Villa at Borgess Place: Undocumented Care Failures - MI
The August inspection at Villa at Borgess Place revealed a pattern of undocumented care that left no record of whether vulnerable residents received prescribed treatments for wounds, skin protection, and breathing assistance.
Resident 47 required suctioning "as needed for secretions," but when inspectors reviewed the treatment administration record, they found documentation for just one date since the order began. On the day of inspection, Licensed Practical Nurse "T" was observed performing the suctioning procedure at 11:49 am.
For another resident, multiple prescribed treatments went undocumented on specific dates when care should have been provided. The resident's orders included daily wound care with border gauze dressing changes, twice-daily heel protectors to prevent pressure sores, and repositioning every two to three hours to prevent moisture-associated skin damage.
The wound care order specified cleaning and covering with border gauze "once per day and as needed if dressing becomes soiled." Documentation showed a blank space for completion on one required date.
Ammonium lactate lotion was prescribed twice daily for dry skin on the resident's arms and legs, with morning and bedtime applications. The bedtime application went undocumented on one date inspectors reviewed.
Heel protectors, ordered twice daily to prevent pressure ulcers, showed no documentation of completion at 8 pm on one date. The treatment was meant to run from a specific start date through a discontinuation date.
The most frequent gaps involved repositioning requirements. Staff were supposed to reposition the resident every two to three hours using a wedge cushion to prevent moisture-associated skin damage and pressure ulcers. Documentation was missing for the 9 pm repositioning on one date, and for both midnight and 3 am repositioning on another date.
When inspectors interviewed Nurse Manager and Registered Nurse "N," she confirmed that both dressing changes and treatments should be documented in the medical record. She specifically stated that documentation was required when performing oral suctioning for Resident 47.
The nurse manager invoked a fundamental principle of medical record-keeping. "If it wasn't documented, it wasn't done," she told inspectors.
This standard creates a documentation dilemma that extends beyond simple paperwork. When treatments designed to prevent serious complications like pressure sores, infections, or respiratory distress go unrecorded, there's no way to verify whether vulnerable residents received the care their conditions required.
Repositioning schedules exist because immobile residents can develop painful and dangerous pressure ulcers within hours. The resident's every-two-to-three-hour schedule was specifically designed for pressure ulcer prevention and managing moisture-associated skin damage.
Heel protectors serve a similar preventive function. Pressure sores on heels can become severe quickly in residents who cannot shift their own weight or position.
For Resident 47, the suctioning procedure addresses a potentially life-threatening issue. Residents who cannot clear their own secretions risk aspiration pneumonia or respiratory distress if the procedure isn't performed when needed.
The inspection found that while staff were observed providing some treatments, the documentation failures created gaps in the medical record that made it impossible to verify consistent care delivery.
Ammonium lactate lotion, while less critical than repositioning or suctioning, was prescribed to address dry skin that can crack and become infected in elderly residents.
The facility's own nurse manager acknowledged the documentation requirements and stated the policy that undocumented care is considered care not provided. This makes the pattern of missing documentation particularly significant, as it suggests either treatments weren't given as prescribed or staff consistently failed to record care they provided.
The inspection covered multiple residents and found documentation gaps across different types of prescribed treatments, from wound care to positioning to respiratory support.
Federal inspectors classified the violations as having minimal harm or potential for actual harm, affecting some residents. The findings occurred during a complaint investigation that examined the facility's treatment documentation practices.
Villa at Borgess Place staff were observed providing care during the inspection, but the missing documentation left questions about whether prescribed treatments were consistently delivered when inspectors weren't present.
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: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Villa at Borgess Place in Kalamazoo, MI was cited for violations during a health inspection on August 13, 2025.
On the day of inspection, Licensed Practical Nurse "T" was observed performing the suctioning procedure at 11:49 am.
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.