview with the Maintenance Director at the time of the survey. This failure to maintain the delayed egress system in accordance with NFPA standards could affect approximately 15 occupants in the event of a fire emergency. The report does not mention any specific residents or their medical conditions at the time of the deficiency, nor does it provide additional context regarding the individuals present beyond the number of potentially affected occupants.
Plan Of Correction
LSC Annual Survey 5.7.25K 222 Egress Doors Element 1: Main entrance door near station 1 was immediately adjusted and validated as working correctly with irreversible opening sequence triggering as it should. Element 2: A full facility audit was conducted to validate that all other egress doors were functioning properly. No other issues were identified. Element 3: The maintenance director was educated on the regulations of tag K222 in accordance with the NFPA 101 guidance. The regulatory maintenance schedule within TELS was reviewed and deemed appropriate, in addition to all other routine scheduled door inspections. Element 4: The maintenance director will validate the proper functioning of all egress doors daily and indefinitely per TELS schedule. NHA will validate with Maintenance Director weekly that all doors are working correctly. The results of all ongoing audits will be reviewed by the QAPI committee. The NHA is responsible for ongoing compliance.
Noncompliant Cooking Equipment Installation
Penalty
Summary
During an observation on May 7, 2025, surveyors identified that a shelf was protruding over the stove top burners in the facility's cooking area. This configuration was found to be noncompliant with NFPA 96, specifically section 10.2.7.3, as the shelf could obstruct the effectiveness of the hood suppression system in the event of a fire. The deficiency was confirmed through an interview with the Maintenance Director at the time of the observation. Approximately six occupants could be affected by this deficiency in the event of a fire emergency, as noted in the findings. No additional details about the medical history or condition of the occupants were provided in the report.
Plan Of Correction
LSC Annual Survey 5.7.25 K 324 Cooking Facilities Element 1 The fire suppression system over the range with the shelf was inspected by Fire Control, who adjusted the angle and type of the nozzles as well as adding. Fire Control then validated that this system was adequate for proper suppression. Element 2 A facility-wide audit does not reveal any other Ansul systems of suppression similar to the one mentioned, nor does it reveal any other obstructed sprinkler heads as part of the standard facility suppression system. Element 3 The maintenance director was educated on the regulations of tag K 324 in accordance with the NFPA 101 guidance. The regulatory maintenance schedule within TELS was reviewed and deemed appropriate, in addition to all other routine scheduled inspections and maintenance of the fire suppression systems. Element 4 The maintenance director will audit the Ansul system monthly in addition to all other routine TELS tasks to ensure nozzles are in proper place and working order. The results of all ongoing audits will be reviewed by the QAPI committee. The NHA is responsible for ongoing compliance.
Fire Extinguisher Mounted Above Allowed Height
Penalty
Summary
During an observation on May 7, 2025, it was found that the ABC fire extinguisher in the laundry room was mounted at approximately 66 inches above the floor, which exceeds the maximum height allowed by NFPA 10, 6.1.3.8.1. This installation did not comply with the requirements for selecting, installing, inspecting, and maintaining portable fire extinguishers as outlined in NFPA 10. The deficiency was confirmed through an interview with the Maintenance Director at the time of observation. Approximately six occupants could be affected by this deficiency in the event of a fire emergency, as noted in the report.
Plan Of Correction
LSC Annual Survey 5.7.25 K 355 Portable Fire Extinguishers Element 1 The laundry room fire extinguisher was moved down 6 inches to the proper height and validated to be mounted correctly. Element 2 An inspection was performed of all fire extinguishers in the facility to ensure none were mounted any higher than 60 inches. Element 3 The maintenance director was educated on the regulations of tag K 355 in accordance with the NFPA 101 guidance. The regulatory maintenance schedule within TELS was reviewed and deemed appropriate, in addition to all other routine scheduled fire extinguisher inspections. Element 4 The maintenance director will continue to validate monthly per TELS the mounting of all fire extinguishers at the proper height. The NHA will validate these findings with the Maintenance Director. The results of all ongoing audits will be reviewed by the QAPI committee. The NHA is responsible for ongoing compliance.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to provide food at a palatable temperature for 15 out of 27 residents interviewed, leading to dissatisfaction with meals and potential nutritional issues. Multiple residents reported that their food was often served cold or cool, and attempts to reheat the food resulted in it becoming rubbery. During interviews, residents expressed that the cold temperature of the food made it unpalatable, with some noting that they were served last, resulting in cold meals. Additionally, issues such as overcooked vegetables and soggy bread were reported, along with the absence of salt and pepper on meal trays. Observations during the survey revealed that the steam table setup for the evening meal included a pan of Brussels sprouts that had been placed in the steam table about an hour before the meal was to begin. The temperature of the Brussels sprouts was measured at 201°F, and they were observed to be overcooked and mushy, indicating a lack of full nutritive value. The Nursing Home Administrator acknowledged the residents' concerns about food temperature, which had been raised in resident council meetings, and recognized the need for improvement in this area.
Food Safety and Hygiene Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by multiple observations and interviews. During an inspection, two pans of sliced ham steaks were found on a food preparation table with temperatures ranging from 54 F to 61 F, which is above the safe holding temperature of 41 F. Additionally, a pan of ham steaks in the refrigerator was at 48 F. A pan of tuna salad was found with expired dates and was disposed of after being identified as expired. The facility's refrigerators had rusted and uncleanable wire rack shelves. In the pantry refrigerators, expired sandwiches and unidentified food items were found, along with eggs not procured from an approved source, which were brought in by staff from a personal farm. Further deficiencies were noted in hand hygiene and food handling practices. The hand towel dispenser at the only hand sink available to food service staff was repeatedly found empty, preventing proper hand drying. A staff member was observed putting on gloves without washing hands first, and the temperature of pureed chicken was found to be 115 F, below the required 135 F for hot holding. Additionally, ham and cheese sandwiches were left at 51 F without any attempt to keep them cold. These practices violate the FDA Food Code 2017, which mandates specific temperature controls and handwashing protocols to prevent foodborne illnesses.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Traverse City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Medilodge Of Gtc | 1.3 mi | ★★★★★ | 20 | 1 |
| Medilodge Of Traverse City | 1.5 mi | ★★★★★ | 0 | 0 |
| Grand Traverse Pavilions | 1.8 mi | ★★★★★ | 6 | 0 |
| Orchard Creek Skilled Nursing | 4.7 mi | ★★★★★ | 14 | 0 |
| Maple Valley Nursing Home | 14.6 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.