Villa at Borgess Place: Abuse Reporting Failures - MI
That delay is at the center of a complaint inspection completed August 13 at Villa at Borgess Place, a nursing home at 3057 Gull Road in Kalamazoo. Federal inspectors also found the facility had failed to report two separate instances in which a resident walked out of the building undetected, and that the nursing home administrator had no documentation of either incident in the resident's medical records.
The resident who reported being molested, identified in inspection records only as Resident #66, was described as a long-term care resident with Alzheimer's disease with late onset, psychotic disorder with delusions, and visual hallucinations. Her records also noted a social history of sexual abuse.
On January 26, 2025, at 5:00 in the afternoon, Resident #66 told her nurse, a licensed practical nurse identified in the report as LPN "ZZ," that a visitor to the facility had molested her. The visitor, whose name was omitted from the inspection report, was described as the husband of another long-term care resident at the facility.
The facility's own incident report documented the allegation this way: Resident #66 "makes statements that [visitor] touches her inappropriately." On that January afternoon, she told her nurse that the man "molested her."
The facility did not submit the report to the state agency until the following morning, January 27, at 11:43 a.m. That is roughly eighteen and a half hours after Resident #66 spoke to her nurse.
The former nursing home administrator who investigated the incident, identified in the report as FNHA "EEE," was interviewed by inspectors on August 13. Asked directly why the report had not gone to the state within two hours of the alleged incident being discovered, she said she did not remember the details of reporting the incident to the state. She confirmed, when pressed, that abuse allegations are supposed to be reported within two hours.
The current nursing home administrator, identified as NHA "A," said the same thing in her own interview that day. Abuse allegations, she told inspectors, must be reported within two hours to the state. She offered no explanation for why her predecessor had not done so.
The facility's own written policy, dated November 28, 2017, states that alleged violations involving abuse, neglect, and mistreatment "are reported immediately, but not later than 2 hours."
Nobody reported within two hours. Nobody, seven months later, could explain why.
Resident #66 was not the only resident whose situation the facility failed to disclose to state regulators.
A family member identified in the report as FM "CCC" told inspectors on August 12 that the facility had called her on two separate occasions to tell her that a resident, identified as Resident #73, had walked out of the building. The first elopement, she said, happened shortly after the resident was admitted. The second occurred "sometime in the last few months."
An elopement, in nursing home terms, means a resident left the building without staff knowledge or authorization. For residents with dementia or cognitive impairment, it is among the most dangerous things that can happen. In 2011, a dementia patient named Dennis Buckham walked away from a Brooklyn nursing home during Thanksgiving activities and was found frozen to death on a sidewalk.
NHA "A" confirmed to inspectors that Resident #73 had exited the building on April 23, 2025. She said the incident had not been reported to the state agency because she believed it had been witnessed by staff.
When inspectors asked her to produce documentation supporting that belief, she could not. She told inspectors she did not have any signed, documented staff interviews related to the incident. She was not aware of any documentation of the event in the resident's medical records at all.
There were no staff interviews. There was nothing in the chart. The administrator's explanation for why she hadn't reported a resident walking out of a locked facility was that she thought someone had seen it happen, and she had no paperwork to show anyone had.
The inspection was triggered by a complaint, not a routine survey. That means someone, likely a family member or staff member, contacted regulators before inspectors arrived. The report does not identify who filed the complaint or when.
Federal inspectors rated the harm level for these violations as "minimal harm or potential for actual harm," affecting few residents. That language, standard in CMS inspection reports, describes the regulatory classification, not the experience of a woman with dementia and a history of sexual abuse who told her nurse she had been molested, and whose allegation sat unreported through the night.
The facility's plan of correction was not included in the publicly available inspection record. CMS directs anyone seeking that information to contact the nursing home or the state survey agency directly.
What the inspection record does contain is this: a former administrator who could not remember why she waited, a current administrator who knew the rule and could not explain the gap, and a resident whose allegation of molestation was documented in the facility's own incident report and still did not reach the state for nearly nineteen hours.
Resident #66's nurse heard what she said. The facility wrote it down. And then, for the rest of that evening and through the night and into the following morning, nothing happened.
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.
Download the official CMS inspection PDF from Medicare.gov
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.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
Villa at Borgess Place in Kalamazoo, MI was cited for abuse-related violations during a health inspection on August 13, 2025.
That delay is at the center of a complaint inspection completed August 13 at Villa at Borgess Place, a nursing home at 3057 Gull Road in Kalamazoo.
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.