Villa At Borgess Place
Villa at Borgess Place in Kalamazoo, MI — inspection on March 26, 2026.
Found 4 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
During the appeal process, the resident will not be discharged . D.
Documentation of notification: a.
The resident's physician and facility staff will document in the resident's record: The resident's health status at the time of notice.
Reason the services provided by the facility are no longer needed, document discharge needs and discharge plan .
Date when staff reviewed the notice and its contents with the resident and resident representative.
Date of formal discharge planning meeting and appeal rights. b.
Documentation will include the basis for the transfer and the services to be provided by the receiving health care provider that will meet the resident's needs . F.
Orientation for transfer/discharge: a.
The facility will provide the resident with sufficient preparation and orientation to the upcoming discharge to ensure that the discharge is safe and orderly.
The orientation will be provided to the resident and resident representative in a form and manner that can be understood .f.
The facility will provide the appropriate education related to medication, treatments, medical care and services, psychosocial needs, care interventions and approaches and other applicable approaches for a safe care transition .
Documentation: a.
The resident needs and discharge plan must be documented in the medical record. If a discharge to the community is determined to not be feasible, document who made the determination and reason. b.
The resident and resident representative will be informed of the final discharge plan . c. An evaluation of the resident's discharge needs will be documented in the resident record on a timely basis.
The results of this evaluation will be discussed with the resident or resident representative .
235289 03/26/2026
Villa at Borgess Place 3057 Gull Road Kalamazoo, MI 49048
Resident #101 one other time and other staff had told her that the resident liked to walk around her
#101's door was closed all night. CNA J reported that the last time she checked on Resident #101
needed to find transfer and ambulation status.In an interview on 3/26/26 at 9:19 AM, Director of Nursing (DON) B reported that Resident #101 was assessed by nursing to be at high risk for falls upon admission and was evaluated by therapy and determined to require at least 1 assist for transfers and ambulation. DON B reported that the nurse managers should enter that information into the care plan.
DON B reported that Resident #101 did not have a fall care plan and/or her transfer status documented in her care plan or Kardex until after she had fallen which was 4 days after admission.
DON B reported the care plan carries over direct care needs to the Kardex. DON B reported that the CNA's are expected to refer to the information in the Kardex to determine the resident's needs; Resident #101 was at high risk for falls and she should have had frequent checks and should not have been ambulating on her own. DON B reported that she was not aware that Resident #101's care plan/kardex was missing the information until talking to this surveyor.In an interview on 3/26/26 at 11:25 AM, Occupational Therapist (OT) R reported that Resident #101 could not follow commands, did not use her call light, got up and walked on her own, but required assistance of at least one person to be safe. OT R reported that Resident #101 was evaluated and then discharged before treatment started.
235289 03/26/2026
Villa at Borgess Place 3057 Gull Road Kalamazoo, MI 49048
some intermittent cough which is mostly dry.He has a multitude of mostly administrative complaints
235289 03/26/2026
Villa at Borgess Place 3057 Gull Road Kalamazoo, MI 49048
.Transfers: toilet transfer: partial/moderate assistance.Cognition/Communication Assessment: .
ADLs.Review of Resident #101's Physical Therapy Evaluation dated 1/16/26 revealed, .Functional
assistance.
Assessment Summary: .Cognition: decision making ability for routine activities: severely impaired.
Review of the facility policy Fall Evaluation Safety Guideline dated 11/28/17 revealed, Purpose: To consistently identify and evaluate residents at risk for falls and those who have fallen to treat or refer for treatment appropriately and develop an organization-wide ownership for fall prevention to: .prevent or reduce injuries related to falls.
Residents who are evaluated as being at risk for falls will be identified and individualized fall precautions will be developed for each resident.
Preventative measures shall be taken to decrease the number of falls whenever possible.Procedure:
- Fall Risk Evaluation will be completed. 2. If evaluation finds the resident at risk, implement resident
specific interventions/precautions. 3.
Initiate, review and revise the fall care plan as appropriate, with new or discontinued interventions.
Falls Prevention: environmental evaluation, individual risk factors, rounding, applied appropriate supervision, footwear, medication regimen review, management of incontinence/toileting program, evaluation for pain, evaluation of mental status, strength and balance, exercise programs, education.