Villa at Borgess Place: Care Plan Failures - Kalamazoo, MI
The resident, identified in inspection records as Resident 40, had been working with therapy on her walking. She practiced between sessions by walking around the unit on her own. Her care plan said she should not be doing that.
The Director of Nursing, identified in the report only as DON "B," reviewed Resident 40's care plan during an interview with inspectors on the day of the survey. She confirmed it herself: Resident 40 should have a gait belt on and staff standing by. Resident 40 should not be walking independently in the hallway.
DON "B" told inspectors her expectation was that care plans were updated when needed and completed consistently each quarter alongside quarterly assessments. Whether Resident 40's care plan had been updated recently, or whether staff had simply been ignoring it, the inspection report does not say. What it does say is that the gap between what the care plan required and what was actually happening in the hallway was not a paperwork problem. It was a daily practice.
A gait belt is a simple tool, a wide strap fastened around a person's waist so a caregiver can steady them if they lose their balance. For someone whose care plan specifies one, the absence of it on every solo walk down the hall is not a minor oversight. Falls in nursing homes are among the most common causes of serious injury for older adults. Broken hips, head injuries, and the long recoveries that follow can permanently change what a person is able to do.
The inspection classified the harm level as minimal or potential for actual harm, and noted that some residents were affected. That classification reflects where things stood when inspectors arrived, not where they could have gone on any given afternoon when Resident 40 decided to take a walk and no one was there.
Villa at Borgess Place is located at 3057 Gull Road in Kalamazoo. The inspection was triggered by a complaint, meaning someone, a resident, a family member, or a staff member, contacted regulators before inspectors ever walked through the door.
The care plan is supposed to be the document that closes the distance between what a resident needs and what staff actually do. DON "B" described it as a living record, updated when a resident's condition changes, reviewed on a schedule. Resident 40's plan apparently reflected her needs accurately. The problem was that no one was following it.
That is the finding inspectors left with: a Director of Nursing who knew what the care plan said, confirmed it was correct, and could not explain why her staff had not been following it.
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.
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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 resident, identified in inspection records as Resident 40, had been working with therapy on her walking.
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.