Villa at Borgess Place
3057 Gull Road · Kalamazoo, MI · 49048 · 2695526500
101 certified beds For profit - Corporation Chain: Villa Healthcare
Why this verdict
- Inspection record is far worse than the national median (deficiency count and severity).
- Federal penalties on record: $45,130 in fines in the last 24 months.
- Inspection results are getting worse cycle over cycle, not better.
- 5 citations involved actual harm to residents.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
Special Focus Facility candidate
CMS lists this facility as a candidate for its Special Focus program for persistently poor inspection performance.
Cited under the freedom-from-abuse rule
Cited 2 times under F600 (freedom from abuse/neglect) below the actual-harm level — worth asking about on a tour.
5 actual-harm citations in the most recent cycle
Inspectors found deficiencies that caused real harm to residents, beyond potential-harm paperwork findings.
Medicare/Medicaid payments were denied
CMS refused payment for new admissions for a period — one of its strongest enforcement tools.
66% of nursing staff left within a year
High turnover disrupts continuity of care; the national median is 45%.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 1 of 5 Staffing: 4 of 5 Quality measures: 4 of 5
| Total nurse hours / resident-day | 4.49 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.83 | 0.55–0.75 |
| Weekend hours / resident-day | 3.86 | ≈ weekday level |
| Nursing turnover / year | 66% | median 45% |
| Fines (3-yr window) | 1 · $45,130 |
Inspection citations (70 in the current record)
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Actual harm · G April 21, 2026 · found via complaint
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected April 22, 2026 · Quality of Life and Care
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Potential for harm · D April 21, 2026 · found via complaint
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected April 22, 2026 · Quality of Life and Care
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Potential for harm · D April 21, 2026 · found via complaint
Provide and implement an infection prevention and control program.
Corrected May 13, 2026 · Infection Control
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Actual harm · G March 26, 2026 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected April 22, 2026 · Quality of Life and Care
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Potential for harm · D March 26, 2026 · found via complaint
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Corrected April 22, 2026 · Resident Rights
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Potential for harm · D March 26, 2026 · found via complaint
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected April 22, 2026 · Resident Assessment and Care Planning
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Potential for harm · D March 26, 2026 · found via complaint
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected April 22, 2026 · Resident Assessment and Care Planning
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Potential for harm · D December 10, 2025 · found via complaint
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected January 5, 2026 · Resident Rights
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Potential for harm · D December 10, 2025 · found via complaint
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected January 5, 2026 · Resident Assessment and Care Planning
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Potential for harm · D December 10, 2025 · found via complaint
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected January 5, 2026 · Resident Assessment and Care Planning
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Potential for harm · D December 10, 2025 · found via complaint
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected January 5, 2026 · Quality of Life and Care
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Potential for harm · D December 10, 2025 · found via complaint
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected January 5, 2026 · Quality of Life and Care
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Potential for harm · D December 10, 2025 · found via complaint
Provide and implement an infection prevention and control program.
Corrected January 5, 2026 · Infection Control
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Actual harm · G August 13, 2025
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected September 9, 2025 · Resident Assessment and Care Planning
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Actual harm · G August 13, 2025
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected October 3, 2025 · Quality of Life and Care
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Potential for harm · E August 13, 2025
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected September 9, 2025 · Resident Rights
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Potential for harm · D August 13, 2025
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.
Corrected September 9, 2025 · Resident Rights
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Potential for harm · D August 13, 2025
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected September 9, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D August 13, 2025
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected September 9, 2025 · Resident Rights
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Potential for harm · D August 13, 2025
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected September 9, 2025 · Resident Assessment and Care Planning
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Potential for harm · D August 13, 2025
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected October 3, 2025 · Quality of Life and Care
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Potential for harm · D August 13, 2025
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected September 9, 2025 · Pharmacy Service
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Potential for harm · D August 13, 2025
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.
Corrected September 9, 2025 · Pharmacy Service
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Potential for harm · F August 13, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected September 9, 2025 · Nutrition and Dietary
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Potential for harm · E August 13, 2025
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected September 9, 2025 · Administration
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| August 13, 2025 | Fine | $45,130 |
| August 13, 2025 | Payment Denial | 23 days |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 235289 · certified since April 16, 1976. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.