Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
The Villa at the Bay
Petoskey, MI · 110 certified beds · Last Life Safety survey May 22, 2025
CMS Certification Number 235429 · first certified March 1983
Ownership
Operated by VILLA HEALTHCARE · For profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within MI
16 citations — more than 60% of the 422 certified nursing homes in MI. Compared within MI rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 8 citations; the earlier surveys in the window averaged 4. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (May 2026 to July 2026), and past the point by which nine in ten MI facilities have been surveyed. This facility’s last Life Safety survey was May 2025. Facilities in MI are typically surveyed 12–14 months after the last one (median 13), measured over 723 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
Get an email about The Villa at the Bay
One email when it happens. No account; stop it any time with one click.
Emergency preparedness
4 of the 16 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
10 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 16 Life Safety citations above. The Physical Environment Index
- F-0880 Provide and implement an infection prevention and control program.
- F-0906 Provide enough power supply for lighting all entrances and exits; equipment for fire detection and alarm systems, and extinguishers.
- F-0919 Make sure that a working call system is available in each resident's bathroom and bathing area.
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
How that compares
Compared with the median facility in MI, and nationally. Surveyors differ markedly between states, so the MI figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 16 |
| Median facility in MI | 14 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| September 20, 2023 | 5 |
| July 17, 2024 | 3 |
| May 22, 2025 | 8 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| E-0041 | Implement emergency and standby power systems. | 2 | 2025-05-22 |
| K-0511 | Have properly installed electrical wiring and gas equipment. | 1 | 2023-09-20 |
| K-0222 | 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. | 1 | 2025-05-22 |
| K-0923 | Have proper medical gas storage and administration areas. | 1 | 2025-05-22 |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | 1 | 2023-09-20 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 1 | 2024-07-17 |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | 1 | 2025-05-22 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 1 | 2025-05-22 |
What the citations cover
- Smoke Deficiencies 6
- Egress Deficiencies 4
- Emergency Preparedness Deficiencies 4
- Gas, Vacuum, and Electrical Systems Deficiencies 1
- Other 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 6 |
| Egress Deficiencies | 4 |
| Emergency Preparedness Deficiencies | 4 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 1 |
| Services Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
May 22, 2025 — 8 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0020 | Establish policies and procedures including evacuation. | Deficient, Provider has date of correction (June 16, 2025) |
| E-0041 | Implement emergency and standby power systems. | Deficient, Provider has date of correction (July 9, 2025) |
| K-0222 | 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. | Deficient, Provider has date of correction (June 16, 2025) |
| K-0241 | Have correct number of accessible exits for each story. | Deficient, Provider has plan of correction (July 7, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (June 16, 2025) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (June 16, 2025) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (June 16, 2025) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (June 16, 2025) |
July 17, 2024 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0232 | Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Deficient, Provider has date of correction (August 13, 2024) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (August 13, 2024) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (August 13, 2024) |
September 20, 2023 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (October 13, 2023) |
| E-0041 | Implement emergency and standby power systems. | Deficient, Provider has date of correction (October 13, 2023) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (October 13, 2023) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (October 13, 2023) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (October 13, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.