Nursing Care Index

Villa At Borgess Place

Kalamazoo, Kalamazoo County, Michigan · CCN 235289 · For-profit (Corporation) · part of Villa Healthcare (18 facilities, chain average 2.8 stars)

CMS rates Villa At Borgess Place 2 of 5 overall as of August 2026. 101 certified beds, 93 residents a day on average. 70 citations on record from the current inspection cycles, 5 involving actual harm; 1 fine totalling $45,130 and 1 payment denial.

CMS’s ratings

The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead.

Overall★★☆☆☆ 2 of 5
Health inspections★☆☆☆☆ 1 of 5
Staffing★★★☆☆ 3 of 5
Quality measures★★★★★ 5 of 5
Quality: long-stay / short-stay5 / 4 of 5

Staffing

Total nurse staffing4.39522 hours per resident per day
Registered nurses0.58411 hours per resident per day
Weekend total3.9019 hours per resident per day
Nursing staff turnover63.6% (registered nurses 61.9%)
Administrators who left2

Citations from health inspections

Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.

SurveyFindingSeverityStatus
2026-04-21
complaint survey
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies · tag F0686
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2026-04-22
2026-04-21
complaint survey
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies · tag F0677
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-04-22
2026-04-21
complaint survey
Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-05-13
2026-03-26
complaint survey
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2026-04-22
2026-03-26
complaint survey
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Resident Rights Deficiencies · tag F0627
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-04-22
2026-03-26
complaint survey
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Resident Assessment and Care Planning Deficiencies · tag F0655
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-04-22
2026-03-26
complaint survey
Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning Deficiencies · tag F0658
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-04-22
2025-12-10
complaint survey
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies · tag F0550
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-01-05
2025-12-10
complaint survey
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Resident Assessment and Care Planning Deficiencies · tag F0655
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-01-05
2025-12-10
complaint survey
Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning Deficiencies · tag F0658
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-01-05
2025-12-10
complaint survey
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Quality of Life and Care Deficiencies · tag F0690
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-01-05
2025-12-10
complaint survey
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Quality of Life and Care Deficiencies · tag F0694
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-01-05
2025-12-10
complaint survey
Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-01-05
2025-08-13 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies · tag F0656
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2025-09-09
2025-08-13 Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies · tag F0686
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2025-10-03
2025-08-13 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies · tag F0812
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2025-09-09
2025-08-13 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies · tag F0550
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-09-09
2025-08-13
complaint survey
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-10-03
2025-08-13
complaint survey
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Assessment and Care Planning Deficiencies · tag F0842
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-09-09
2025-08-13 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Administration Deficiencies · tag F0847
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-09-09
2025-08-13 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Environmental Deficiencies · tag F0921
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-09-09
2025-08-13 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.
Resident Rights Deficiencies · tag F0578
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-09-09
2025-08-13
complaint survey
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-09-09
2025-08-13 Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0605
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-09-09
2025-08-13
complaint survey
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-09-09
2025-08-13 Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Resident Rights Deficiencies · tag F0628
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-09-09
2025-08-13 Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Resident Assessment and Care Planning Deficiencies · tag F0655
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-09-09
2025-08-13 Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies · tag F0677
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-10-03
2025-08-13 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Pharmacy Service Deficiencies · tag F0756
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-09-09
2025-08-13 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.
Pharmacy Service Deficiencies · tag F0761
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-09-09
2025-08-13 Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-10-03
2025-06-09
complaint survey
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689
G Actual harm that is not immediate jeopardy; isolated Past Non-Compliance
2025-05-12
2025-06-09
complaint survey
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.
Nutrition and Dietary Deficiencies · tag F0803
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2025-07-14
2025-06-09
complaint survey
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Nutrition and Dietary Deficiencies · tag F0806
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-07-14
2025-06-09
complaint survey
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies · tag F0550
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-07-14
2025-06-09
complaint survey
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0607
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-07-14
2025-06-09
complaint survey
Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning Deficiencies · tag F0658
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-07-14
2025-06-09
complaint survey
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies · tag F0677
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-07-14
2025-02-25
complaint survey
Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-03-21
2025-02-11
complaint survey
Ensure that residents are free from significant medication errors.
Pharmacy Service Deficiencies · tag F0760
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-03-21
2025-02-11
complaint survey
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.
Pharmacy Service Deficiencies · tag F0761
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-03-21
2025-02-11
complaint survey
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Administration Deficiencies · tag F0940
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-03-21
2024-09-18
complaint survey
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies · tag F0686
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-10-10
2024-09-18
complaint survey
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-10-10
2024-09-18
complaint survey
Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-10-10
2024-08-29 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies · tag F0812
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2024-10-04
2024-08-29 Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Resident Rights Deficiencies · tag F0623
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-10-04
2024-08-29 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies · tag F0550
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-10-04
2024-08-29 Reasonably accommodate the needs and preferences of each resident.
Resident Rights Deficiencies · tag F0558
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-10-04
2024-08-29 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.
Resident Rights Deficiencies · tag F0584
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-10-04
2024-08-29 Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0607
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-10-04
2024-08-29 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-10-04
2024-08-29 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies · tag F0656
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-10-04
2024-08-29 Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · tag F0684
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-10-04
2024-08-29 Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies · tag F0695
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-10-04
2024-08-29 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.
Pharmacy Service Deficiencies · tag F0758
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-10-04
2024-08-29 Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Nutrition and Dietary Deficiencies · tag F0813
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-10-04
2024-08-29 Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-10-04
2024-08-29 Develop and implement policies and procedures for flu and pneumonia vaccinations.
Infection Control Deficiencies · tag F0883
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-10-04
2024-08-29 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.
Infection Control Deficiencies · tag F0887
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-10-04
2024-01-03
complaint survey
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-02-02
2023-09-06
complaint survey
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · tag F0684
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-10-13
2023-07-12 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies · tag F0812
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2023-08-09
2023-07-12 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Nursing and Physician Services Deficiencies · tag F0725
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2023-08-09
2023-07-12 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.
Pharmacy Service Deficiencies · tag F0761
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2023-08-09
2023-07-12 Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2023-08-09
2023-07-12 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Resident Rights Deficiencies · tag F0582
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-08-09
2023-07-12 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-08-09
2023-07-12 Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies · tag F0677
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-08-09
2023-07-12 Provide care or services that was trauma informed and/or culturally competent.
Quality of Life and Care Deficiencies · tag F0699
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-08-09

