Kalamazoo, MI

Villa at Borgess Place

1-star overall rating with 1-star inspections with $69,430 in total fines with 31 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle

3057 Gull Road, Kalamazoo, MI

(269) 552-6500

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

1 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

101

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Villa Healthcare

Operator or chain grouping

Approved since

1976-04-16

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

18 facilities

Chain averages 3 overall / 2 health / 3 staffing / 5 quality stars

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.89

Registered nurse staffing · state 0.77 · national 0.68

LPN hours / resident day

1.09

Licensed practical nurse staffing · state 0.88 · national 0.87

Aide hours / resident day

2.63

Nurse aide staffing · state 2.38 · national 2.35

Total nurse hours

4.62

All reported nurse hours · state 4.03 · national 3.89

Licensed hours

1.98

RN + LPN hours · state 1.65 · national 1.54

Weekend hours

4.11

Weekend nurse staffing · state 3.52 · national 3.43

Weekend RN hours

0.59

Weekend registered nurse coverage · state 0.49 · national 0.47

Physical therapist

0.07

Reported PT staffing · state 0.07 · national 0.07

Adjusted RN hours

0.91

CMS adjusted RN staffing hours

Adjusted total hours

4.70

CMS adjusted total nurse staffing hours

Case-mix index

1.34

Higher values indicate more complex resident acuity

RN turnover

71%

Annual RN turnover · state 41% · national 45%

Total nurse turnover

68%

Annual nurse turnover · state 44% · national 46%

SNF VBP

Value-based purchasing

Program rank

8,702

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

25.92

Composite VBP score used to determine payment impact.

Payment multiplier

0.9840

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

5.60

Baseline 18.94% · Performance 18.83% · Measure score 5.60 · Achievement 5.60 · Improvement 0.06

Healthcare-associated infections

2.12

Baseline 5.14% · Performance 7.20% · Measure score 2.12 · Achievement 2.12 · Improvement 0

Total nurse turnover

Baseline 57.47% · Performance 71.82% · Measure score 0 · Achievement 0 · Improvement 0

Adjusted total nurse staffing

2.64

Baseline 4.20 hours · Performance 3.83 hours · Measure score 2.64 · Achievement 2.64 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.4%	10.72% 0.3 pts better	No Different than the National Rate · Eligible stays 238 · Observed rate 8.82% · Lower 95% interval 7.6%
Discharge to community	53.17%	50.57% 2.6 pts better	No Different than the National Rate · Eligible stays 237 · Observed rate 50.63% · Lower 95% interval 47.65%
Medicare spending per beneficiary	0.76	1.02 0.3 pts better
Drug regimen review with follow-up	95.27%	95.27% About the same	Numerator 141 · Denominator 148
Falls with major injury	0.68%	0.77% 0.1 pts better	Numerator 1 · Denominator 148
Discharge self-care score	38%	53.69% 15.7 pts worse	Numerator 38 · Denominator 100
Discharge mobility score	39%	50.94% 11.9 pts worse	Numerator 39 · Denominator 100
Pressure ulcers or injuries, new or worsened	2.04%	2.29% 0.2 pts better	Numerator 3 · Denominator 147 · Adjusted rate 2.29%
Healthcare-associated infections requiring hospitalization	7.2%	7.12% 0.1 pts worse	No Different than the National Rate · Eligible stays 127 · Observed rate 6.3% · Lower 95% interval 4.4%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 133
Staff flu vaccination coverage	0%	42% 42 pts worse	Numerator 0 · Denominator 205
Discharge function score	49%	56.45% 7.5 pts worse	Numerator 49 · Denominator 100
Transfer of health information to provider	41.67%	95.95% 54.3 pts worse	Numerator 10 · Denominator 24
Transfer of health information to patient	97.27%	96.28% 1 pts better	Numerator 107 · Denominator 110
Resident COVID-19 vaccinations up to date	43.59%	25.2% 18.4 pts better	Numerator 34 · Denominator 78

