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.
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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/13/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Villa at Borgess Place
3057 Gull Road Kalamazoo, MI 49048
SUMMARY STATEMENT OF DEFICIENCIES
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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/13/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Villa at Borgess Place
3057 Gull Road Kalamazoo, MI 49048
SUMMARY STATEMENT OF DEFICIENCIES
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.
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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/13/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Villa at Borgess Place
3057 Gull Road Kalamazoo, MI 49048
SUMMARY STATEMENT OF DEFICIENCIES
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”.
Facility ID:
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.