Fines and payment denials

DatePenaltyAmount
2025-08-13Payment denial for 23 days from 2025-09-10
2025-08-13Fine$45,130

Who owns and runs it

Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.

NameRoleShareSince
Aaron Family Investment Trust
Organization
5% or greater direct ownership interest31%2024-09-03
Ab Investment Trust U/A/D 01/03/23
Organization
5% or greater direct ownership interest13%2024-09-03
3057 Gull Road LLC
Organization
adp of the snf2024-12-12
Aaron Family Investment Trust
Organization
adp of the snf2024-12-02
Ab Investment Trust U/A/D 01/03/23
Organization
adp of the snf2024-12-02
Israel Family Investment Trust
Organization
adp of the snf2024-12-02
Israel Investment Tr
Organization
adp of the snf2024-12-02
Omnia Healthcare Group LLC
Organization
adp of the snf2024-12-23
Todd A Stern 2015 Irrv Ins Tr
Organization
adp of the snf2024-12-02
Omnia Healthcare Group LLC
Organization
operational/managerial control2024-12-23
Baumol, Yehoshua
Individual
5% or greater direct ownership interest27%2024-09-03
Aaron, Jonathan
Individual
adp of the snf2024-12-23
Baumol, Yehoshua
Individual
adp of the snf2024-12-02
Berger, Menachem
Individual
adp of the snf2024-12-23
Cudney, Kiersten
Individual
adp of the snf2024-12-02
Graf, Marcella
Individual
adp of the snf2024-12-23
Israel, Benjamin
Individual
adp of the snf2024-12-05
Nagel, Steven
Individual
adp of the snf2024-12-02
Oprescu, Nicoara
Individual
adp of the snf2024-12-12
Stern, Todd
Individual
adp of the snf2024-12-05
Aaron, Jonathan
Individual
corporate officer2024-09-03
Aaron, Jonathan
Individual
managing control - governing body2024-09-03
Aaron, Jonathan
Individual
operational/managerial control2024-09-03
Cudney, Kiersten
Individual
operational/managerial control2024-12-02
Graf, Marcella
Individual
operational/managerial control2024-12-02
Cudney, Kiersten
Individual
w-2 managing employee2024-09-03
Graf, Marcella
Individual
w-2 managing employee2024-09-03
Oprescu, Nicoara
Individual
w-2 managing employee2024-09-03

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Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Every nursing home in Kalamazoo County.