Last Updated: October 2026
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Composite Quality Score

Comprehensive rating based on CMS data, staffing, quality measures, and compliance

B
Grade
55
Score
CMS Ratings
10.6/22
Staffing Quality
10.0/20
Quality Measures
0.0/22
Compliance
18.0/18
Safety
13.0/13
Availability
6.0/10

Current Availability Estimate

Occupancy Rate91.7%
101
Total Beds
93
Occupied
8
Available

Basic Information

Address:

3057 Gull Road

Kalamazoo, MI 49048

Number of Beds:

101

Estimated Occupancy:

92% (~8 available)

Chain:

VILLA HEALTHCARE

Quality Ratings

Overall Rating:2/5 Stars
Health Inspection:1/5 Stars
Staffing Rating:3/5 Stars
Quality Measures:5/5 Stars

Safety Information

Abuse Issues:No Issues Reported
Special Focus:Not Under Special Focus

Additional Information

CMS Certification Number:

235289

Provider Type:

Medicare and Medicaid

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Staffing Metrics

Higher staffing hours generally indicate better care quality. Lower turnover indicates more experienced, stable staff.

Registered Nurse (RN) Hours

Per resident per day

Average

This Facility

0.58

hours

National Avg

0.64

hours

Total Nursing Staff Hours

RN + LPN + Nurse Aides per resident per day

Above Average

This Facility

4.40

hours

National Avg

3.89

hours

Breakdown:

RN: 0.58hLPN: 1.09hAide: 2.72h

Staff Turnover Rate

Annual nursing staff turnover

Above Average

This Facility

63.6%

National Avg

46.6%

RN Turnover: 61.9%

Understanding Staffing Metrics

Staffing hours: Higher hours generally mean more staff attention per resident. Federal minimum is 3.5 total hours per resident per day, but quality facilities often exceed 4+ hours.

Turnover: High turnover (>50%) can indicate staffing issues and affect care continuity. Lower turnover means more experienced staff familiar with residents' needs.

Detailed Quality Measures

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Health Inspections & Deficiencies

Total Deficiencies

76

Inspections

8

Feb 25, 2025 - Health Survey

2 deficiencies cited

Medium - PatternTag F0880

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Corrected: Mar 21, 2025From Complaint
Medium - PatternTag F0880

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Corrected: Mar 21, 2025From Complaint

Feb 11, 2025 - Health Survey

6 deficiencies cited

Medium - PatternTag F0761

Pharmacy Service Deficiencies

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: Mar 21, 2025From Complaint
Medium - PatternTag F0760

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Corrected: Mar 21, 2025From Complaint
Medium - PatternTag F0760

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Corrected: Mar 21, 2025From Complaint
Medium - PatternTag F0940

Administration Deficiencies

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

Corrected: Mar 21, 2025From Complaint
Medium - PatternTag F0761

Pharmacy Service Deficiencies

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: Mar 21, 2025From Complaint
Medium - PatternTag F0940

Administration Deficiencies

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

Corrected: Mar 21, 2025From Complaint

Sep 18, 2024 - Health Survey

6 deficiencies cited

Medium - PatternTag F0880

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Corrected: Oct 10, 2024From Complaint
Medium - PatternTag F0686

Quality of Life and Care Deficiencies

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

Corrected: Oct 10, 2024From Complaint
Medium - PatternTag F0689

Quality of Life and Care Deficiencies

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

Corrected: Oct 10, 2024From Complaint
Medium - PatternTag F0880

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Corrected: Oct 10, 2024From Complaint
Medium - PatternTag F0689

Quality of Life and Care Deficiencies

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

Corrected: Oct 10, 2024From Complaint
Medium - PatternTag F0686

Quality of Life and Care Deficiencies

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

Corrected: Oct 10, 2024From Complaint

Aug 29, 2024 - Health Survey

30 deficiencies cited

Medium - PatternTag F0887

Infection Control Deficiencies

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.

Corrected: Oct 4, 2024
Medium - PatternTag F0813

Nutrition and Dietary Deficiencies

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

Corrected: Oct 4, 2024
Medium - PatternTag F0550

Resident Rights Deficiencies

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

Corrected: Oct 4, 2024
Medium - PatternTag F0584

Resident Rights Deficiencies

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.

