Villa At Borgess Place
Villa at Borgess Place in Kalamazoo, MI — inspection on August 13, 2025.
Found 18 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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.
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.
reported Resident #81 was normally social, and not one to make allegations against others. In an
she was pretty independent but lately she had not been feeling well and required assistance. In an
the emergency room for evaluation. DON B reported she had interviewed Resident #81 following being notified of the resident's report to the CNA. DON B reported she had asked her to give me the details of the incident and what she had told the CNA she reported it to. DON B reported Resident #81 reported a couple weeks prior to last week, Wound Nurse KKK had been in her room performing an assessment on her and she reported she had felt his fingers were inside of her vagina which he moved around in there. DON B reported she explained to Resident #81 the facility would contact the police and the steps the facility could do; she was offered to go to the hospital but Resident #81 felt it was not necessary.
When queried, DON B reported Resident #81 did experience vaginal dryness and expressed she had vaginal discomfort as well as pain above the pubic bone. DON B reported Wound Nurse FFF was not on shift when the incident was reported. DON B reported she contacted him via the phone and informed him of his immediate suspension. DON B reported Wound Nurse FFF had come to the facility for a few minutes, NHA A asked him to give us a scenario of what happened, he refused, and NHA A explained the process to him and why the facility needed him to give us his side of the events. DON B reported he stated he didn't want to say anything at this time, and he was informed to reach out if he changed his mind. In an interview on 08/13/25 at 3:04 PM, NHA A reported she got a phone call from the LPN SS and CNA J. NHA A reported CNA J was giving Resident #81 a shower and she reported to the CNA she was glad her fungal/yeast infection were cleared up and she didn't like the wound care nurse coming and touching her. Resident #81 had informed CNA J she didn't feel comfortable with him touching me down there. NHA A reported the Unit Manager and the DON had come into the building to assess and begin investigation of the allegation. NHA A reported the Wound Nurse KKK was suspended that day, 7/12/25. NHA A reported on Monday, she called Wound Nurse KKK, and he had come in to talk to her and she wanted to get his statement. NHA A informed him of the allegation, and he immediately didn't want to say anything, he didn't want to talk unless he had representation, and he left the building. NHA A reported she reached out to him again for him to provide a statement, and he refused to participate in the investigation. NHA A reported she was informed he had obtained an attorney but had not provided a statement to the allegation to this date.
NHA A reported as far as she knew the police investigation was ongoing as the detective reported to her, he was waiting for Wound Nurse KKK's attorney to contact the 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.
235289 08/13/2025
Villa at Borgess Place 3057 Gull Road Kalamazoo, MI 49048
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.
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.
235289 08/13/2025
Villa at Borgess Place 3057 Gull Road Kalamazoo, MI 49048
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.
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.
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.
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.
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.
completed with therapy during her sessions and she would practice it when she wasn’t
In an interview on [DATE] at 2:27 pm, “Director of Nursing” (DON) “B”
quarterly 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.
235289 08/13/2025
Villa at Borgess Place 3057 Gull Road Kalamazoo, MI 49048
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.
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.
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.
During an observation on [DATE] 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] and the only noted documented date of suctioning was [DATE]…” During an interview on [DATE] “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”.
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.
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.
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.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.