Villa at Borgess Place: Advance Directive Failures - MI
The deficiency, cited during a complaint inspection on August 13, 2025, falls under a category that covers some of the most fundamental protections in long-term care: the right to request, refuse, or discontinue treatment; the right to decline participation in experimental research; and the right to formulate an advance directive. Inspectors classified the violation as isolated, with no actual harm documented, but with potential for more than minimal harm.
That last phrase carries weight. An advance directive is the document that speaks when a person can no longer speak. It is the difference between a resident receiving aggressive intervention they never wanted and dying the way they chose. When a facility fails to properly honor or facilitate those documents, the residents most at risk are those least able to advocate for themselves in the moment.
Villa at Borgess Place was cited for 18 separate deficiencies during the same inspection. This violation was one of them.
The facility falls under the category of resident rights deficiencies, a classification that covers not medical errors or staffing shortfalls but the basic legal and ethical framework that governs how residents are treated as people. Inspectors cited the home for deficient practice in this area without documenting that a specific resident was harmed, but the regulatory standard recognizes that the potential for harm in advance directive failures is real and serious.
The facility reported a correction date of September 9, 2025, nearly four weeks after inspectors walked out the door.
What the inspection report does not say is as notable as what it does. It does not describe how many residents were affected. It does not say whether a resident's documented wishes were overridden, whether staff failed to ask about advance directives at admission, or whether existing directives were simply not accessible when decisions needed to be made. The report identifies a deficiency and a scope, isolated, meaning inspectors did not find the problem spread across the facility, but it does not reconstruct the moment when a resident's right went unrecognized.
That gap is not unusual. Inspection reports at this severity level, a D on the federal scale, often record the finding without the full narrative of what triggered the complaint in the first place. Someone, somewhere, filed a complaint about this facility. Inspectors came and found something wrong in the area of treatment rights and advance directives. The details of what that looked like for the resident or residents involved are not in the public record.
What is in the public record is that Villa at Borgess Place was found deficient in 18 areas during a single inspection. Resident rights violations are not the same as medication errors or fall prevention failures. They require a different kind of institutional attention, one that goes beyond clinical protocols and into how staff are trained to talk with residents, how admissions processes handle documentation, and whether the people who work in a building understand that a resident's no means no, regardless of what a family member wants, regardless of what a physician recommends, and regardless of what is easier for the facility.
Advance directive failures can be invisible until they are not. A resident who checked a box at admission and never heard about it again. A document filed in a chart that nobody pulled when the ambulance was called. A staff member who did not know the policy, or knew it and did not follow it.
The facility has since reported that it corrected the deficiency. Whether that correction holds, and what it looked like in practice, will be tested the next time an inspector walks through the door, or the next time a resident tries to exercise a right they are legally guaranteed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Villa At Borgess Place from 2025-08-13 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: October 24, 2026 · Our methodology
Villa at Borgess Place in Kalamazoo, MI was cited for violations during a health inspection on August 13, 2025.
Inspectors classified the violation as isolated, with no actual harm documented, but with potential for more than minimal harm.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.