Corrected: Oct 4, 2024
Medium - PatternTag F0607

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

Corrected: Oct 4, 2024
Medium - PatternTag F0609

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

Corrected: Oct 4, 2024
Medium - PatternTag F0623

Resident Rights Deficiencies

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

Corrected: Oct 4, 2024
Medium - PatternTag F0656

Resident Assessment and Care Planning Deficiencies

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

Corrected: Oct 4, 2024
Medium - PatternTag F0684

Quality of Life and Care Deficiencies

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

Corrected: Oct 4, 2024
Medium - PatternTag F0695

Quality of Life and Care Deficiencies

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

Corrected: Oct 4, 2024
Medium - PatternTag F0758

Pharmacy Service Deficiencies

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.

Corrected: Oct 4, 2024
Medium - PatternTag F0812

Nutrition and Dietary Deficiencies

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

Corrected: Oct 4, 2024
Medium - PatternTag F0558

Resident Rights Deficiencies

Reasonably accommodate the needs and preferences of each resident.

Corrected: Oct 4, 2024
Medium - PatternTag F0880

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Corrected: Oct 4, 2024
Medium - PatternTag F0883

Infection Control Deficiencies

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

Corrected: Oct 4, 2024
Medium - PatternTag F0550

Resident Rights Deficiencies

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

Corrected: Oct 4, 2024
Medium - PatternTag F0558

Resident Rights Deficiencies

Reasonably accommodate the needs and preferences of each resident.

Corrected: Oct 4, 2024
Medium - PatternTag F0584

Resident Rights Deficiencies

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.

Corrected: Oct 4, 2024
Medium - PatternTag F0607

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

Corrected: Oct 4, 2024
Medium - PatternTag F0609

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

Corrected: Oct 4, 2024
Medium - PatternTag F0623

Resident Rights Deficiencies

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

Corrected: Oct 4, 2024
Medium - PatternTag F0656

Resident Assessment and Care Planning Deficiencies

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

Corrected: Oct 4, 2024
Medium - PatternTag F0684

Quality of Life and Care Deficiencies

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

Corrected: Oct 4, 2024
Medium - PatternTag F0695

Quality of Life and Care Deficiencies

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

Corrected: Oct 4, 2024
Medium - PatternTag F0758

Pharmacy Service Deficiencies

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.

Corrected: Oct 4, 2024
Medium - PatternTag F0812

Nutrition and Dietary Deficiencies

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

Corrected: Oct 4, 2024
Medium - PatternTag F0813

Nutrition and Dietary Deficiencies

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

Corrected: Oct 4, 2024
Medium - PatternTag F0880

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Corrected: Oct 4, 2024
Medium - PatternTag F0883

Infection Control Deficiencies

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

Corrected: Oct 4, 2024
Medium - PatternTag F0887

Infection Control Deficiencies

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.

Corrected: Oct 4, 2024

Jan 3, 2024 - Health Survey

2 deficiencies cited

Medium - PatternTag F0689

Quality of Life and Care Deficiencies

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

Corrected: Feb 2, 2024From Complaint
Medium - PatternTag F0689

Quality of Life and Care Deficiencies

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

Corrected: Feb 2, 2024From Complaint

Sep 6, 2023 - Health Survey

2 deficiencies cited

Medium - PatternTag F0684

Quality of Life and Care Deficiencies

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

Corrected: Oct 13, 2023From Complaint
Medium - PatternTag F0684

Quality of Life and Care Deficiencies

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

Corrected: Oct 13, 2023From Complaint

Jul 12, 2023 - Health Survey

16 deficiencies cited

Medium - PatternTag F0761

Pharmacy Service Deficiencies

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: Aug 9, 2023
Medium - PatternTag F0812

Nutrition and Dietary Deficiencies

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

Corrected: Aug 9, 2023
Medium - PatternTag F0880

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Corrected: Aug 9, 2023
Medium - PatternTag F0600

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

Corrected: Aug 9, 2023From Complaint
Medium - PatternTag F0677

Quality of Life and Care Deficiencies

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

Corrected: Aug 9, 2023From Complaint
Medium - PatternTag F0725

Nursing and Physician Services Deficiencies

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

Corrected: Aug 9, 2023From Complaint
Medium - PatternTag F0600

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

Corrected: Aug 9, 2023From Complaint
Medium - PatternTag F0699

Quality of Life and Care Deficiencies

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

Corrected: Aug 9, 2023
Medium - PatternTag F0582

Resident Rights Deficiencies

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

Corrected: Aug 9, 2023
Medium - PatternTag F0677

Quality of Life and Care Deficiencies

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

Corrected: Aug 9, 2023From Complaint
Medium - PatternTag F0725

Nursing and Physician Services Deficiencies

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

Corrected: Aug 9, 2023From Complaint
Medium - PatternTag F0880

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Corrected: Aug 9, 2023
Medium - PatternTag F0812