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	0.9	1.7 0.8 pts better	1.9 1 pts better	Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 1.0 · Expected 1.9 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	0.8	1.5 0.7 pts better	1.8 1 pts better	Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.8 · Expected 1.6 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	99.1%	95.0% 4.1 pts better	93.4% 5.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 96.2% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.1%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	95.0% 5 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury	2.7%	3.1% 0.4 pts better	3.3% 0.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 1.8% · Q3 3.4% · Q4 1.9% · 4Q avg 2.7% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	4.0%	4.1% 0.1 pts better	11.4% 7.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 7.4% · Q4 8.3% · 4Q avg 4.0%
Percentage of long-stay residents who lose too much weight	1.9%	5.5% 3.6 pts better	5.4% 3.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 4.8% · Q3 0.0% · Q4 0.0% · 4Q avg 1.9%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	14.2%	19.6% 5.4 pts better	19.6% 5.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 17.1% · Q2 16.7% · Q3 12.5% · Q4 10.3% · 4Q avg 14.2%
Percentage of long-stay residents who received an antipsychotic medication	6.2%	16.5% 10.3 pts better	16.7% 10.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 5.9% · Q3 6.1% · Q4 6.7% · 4Q avg 6.2% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.1% 0.1 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	18.7%	13.9% 4.8 pts worse	16.3% 2.4 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 18.7% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	12.1%	11.7% 0.4 pts worse	14.9% 2.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 24.2% · Q2 10.5% · Q3 10.3% · Q4 5.1% · 4Q avg 12.1% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	1.8%	0.9% 0.9 pts worse	1.0% 0.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 1.3% · Q3 1.3% · Q4 1.5% · 4Q avg 1.8% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	1.4%	1.7% 0.3 pts better	1.7% 0.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 3.6% · Q3 0.0% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	31.6%	20.4% 11.2 pts worse	19.8% 11.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 31.4% · Q2 29.2% · Q3 31.6% · Q4 34.1% · 4Q avg 31.6%
Percentage of long-stay residents with pressure ulcers	9.7%	5.6% 4.1 pts worse	5.1% 4.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 11.3% · Q2 11.3% · Q3 8.9% · Q4 7.4% · 4Q avg 9.7% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	90.7%	82.8% 7.9 pts better	81.7% 9 pts better	Short Stay · 2024Q4-2025Q3 · Q1 89.2% · Q2 96.2% · Q3 91.3% · Q4 86.8% · 4Q avg 90.7%
Percentage of short-stay residents who had an outpatient emergency department visit	12.6%	11.5% 1.1 pts worse	12.0% 0.6 pts worse	Short Stay · 20240701-20250630 · Adjusted 12.6% · Observed 11.9% · Expected 10.5% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.0%	1.3% 1.3 pts better	1.6% 1.6 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	94.1%	79.5% 14.6 pts better	79.7% 14.4 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 94.1%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	25.9%	24.2% 1.7 pts worse	23.9% 2 pts worse	Short Stay · 20240701-20250630 · Adjusted 25.9% · Observed 23.0% · Expected 21.2% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-08-13 · Fire 2025-08-13

31 health deficiencies

Top issue: Quality of Life and Care (7 deficiencies)

7 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 2 Health 2024-08-29 · Fire 2024-08-29

22 health deficiencies

Top issue: Infection Control (5 deficiencies)

5 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 3 Health 2023-07-12 · Fire 2023-07-12

10 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

4 fire-safety deficiencies

Top issue: Miscellaneous (2 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-08-13

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2025-09-05

F · Potential for more than minimal harm 2025-08-13

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-09-05

E · Potential for more than minimal harm 2025-08-13

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2025-09-05

E · Potential for more than minimal harm 2025-08-13

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2025-09-05

E · Potential for more than minimal harm 2025-08-13

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2025-09-05

E · Potential for more than minimal harm 2025-08-13

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2025-09-05

E · Potential for more than minimal harm 2025-08-13

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2025-09-05

F · Potential for more than minimal harm 2024-08-29

E15 · Emergency Preparedness Deficiencies

Fire Safety

Address subsistence needs for staff and patients.

Corrected 2024-10-04

F · Potential for more than minimal harm 2024-08-29

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-10-04

E · Potential for more than minimal harm 2024-08-29

K232 · Egress Deficiencies

Fire Safety

Have corridors or aisles that are unobstructed and are at least 8 feet in width.

