Facility Watch Inspection records for every certified US nursing home

Villa at Borgess Place

3057 Gull Road
Kalamazoo, MI 49048
(269) 552-6500

Special Focus Facility — SFF Candidate
CCN
235289
Certified beds
101
Ownership
For profit - Corporation
Chain
Villa Healthcare

Nurse staffing

4.59
Total nurse staffing hours per resident per day, case-mix adjusted

Registered nurses: 0.85 hours per resident per day

Nursing staff turnover: 66% a year

Derived by CMS from the Payroll-Based Journal and refreshed quarterly.

Inspection history

Inspected April 21, 2026

3 citations · from a complaint investigation · Health
D
F0677 No actual harm with potential for more than minimal harm · Isolated

Provide care and assistance to perform activities of daily living for any resident who is unable.

Deficient, Provider has date of correction · corrected April 22, 2026
D
F0880 No actual harm with potential for more than minimal harm · Isolated

Provide and implement an infection prevention and control program.

Deficient, Provider has date of correction · corrected May 13, 2026
G
F0686 Actual harm · Isolated

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Deficient, Provider has date of correction · corrected April 22, 2026

Inspected March 26, 2026

4 citations · from a complaint investigation · Health
D
F0627 No actual harm with potential for more than minimal harm · Isolated

Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.

Deficient, Provider has date of correction · corrected April 22, 2026
D
F0655 No actual harm with potential for more than minimal harm · Isolated

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Deficient, Provider has date of correction · corrected April 22, 2026
D
F0658 No actual harm with potential for more than minimal harm · Isolated

Ensure services provided by the nursing facility meet professional standards of quality.

Deficient, Provider has date of correction · corrected April 22, 2026
G
F0689 Actual harm · Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Deficient, Provider has date of correction · corrected April 22, 2026

Inspected December 10, 2025

6 citations · from a complaint investigation · Health
D
F0550 No actual harm with potential for more than minimal harm · Isolated

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Deficient, Provider has date of correction · corrected January 5, 2026
D
F0655 No actual harm with potential for more than minimal harm · Isolated

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Deficient, Provider has date of correction · corrected January 5, 2026
D
F0658 No actual harm with potential for more than minimal harm · Isolated

Ensure services provided by the nursing facility meet professional standards of quality.

Deficient, Provider has date of correction · corrected January 5, 2026
D
F0690 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Deficient, Provider has date of correction · corrected January 5, 2026
D
F0694 No actual harm with potential for more than minimal harm · Isolated

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Deficient, Provider has date of correction · corrected January 5, 2026
D
F0880 No actual harm with potential for more than minimal harm · Isolated

Provide and implement an infection prevention and control program.

Deficient, Provider has date of correction · corrected January 5, 2026

Inspected August 13, 2025

18 citations · from a complaint investigation · Health
D
F0578 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected September 9, 2025
D
F0600 No actual harm with potential for more than minimal harm · Isolated

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Deficient, Provider has date of correction · corrected September 9, 2025
D
F0605 No actual harm with potential for more than minimal harm · Isolated

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Deficient, Provider has date of correction · corrected September 9, 2025
D
F0609 No actual harm with potential for more than minimal harm · Isolated

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Deficient, Provider has date of correction · corrected September 9, 2025
D
F0628 No actual harm with potential for more than minimal harm · Isolated

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Deficient, Provider has date of correction · corrected September 9, 2025
D
F0655 No actual harm with potential for more than minimal harm · Isolated

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Deficient, Provider has date of correction · corrected September 9, 2025
D
F0677 No actual harm with potential for more than minimal harm · Isolated

Provide care and assistance to perform activities of daily living for any resident who is unable.

Deficient, Provider has date of correction · corrected October 3, 2025
D
F0756 No actual harm with potential for more than minimal harm · Isolated

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Deficient, Provider has date of correction · corrected September 9, 2025
D
F0761 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected September 9, 2025
D
F0880 No actual harm with potential for more than minimal harm · Isolated

Provide and implement an infection prevention and control program.

Deficient, Provider has date of correction · corrected October 3, 2025
E
F0550 No actual harm with potential for more than minimal harm · Pattern

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Deficient, Provider has date of correction · corrected September 9, 2025
E
F0689 No actual harm with potential for more than minimal harm · Pattern

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Deficient, Provider has date of correction · corrected October 3, 2025
E
F0842 No actual harm with potential for more than minimal harm · Pattern

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Deficient, Provider has date of correction · corrected September 9, 2025
E
F0847 No actual harm with potential for more than minimal harm · Pattern

Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

Deficient, Provider has date of correction · corrected September 9, 2025
E
F0921 No actual harm with potential for more than minimal harm · Pattern

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Deficient, Provider has date of correction · corrected September 9, 2025
F
F0812 No actual harm with potential for more than minimal harm · Widespread

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Deficient, Provider has date of correction · corrected September 9, 2025
G
F0656 Actual harm · Isolated

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Deficient, Provider has date of correction · corrected September 9, 2025
G
F0686 Actual harm · Isolated

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Deficient, Provider has date of correction · corrected October 3, 2025

Inspected June 9, 2025

7 citations · from a complaint investigation · Health
D
F0550 No actual harm with potential for more than minimal harm · Isolated

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Deficient, Provider has date of correction · corrected July 14, 2025
D
F0607 No actual harm with potential for more than minimal harm · Isolated

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Deficient, Provider has date of correction · corrected July 14, 2025
D
F0658 No actual harm with potential for more than minimal harm · Isolated

Ensure services provided by the nursing facility meet professional standards of quality.

Deficient, Provider has date of correction · corrected July 14, 2025
D
F0677 No actual harm with potential for more than minimal harm · Isolated

Provide care and assistance to perform activities of daily living for any resident who is unable.