Nutrition and Dietary Deficiencies

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

Corrected: Aug 9, 2023
Medium - PatternTag F0761

Pharmacy Service Deficiencies

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: Aug 9, 2023
Medium - PatternTag F0699

Quality of Life and Care Deficiencies

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

Corrected: Aug 9, 2023
Medium - PatternTag F0582

Resident Rights Deficiencies

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

Corrected: Aug 9, 2023

Mar 24, 2022 - Health Survey

12 deficiencies cited

Medium - PatternTag F0656

Resident Assessment and Care Planning Deficiencies

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

Corrected: Apr 29, 2022
Medium - PatternTag F0690

Quality of Life and Care Deficiencies

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: Apr 29, 2022
Medium - PatternTag F0695

Quality of Life and Care Deficiencies

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

Corrected: Apr 29, 2022
Medium - PatternTag F0812

Nutrition and Dietary Deficiencies

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

Corrected: Apr 29, 2022
Medium - PatternTag F0695

Quality of Life and Care Deficiencies

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

Corrected: Apr 29, 2022
Medium - PatternTag F0812

Nutrition and Dietary Deficiencies

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

Corrected: Apr 29, 2022
Low - IsolatedTag F0813

Nutrition and Dietary Deficiencies

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

Corrected: Apr 29, 2022
Medium - PatternTag F0880

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Corrected: Apr 29, 2022
Medium - PatternTag F0690

Quality of Life and Care Deficiencies

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: Apr 29, 2022
Low - IsolatedTag F0813

Nutrition and Dietary Deficiencies

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

Corrected: Apr 29, 2022
Medium - PatternTag F0880

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Corrected: Apr 29, 2022
Medium - PatternTag F0656

Resident Assessment and Care Planning Deficiencies

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

Corrected: Apr 29, 2022

Understanding Deficiencies

Deficiencies are violations of federal health and safety standards identified during CMS inspections. They are categorized by scope (isolated, pattern, or widespread) and severity (potential for harm vs. actual harm).

Critical deficiencies involve actual harm to residents and should be carefully considered. Facilities typically have opportunities to correct deficiencies and implement preventive measures.

Understanding deficiencies: Not all deficiencies indicate poor care. Learn how to interpret health inspection results and identify serious warning signs. Read our guide on warning signs →

Penalties & Enforcement

2 penalties in the past 3 years

Total fines: $45,130

FineAugust 13, 2025

$45,130

Data processed: August 1, 2026

Payment DenialAugust 13, 2025

Payment Denial: Started September 10, 2025

Duration: 23 days

Data processed: August 1, 2026

About Penalties: This data comes from CMS (Centers for Medicare & Medicaid Services) and shows fines and payment denials issued for health and safety violations. Penalties indicate serious deficiencies that required enforcement action.

Key Highlights

🛏
Beds Available
Approximately 8 beds potentially available
🏢
Part of Healthcare Chain
VILLA HEALTHCARE

Frequently Asked Questions

What is the quality rating for Villa at Borgess Place?

Villa at Borgess Place has an overall CMS rating of 2 out of 5 stars. This rating is based on health inspections, staffing levels, and quality measures reported by Medicare.

How many beds does this facility have?

Villa at Borgess Place has 101 certified beds. The facility averages 93 residents per day, with an occupancy rate of approximately 92%.

What type of ownership does this facility have?

This facility is for profit - corporation owned. It is part of the VILLA HEALTHCARE network.

How can I contact Villa at Borgess Place?

You can call Villa at Borgess Place at (269)552-6500. The facility is located at 3057 Gull Road, Kalamazoo, MI 49048.

What should I look for when choosing a nursing home?

When selecting a nursing home, consider: CMS star ratings (overall, health inspection, staffing, and quality measures), nurse staffing levels, staff turnover rates, recent health inspection results, complaint history, proximity to family, and available services. We recommend visiting facilities in person, talking to current residents and staff, and checking multiple sources of information before making your decision. Use our comprehensive tour checklist when visiting facilities.

📚 Learn How to Evaluate Facilities

Understanding quality metrics helps you make better decisions. Check out these data-driven guides: