Villa at Borgess Place: Unreported Elopements - MI
The January incident was one of several reporting failures discovered during an August inspection at the 3057 Gull Road facility. Administrators also failed to report two separate instances when a resident escaped the building, including one incident they never documented at all.
Resident 66, who has Alzheimer's disease and a history of sexual abuse, told Licensed Practical Nurse "ZZ" on January 26 at 5:00 PM that a visitor — the husband of another resident — had molested her. The facility's incident report wasn't submitted until 11:43 AM the following day.
Former Nursing Home Administrator "EEE" conducted the investigation but couldn't remember details about reporting the incident to the state when questioned by inspectors in August. She confirmed that abuse allegations should be reported within two hours.
The facility's own policy, dated November 28, 2017, states administrators must "report 'abuse' to the state agency per State and Federal requirements immediately" and "not later than 2 hours."
Current Administrator "A" acknowledged the two-hour reporting requirement during her August 13 interview with inspectors.
The resident who made the allegation has multiple diagnoses including late-onset Alzheimer's disease, psychotic disorder with delusions, and visual hallucinations. Her medical record notes a social history of sexual abuse.
Separate reporting failures involved Resident 73, who escaped the building twice. Family Member "CCC" told inspectors the facility called her on two occasions to report her relative had eloped. The first escape occurred shortly after the resident was admitted. The second happened "sometime in the last few months."
Administrator "A" confirmed Resident 73 exited the building on April 23, 2025. She said the incident wasn't reported to the state because she believed staff witnessed it. When inspectors pressed for documentation, she admitted having no signed staff interviews about the incident and was unaware of any records in the resident's medical file.
The administrator's reasoning contradicts federal requirements. Facilities must report all incidents involving residents leaving the premises without authorization, regardless of whether staff witnessed the departure.
Both elopements went unreported despite clear regulatory obligations. The facility's failure to document the April incident suggests a broader pattern of inadequate record-keeping around serious safety events.
The inspection revealed systemic problems with incident reporting at Villa at Borgess Place. Administrators either misunderstood their obligations or chose not to follow them, leaving state oversight agencies unaware of multiple serious incidents.
For Resident 66, the delayed reporting meant state investigators couldn't immediately assess the abuse allegation or take protective measures. The 18-hour delay violated federal standards designed to ensure rapid response to vulnerable residents' safety concerns.
The facility's handling of both the abuse allegation and the elopements raises questions about staff training and administrative oversight. Neither the former nor current administrator demonstrated clear understanding of reporting requirements during inspector interviews.
Resident 73's two escapes particularly highlight security concerns. Facilities caring for residents with dementia must implement safeguards to prevent wandering, a potentially life-threatening behavior. The fact that one escape went completely undocumented suggests inadequate monitoring systems.
The April 23 elopement occurred during spring weather, but residents who wander from facilities face serious risks regardless of season. They can become disoriented, suffer injuries, or encounter traffic hazards. Prompt reporting allows law enforcement and emergency services to respond quickly.
Administrator "A's" assumption that witnessed elopements don't require reporting reflects a fundamental misunderstanding of federal rules. All unauthorized departures must be reported within 24 hours, with immediate notification for incidents involving injury or when residents remain missing.
The facility's policy manual clearly outlines reporting requirements, yet administrators failed to follow their own procedures. This disconnect between written policies and actual practice suggests inadequate staff training or supervision.
Family Member "CCC" received calls about both elopements, indicating the facility recognized these as serious incidents. Yet administrators chose not to notify state authorities who monitor facility safety and investigate patterns of concern.
The inspection findings reveal a facility where serious incidents affecting resident safety weren't properly reported or documented. Both the sexual abuse allegation and the elopements required immediate state notification under federal law.
Resident 66's complex medical history, including her vulnerability due to past trauma and current cognitive impairment, made the delayed abuse reporting particularly concerning. Residents with dementia and histories of abuse require heightened protection and immediate response to safety concerns.
The former administrator's inability to recall details about reporting the abuse allegation suggests either poor record-keeping or inadequate attention to serious incidents. Federal inspectors expect administrators to maintain detailed knowledge of all reported incidents.
Villa at Borgess Place's reporting failures left state oversight agencies unaware of multiple serious safety concerns over several months. The pattern suggests systemic problems with incident management and regulatory compliance.
Current Administrator "A" acknowledged the two-hour reporting requirement but failed to apply it consistently. Her rationale for not reporting the April elopement demonstrates ongoing confusion about federal obligations.
The facility's failure to document Resident 73's escape compounds the reporting violation. Without written records, inspectors cannot assess what happened, what caused the incident, or what measures were taken to prevent recurrence.
Both residents involved in these incidents have conditions that make them particularly vulnerable. Resident 66's dementia and trauma history require careful protection, while Resident 73's elopement risk demands constant vigilance and proper security measures.
The inspection revealed a facility where administrators either didn't understand or chose to ignore federal reporting requirements designed to protect vulnerable residents. Family Member "CCC" continues to worry about her relative's safety after two separate escapes from the building.
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.
The January incident was one of several reporting failures discovered during an August inspection at the 3057 Gull Road facility.
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.