Deficient, Provider has date of correction · corrected July 14, 2025
E
F0806 No actual harm with potential for more than minimal harm · Pattern

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Deficient, Provider has date of correction · corrected July 14, 2025
F
F0803 No actual harm with potential for more than minimal harm · Widespread

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Deficient, Provider has date of correction · corrected July 14, 2025
G
F0689 Actual harm · Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Past Non-Compliance · corrected May 12, 2025

Inspected February 25, 2025

1 citation · from a complaint investigation · Health
D
F0880 No actual harm with potential for more than minimal harm · Isolated

Provide and implement an infection prevention and control program.

Deficient, Provider has date of correction · corrected March 21, 2025

Inspected February 11, 2025

3 citations · from a complaint investigation · Health
D
F0760 No actual harm with potential for more than minimal harm · Isolated

Ensure that residents are free from significant medication errors.

Deficient, Provider has date of correction · corrected March 21, 2025
D
F0761 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected March 21, 2025
D
F0940 No actual harm with potential for more than minimal harm · Isolated

Develop, implement, and/or maintain an effective training program for all new and existing staff members.

Deficient, Provider has date of correction · corrected March 21, 2025

Inspected September 18, 2024

3 citations · from a complaint investigation · Health
D
F0686 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Deficient, Provider has date of correction · corrected October 10, 2024
D
F0689 No actual harm with potential for more than minimal harm · Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Deficient, Provider has date of correction · corrected October 10, 2024
D
F0880 No actual harm with potential for more than minimal harm · Isolated

Provide and implement an infection prevention and control program.

Deficient, Provider has date of correction · corrected October 10, 2024

Inspected August 29, 2024

15 citations · Health
D
F0550 No actual harm with potential for more than minimal harm · Isolated

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Deficient, Provider has date of correction · corrected October 4, 2024
D
F0558 No actual harm with potential for more than minimal harm · Isolated

Reasonably accommodate the needs and preferences of each resident.

Deficient, Provider has date of correction · corrected October 4, 2024
D
F0584 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected October 4, 2024
D
F0607 No actual harm with potential for more than minimal harm · Isolated

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Deficient, Provider has date of correction · corrected October 4, 2024
D
F0609 No actual harm with potential for more than minimal harm · Isolated

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Deficient, Provider has date of correction · corrected October 4, 2024
D
F0656 No actual harm with potential for more than minimal harm · Isolated

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Deficient, Provider has date of correction · corrected October 4, 2024
D
F0684 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Deficient, Provider has date of correction · corrected October 4, 2024
D
F0695 No actual harm with potential for more than minimal harm · Isolated

Provide safe and appropriate respiratory care for a resident when needed.

Deficient, Provider has date of correction · corrected October 4, 2024
D
F0758 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected October 4, 2024
D
F0813 No actual harm with potential for more than minimal harm · Isolated

Have a policy regarding use and storage of foods brought to residents by family and other visitors.

Deficient, Provider has date of correction · corrected October 4, 2024
D
F0880 No actual harm with potential for more than minimal harm · Isolated

Provide and implement an infection prevention and control program.

Deficient, Provider has date of correction · corrected October 4, 2024
D
F0883 No actual harm with potential for more than minimal harm · Isolated

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Deficient, Provider has date of correction · corrected October 4, 2024
D
F0887 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected October 4, 2024
E
F0623 No actual harm with potential for more than minimal harm · Pattern

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Deficient, Provider has date of correction · corrected October 4, 2024
F
F0812 No actual harm with potential for more than minimal harm · Widespread

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Deficient, Provider has date of correction · corrected October 4, 2024

Inspected January 3, 2024

1 citation · from a complaint investigation · Health
D
F0689 No actual harm with potential for more than minimal harm · Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Deficient, Provider has date of correction · corrected February 2, 2024

Inspected September 6, 2023

1 citation · from a complaint investigation · Health
D
F0684 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Deficient, Provider has date of correction · corrected October 13, 2023

Inspected July 12, 2023

8 citations · from a complaint investigation · Health
D
F0582 No actual harm with potential for more than minimal harm · Isolated

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Deficient, Provider has date of correction · corrected August 9, 2023
D
F0600 No actual harm with potential for more than minimal harm · Isolated

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Deficient, Provider has date of correction · corrected August 9, 2023
D
F0677 No actual harm with potential for more than minimal harm · Isolated

Provide care and assistance to perform activities of daily living for any resident who is unable.

Deficient, Provider has date of correction · corrected August 9, 2023
D
F0699 No actual harm with potential for more than minimal harm · Isolated

Provide care or services that was trauma informed and/or culturally competent.

Deficient, Provider has date of correction · corrected August 9, 2023
E
F0725 No actual harm with potential for more than minimal harm · Pattern

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Deficient, Provider has date of correction · corrected August 9, 2023
E
F0761 No actual harm with potential for more than minimal harm · Pattern

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.

Deficient, Provider has date of correction · corrected August 9, 2023
E
F0880 No actual harm with potential for more than minimal harm · Pattern

Provide and implement an infection prevention and control program.

Deficient, Provider has date of correction · corrected August 9, 2023
F
F0812 No actual harm with potential for more than minimal harm · Widespread

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Deficient, Provider has date of correction · corrected August 9, 2023

Penalties

DateTypeAmount
August 13, 2025Fine$45,130
August 13, 2025Payment Denial · 23 days

Ownership transfers

EffectiveSellerBuyer
09/03/2024Borgess Nursing Home INCVilla at Borgess Place LLC

From the CMS Skilled Nursing Facility Change of Ownership dataset. A sale does not by itself say anything about care quality.