Villa At Borgess Place
Inspection Findings
F-Tag F0550
Federal health inspectors cited Villa at Borgess Place in Kalamazoo, MI for a deficiency under regulatory tag F-F0550 during a standard health inspection conducted on 2025-08-13.
Category: Resident Rights Deficiencies
The facility was found deficient in the following area: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 18 deficiencies cited during this inspection of Villa at Borgess Place.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-09.
F-Tag F0578
Federal health inspectors cited Villa at Borgess Place in Kalamazoo, MI for a deficiency under regulatory tag F-F0578 during a standard health inspection conducted on 2025-08-13.
Category: Resident Rights Deficiencies
The facility was found deficient in the following area: 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.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 18 deficiencies cited during this inspection of Villa at Borgess Place.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-09.
F-Tag F0600
F 0600 Level of Harm - Minimal harm or potential for actual harm
police and provide a statement. NHA A reported she had reached out to the Wound Nurse KKK again, and
he did not respond. NHA A reported he was terminated from the facility. This writer attempted to contact Wound Nurse KKK, this writer did not hear from Wound Nurse KKK prior to exit of survey.
Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
08/13/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Villa at Borgess Place
3057 Gull Road Kalamazoo, MI 49048
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0605
Federal health inspectors cited Villa at Borgess Place in Kalamazoo, MI for a deficiency under regulatory tag F-F0605 during a standard health inspection conducted on 2025-08-13.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
The facility was found deficient in the following area: Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 18 deficiencies cited during this inspection of Villa at Borgess Place.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-09.
F-Tag F0609
F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
In an interview on 8/12/25 at 11:50am, Family Member (FM) “CCC” reported the facility called her on two separate occasions to report Resident #73 had eloped from the building. FM “CCC” reported the first elopement occurred shortly after the resident was admitted to the facility on [DATE REDACTED] and again, “sometime in the last few months”.
In an interview on 8/13/25 at 12:48pm, NHA “A” reported Resident #73 exited the building on 4/23/25. NHA “A” reported the incident was not submitted to the state agency because she thought the incident was witnessed by staff. When further queried, NHA “A” reported she did not have any signed, documented staff interviews related to the incident and was not aware of any documentation of the event in the resident’s medical records.
Review of an “Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property” facility policy with a reference date of 11/28/17, revealed “PURPOSE:…The Nursing Home Administrator or designee will report “abuse” to the state agency per State and Federal requirements immediately…REPORTING AND RESPONSE:…The facility will ensure that alleged violations involving abuse…neglect…mistreatment…are reported immediately, but not later than 2 hours…”.
Resident #66
Review of an “admission Record” revealed Resident #66 was a female, with pertinent diagnoses which included: Alzheimer’s Disease (a form of dementia) with late onset, psychotic disorder with delusions due to known physiological condition, and visual hallucinations.
Review of a “Facility Report Incident” (FRI) incident report revealed, “…Details Type of Alleged Incident: Abuse…Date/Time Incident Discovered 1/26/25 05:00 PM…Facility Investigator: (“Former Nursing Home Administrator” (FNHA) “EEE”) .Incident
Summary
(Resident #66) is a long term care resident with medical history of dementia and depressive and psychotic disorders and a social history of sexual abuse in her past. (Resident #66) makes statements that (visitor name omitted), the husband of another long term care resident, touches her inappropriately. On 1/26/25 (Resident #66) told her nurse (“Licensed Practical Nurse” (LPN) “ZZ”) that (visitor name omitted) molested her…Submitted Date/Time: 1/27/25 11:43 AM…”
In an interview on 8/13/25 at 12:05 PM, “Nursing Home Administrator” (NHA) “A” reported abuse allegations must be reported within 2 hours to the State.
In an interview on 8/13/25 at 12:26 PM, FNHA “EEE”, when queried as to why the FRI reported on 1/27/25 at 11:43 AM for Resident #66 had not been reported to the State Agency within two hours of the Date/Time Incident Discovered on 1/26/25 at 5:00 PM, FNHA “EEE” reported
she did not remember the details of reporting the incident to the State. FNHA “EEE” confirmed an allegation of abuse should be reported within 2 hours to the State.
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
08/13/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Villa at Borgess Place
3057 Gull Road Kalamazoo, MI 49048
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0628
Federal health inspectors cited Villa at Borgess Place in Kalamazoo, MI for a deficiency under regulatory tag F-F0628 during a standard health inspection conducted on 2025-08-13.
Category: Resident Rights Deficiencies
The facility was found deficient in the following area: Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 18 deficiencies cited during this inspection of Villa at Borgess Place.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-09.
F-Tag F0655
Federal health inspectors cited Villa at Borgess Place in Kalamazoo, MI for a deficiency under regulatory tag F-F0655 during a standard health inspection conducted on 2025-08-13.
Category: Resident Assessment and Care Planning Deficiencies
The facility was found deficient in the following area: Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 18 deficiencies cited during this inspection of Villa at Borgess Place.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-09.
F-Tag F0656
Federal health inspectors cited Villa at Borgess Place in Kalamazoo, MI for a deficiency under regulatory tag F-F0656 during a standard health inspection conducted on 2025-08-13.
Category: Resident Assessment and Care Planning Deficiencies
The facility was found deficient in the following area: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Scope/Severity Level G: isolated, actual harm that is not immediate jeopardy.
