Villa At Borgess Place
Inspection History Overview
Detailed Inspection Reports
Notice: These are official CMS inspection narratives containing detailed regulatory findings. This information is not available in searchable format anywhere else online.
Fines and Penalties by Year
2022 1 penalties totaling $15,000
Fine
2020 1 penalties totaling $15,000
Fine
Health Violations by Year
2025 4 violations
Provide and implement an infection prevention and control program.
Ensure that residents are free from significant medication errors.
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
2024 16 violations
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Reasonably accommodate the needs and preferences of each resident.
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Provide safe and appropriate respiratory care for a resident when needed.
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Provide and implement an infection prevention and control program.
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
2023 9 violations
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Provide care and assistance to perform activities of daily living for any resident who is unable.
Provide care or services that was trauma informed and/or culturally competent.
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Provide and implement an infection prevention and control program.
2022 6 violations
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Provide safe and appropriate respiratory care for a resident when needed.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Provide and implement an infection prevention and control program.
2020 7 violations
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Provide and implement an infection prevention and control program.
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Provide safe and appropriate respiratory care for a resident when needed.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Provide and implement an infection prevention and control program.
2019 21 violations
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Provide and implement an infection prevention and control program.
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Respond appropriately to all alleged violations.
Provide care and assistance to perform activities of daily living for any resident who is unable.
Allow residents to self-administer drugs if determined clinically appropriate.
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Provide activities to meet all resident's needs.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Provide and implement an infection prevention and control program.
2018 6 violations
Reasonably accommodate the needs and preferences of each resident.
Keep residents' personal and medical records private and confidential.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Provide enough food/fluids to maintain a resident's health.
Provide safe and appropriate respiratory care for a resident when needed.
Provide and implement an infection prevention and control program.
2017 3 violations
Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being.
Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse.
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
Villa at Borgess Place is a 1-star nursing home in Kalamazoo, MI with 101 beds.
Most recent inspection: Data not available. No current violations on record.
📍 3057 Gull Road, Kalamazoo, MI
💵 Accepts Medicare and Medicaid