
Report
TheVardellReport
Villa at Borgess Place
Skilled nursing facility and nursing facility
3057 Gull Road
Kalamazoo, MI 49048

TheVardellReport
Skilled nursing facility and nursing facility
3057 Gull Road
Kalamazoo, MI 49048
Life by Vardell Presents
The deeper story, beautifully organized. Available records, historical context, and questions worth asking.
This report is free. Vardell does not certify, grade or endorse; it shows what the record documents.
The Essentials
Across 11 inspections from July 2023 to April 2026, state surveyors documented 69 findings at Villa at Borgess Place; 69 have a recorded correction; CMS lists 2 enforcement actions in the window.
* Partial year, through October 1, 2026.
| Year | Inspections | Findings | Of which, actual harm (level G or above) |
|---|---|---|---|
| 2023 | 1 | 8 | 0 |
| 2024 | 3 | 19 | 0 |
| 2025 | 5 | 35 | 3 |
| 2026 | 2 | 7 | 2 |
Chronology
Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.
3 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
4 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
6 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
18 findings
The same visit included a complaint investigation.
Enforcement Action
Civil money penalty, $46,409 imposed August 13, 2025. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of August 13, 2025, the nearest before the penalty date.
Enforcement Action
Denial of payment imposed August 13, 2025. Status: Closed, October 3, 2025. CMS does not tie a penalty to a survey; listed with the standard health inspection of August 13, 2025, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
7 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
1 finding
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
3 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
3 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
15 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
1 finding
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
8 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.
Context
A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.
Inspectors cited F880 in July 2023, August 2024, September 2024, February 2025, August 2025, December 2025 and April 2026. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F689 in January 2024, September 2024, June 2025, August 2025 and March 2026. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F550 in August 2024, June 2025, August 2025 and December 2025. This citation covers residents’ right to dignity, to make their own choices and to communicate. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F677 in July 2023, June 2025, August 2025 and April 2026. This citation covers help with bathing, dressing, eating and toileting for residents who cannot manage alone. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F655 in August 2025, December 2025 and March 2026. This citation covers the baseline care plan for a new resident’s immediate needs, due within 48 hours of admission. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F658 in June 2025, December 2025 and March 2026. This citation covers whether the home’s services meet professional standards of quality. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F686 in September 2024, August 2025 and April 2026. This citation covers how the home prevents and treats pressure injuries (bedsores). The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F761 in July 2023, February 2025 and August 2025. This citation covers how drugs are labeled and kept locked, including controlled drugs. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F812 in July 2023, August 2024 and August 2025. This citation covers how food is stored, prepared and served. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F600 in July 2023 and August 2025. This citation covers whether residents are protected from abuse and neglect by anyone. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F607 in August 2024 and June 2025. The agency describes it this way: Develop and implement policies and procedures to prevent abuse, neglect, and theft. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F609 in August 2024 and August 2025. This citation covers whether suspected abuse, neglect or theft is reported to the authorities on time, with the results of the home’s investigation. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F656 in August 2024 and August 2025. This citation covers whether each resident has a written care plan that meets their needs, with goals that can be measured. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
For Your Next Visit
Bring these to the tour. Each one comes from something in the record; the reason is under the question.
Who leads infection control here, and how often are hand-hygiene and isolation practices audited?
Infection Control: cited in seven inspections, most seriously at level E.
What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?
Accident Hazards and Supervision: cited in five inspections, most seriously at level G.
How do staff learn each resident’s preferences, and how is a complaint about dignity handled?
Dignity and Resident Rights: cited in four inspections, most seriously at level E.
How long do residents usually wait for help with bathing, dressing or the bathroom, and how is that tracked?
Help With Daily Living: cited in four inspections, most seriously at level D.
What happens in the first 48 hours after admission, and who writes the first care plan?
The First 48 Hours: cited in three inspections, most seriously at level D.
How do you check that nurses and aides follow professional standards, and what happens when they do not?
Professional Standards: cited in three inspections, most seriously at level D.
How often are residents checked for pressure injuries and repositioned, and who is responsible for it?
Pressure Injury Care: cited in three inspections, most seriously at level G.
How are medications stored and secured, and who checks the medication carts?
Medication Labeling and Storage: cited in three inspections, most seriously at level E.
May we see the kitchen, and what do your own sanitation checks look like week to week?
Kitchen and Food Safety: cited in three inspections, most seriously at level F.
What happened after the abuse or neglect citation, and what changed in training or supervision?
Protection From Abuse and Neglect: cited in two inspections, most seriously at level D.
What changed after F607 was cited, and how do you check it now?
Citation F607: cited in two inspections, most seriously at level D.
How are staff trained to report suspected abuse or neglect, and who reports it to the state?
Reporting Suspected Abuse: cited in two inspections, most seriously at level D.
How is a care plan written and reviewed here, and how do families take part in it?
Care Plans: cited in two inspections, most seriously at level G.
How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?
Insufficient nursing staff was cited in July 2023.
What led to the 2025 fine, and has it been paid?
A $46,409 civil money penalty was imposed August 13, 2025. CMS publishes the fine, not whether it has been paid. The record holds two enforcement actions in the window.
The Evidence
Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Michigan state survey agency.
Michigan state survey agency
Inspection Jul 12, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Michigan state survey agency
Inspection Jan 3, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Michigan state survey agency
Inspection Aug 29, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Michigan state survey agency
Inspection Sep 18, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Michigan state survey agency
Inspection Feb 11, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Michigan state survey agency
Inspection Feb 25, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Michigan state survey agency
Inspection Jun 9, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Michigan state survey agency
Inspection Aug 13, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Michigan state survey agency
Inspection Dec 10, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Michigan state survey agency
Inspection Mar 26, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Michigan state survey agency
Inspection Apr 21, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Centers for Medicare & Medicaid Services
Published Oct 1, 2026 · Retrieved Nov 1, 2026
Centers for Medicare & Medicaid Services · 235289
Published Oct 1, 2026 · Retrieved Nov 1, 2026
Record windowJuly 12, 2023 – October 1, 2026
Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.
Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.