Actual harm to residents was documented as a result of this deficiency.
This was one of 18 deficiencies cited during this inspection of Villa at Borgess Place.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-09.
F-Tag F0677
Federal health inspectors cited Villa at Borgess Place in Kalamazoo, MI for a deficiency under regulatory tag F-F0677 during a standard health inspection conducted on 2025-08-13.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide care and assistance to perform activities of daily living for any resident who is unable.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 18 deficiencies cited during this inspection of Villa at Borgess Place.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-03.
F-Tag F0686
Federal health inspectors cited Villa at Borgess Place in Kalamazoo, MI for a deficiency under regulatory tag F-F0686 during a standard health inspection conducted on 2025-08-13.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Scope/Severity Level G: isolated, actual harm that is not immediate jeopardy.
Actual harm to residents was documented as a result of this deficiency.
This was one of 18 deficiencies cited during this inspection of Villa at Borgess Place.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-03.
F-Tag F0689
F 0689 Level of Harm - Minimal harm or potential for actual harm
with the quarterly assessments. DON “B” reviewed Resident #40’s care plan and confirmed Resident #40 should have a gait belt on and staff standing by; Resident #40 should not be walking independently in the hallway.
Residents Affected - Some
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
08/13/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Villa at Borgess Place
3057 Gull Road Kalamazoo, MI 49048
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0756
Federal health inspectors cited Villa at Borgess Place in Kalamazoo, MI for a deficiency under regulatory tag F-F0756 during a standard health inspection conducted on 2025-08-13.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 18 deficiencies cited during this inspection of Villa at Borgess Place.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-09.
F-Tag F0761
Federal health inspectors cited Villa at Borgess Place in Kalamazoo, MI for a deficiency under regulatory tag F-F0761 during a standard health inspection conducted on 2025-08-13.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: 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.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 18 deficiencies cited during this inspection of Villa at Borgess Place.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-09.
F-Tag F0812
Federal health inspectors cited Villa at Borgess Place in Kalamazoo, MI for a deficiency under regulatory tag F-F0812 during a standard health inspection conducted on 2025-08-13.
Category: Nutrition and Dietary Deficiencies
The facility was found deficient in the following area: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 18 deficiencies cited during this inspection of Villa at Borgess Place.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-09.
F-Tag F0842
F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some
wound and cover with boarder gauze once per day and as needed if dressing becomes soiled every day shift for MASD (moisture associated skin damage) with a start date of [DATE REDACTED] and a D/C date of [DATE REDACTED], there was no noted documentation for completion on [DATE REDACTED], the date was blank .
Ammonium Lactate External Lotion 5% .Apply to arms and legs topically every morning and at bedtime for dry skin with a start dates of [DATE REDACTED]… there was no noted documentation for completion on [DATE REDACTED] at bedtime… Heel protectors to prevent decubitus ulcers on the heels two times a day with a start date of [DATE REDACTED] and a D/C date of [DATE REDACTED] with no noted documentation of completion on [DATE REDACTED] at 2000 (8 pm)… Reposition resident every 2-3 hours and PRN (as needed); use wedge cushion at resident’s bedside to assist with repositioning every 3 hours for MASD, pressure ulcer prevention with a start date of [DATE REDACTED] with no noted documentation of completion on [DATE REDACTED] 21:00 (9:00 pm), [DATE REDACTED] at 0000 (12:00 am) and 0300 (3:00 am)…”
During an observation on [DATE REDACTED] at 11:49 am, “Licensed Practical Nurse” (LPN) “T” was observed performing oral suctioning on Resident #47.
Review of the “TAR” for Resident #47 revealed “…May suction as needed as needed for secretions with a start date of [DATE REDACTED] and the only noted documented date of suctioning was [DATE REDACTED]…”
During an interview on [DATE REDACTED] “Nurse Manager/Registered Nurse” (NM/RN) “N” reported that dressing changes and treatments should be documented in the record.
NM/RN “N” reported that documentation was required when performing oral suctioning for Resident #47. NM/RN “N” stated “If it wasn’t documented, it wasn’t done”.
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
F-Tag F0847
Federal health inspectors cited Villa at Borgess Place in Kalamazoo, MI for a deficiency under regulatory tag F-F0847 during a standard health inspection conducted on 2025-08-13.
Category: Administration Deficiencies
The facility was found deficient in the following area: Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 18 deficiencies cited during this inspection of Villa at Borgess Place.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-09.
F-Tag F0880
Federal health inspectors cited Villa at Borgess Place in Kalamazoo, MI for a deficiency under regulatory tag F-F0880 during a standard health inspection conducted on 2025-08-13.
Category: Infection Control Deficiencies
The facility was found deficient in the following area: Provide and implement an infection prevention and control program.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 18 deficiencies cited during this inspection of Villa at Borgess Place.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-03.
F-Tag F0921
Federal health inspectors cited Villa at Borgess Place in Kalamazoo, MI for a deficiency under regulatory tag F-F0921 during a standard health inspection conducted on 2025-08-13.
Category: Environmental Deficiencies
The facility was found deficient in the following area: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 18 deficiencies cited during this inspection of Villa at Borgess Place.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-09.
Villa at Borgess Place in Kalamazoo, MI inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Kalamazoo, MI, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Villa at Borgess Place or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.