Villa at Borgess Place: Drug Storage Violations - MI
The citation, issued August 13, 2025, fell under the category of pharmacy service deficiencies. Inspectors determined the facility was not storing drugs and biologicals in locked compartments, and was not keeping controlled substances in separately locked storage as required. Labeling was also found to be out of compliance with accepted professional standards.
The violation was classified at Scope/Severity Level D, meaning inspectors identified it as an isolated problem with no documented harm to any resident. But the classification also carries a specific finding: there was potential for more than minimal harm. In a facility where residents may be living with dementia, mobility limitations, or complex medication regimens, unsecured drugs and missing or incorrect labels are not a paperwork problem. They are the conditions under which a resident receives someone else's medication, or a controlled substance disappears without anyone knowing.
The drug storage citation was one of 18 deficiencies inspectors cited during this single visit.
That number matters. Eighteen deficiencies in one inspection does not describe a facility with one overlooked cabinet. It describes a facility where inspectors found problems moving from area to area, department to department. The pharmacy violation is the one that made this report, but it arrived in the company of 17 others.
Villa at Borgess Place reported a correction date of September 9, 2025, roughly four weeks after the inspection.
Whether the fix involved relocking a cabinet, reprinting labels, restructuring how controlled substances are stored, or some combination of those things is not something the inspection record specifies. What the record specifies is that on August 13, the drugs were not secured and not properly labeled. Residents living in the facility that day were in an environment where the basic infrastructure meant to protect them from medication error had broken down.
Medication errors in nursing homes are not rare events that happen despite good systems. They tend to happen because the systems are not maintained. A label peels off and nobody replaces it. A lock breaks and nobody reports it. A controlled substance log goes unchecked. Each of those failures is small in isolation. Together, they describe a facility where the habits that prevent harm have slipped.
The inspection that produced this citation was a complaint inspection, meaning someone prompted regulators to take a closer look. Inspectors arrived and found 18 things wrong.
For the residents at Villa at Borgess Place, the correction date of September 9 means that for at least 27 days after inspectors documented the problem, the facility was operating under a known deficiency. The drugs are reportedly secured now. The labels are reportedly in order. The 18 deficiencies from August have, according to the facility, been addressed.
What the inspection record cannot answer is how long the cabinet was unlocked before anyone noticed, or whether any resident was harmed in a way that went undocumented. Level D citations record potential, not outcomes. The absence of documented harm is not the same as the absence of harm.
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 22, 2026 · Our methodology
Villa at Borgess Place in Kalamazoo, MI was cited for violations during a health inspection on August 13, 2025.
The citation, issued August 13, 2025, fell under the category of pharmacy service deficiencies.
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.