Corrected 2024-10-04

E · Potential for more than minimal harm 2024-08-29

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2024-10-04

E · Potential for more than minimal harm 2024-08-29

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2024-10-04

F · Potential for more than minimal harm 2023-07-12

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2023-08-09

F · Potential for more than minimal harm 2023-07-12

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2023-08-09

E · Potential for more than minimal harm 2023-07-12

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2023-08-09

D · Potential for more than minimal harm 2023-07-12

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2023-08-09

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-12-10

F550 · Resident Rights Deficiencies

Health

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

Corrected 2026-01-05

D · Potential for more than minimal harm 2025-12-10

F655 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2026-01-05

D · Potential for more than minimal harm 2025-12-10

F658 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2026-01-05

D · Potential for more than minimal harm 2025-12-10

F690 · Quality of Life and Care Deficiencies

Health

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 2026-01-05

D · Potential for more than minimal harm 2025-12-10

F694 · Quality of Life and Care Deficiencies

Health

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

Corrected 2026-01-05

D · Potential for more than minimal harm 2025-12-10

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2026-01-05

G · Actual harm 2025-08-13

F656 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2025-09-09

G · Actual harm 2025-08-13

F686 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-10-03

F · Potential for more than minimal harm 2025-08-13

F812 · Nutrition and Dietary Deficiencies

Health

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

Corrected 2025-09-09

E · Potential for more than minimal harm 2025-08-13

F550 · Resident Rights Deficiencies

Health

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

Corrected 2025-09-09

E · Potential for more than minimal harm 2025-08-13

F689 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-10-03

E · Potential for more than minimal harm 2025-08-13

F842 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2025-09-09

E · Potential for more than minimal harm 2025-08-13

F847 · Administration Deficiencies

Health

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

Corrected 2025-09-09

E · Potential for more than minimal harm 2025-08-13

F921 · Environmental Deficiencies

Health

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

Corrected 2025-09-09

D · Potential for more than minimal harm 2025-08-13

F578 · Resident Rights Deficiencies

Health

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 2025-09-09

D · Potential for more than minimal harm 2025-08-13

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

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

Corrected 2025-09-09

D · Potential for more than minimal harm 2025-08-13

F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

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

Corrected 2025-09-09

D · Potential for more than minimal harm 2025-08-13

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

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

Corrected 2025-09-09

D · Potential for more than minimal harm 2025-08-13

F628 · Resident Rights Deficiencies

Health

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

Corrected 2025-09-09

D · Potential for more than minimal harm 2025-08-13

F655 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2025-09-09

D · Potential for more than minimal harm 2025-08-13

F677 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-10-03

D · Potential for more than minimal harm 2025-08-13

F756 · Pharmacy Service Deficiencies

Health

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

Corrected 2025-09-09

D · Potential for more than minimal harm 2025-08-13

F761 · Pharmacy Service Deficiencies

Health

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 2025-09-09

D · Potential for more than minimal harm 2025-08-13

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-10-03

G · Actual harm 2025-06-09

F689 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-05-12

F · Potential for more than minimal harm 2025-06-09

F803 · Nutrition and Dietary Deficiencies

Health

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.

Corrected 2025-07-14

E · Potential for more than minimal harm 2025-06-09

F806 · Nutrition and Dietary Deficiencies

Health

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

Corrected 2025-07-14

D · Potential for more than minimal harm 2025-06-09

F550 · Resident Rights Deficiencies

Health

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

Corrected 2025-07-14

D · Potential for more than minimal harm 2025-06-09

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

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

Corrected 2025-07-14

D · Potential for more than minimal harm 2025-06-09

F658 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2025-07-14

D · Potential for more than minimal harm 2025-06-09

F677 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-07-14

D · Potential for more than minimal harm 2025-02-25

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-03-21

D · Potential for more than minimal harm 2025-02-11

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2025-03-21

D · Potential for more than minimal harm 2025-02-11

F761 · Pharmacy Service Deficiencies

Health

Corrected 2025-03-21

D · Potential for more than minimal harm 2025-02-11

F940 · Administration Deficiencies

Health

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

Corrected 2025-03-21

D · Potential for more than minimal harm 2024-09-18

F686 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-10-10

D · Potential for more than minimal harm 2024-09-18

F689 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-10-10

D · Potential for more than minimal harm 2024-09-18

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-10-10

F · Potential for more than minimal harm 2024-08-29

F812 · Nutrition and Dietary Deficiencies

Health

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

Corrected 2024-10-04

E · Potential for more than minimal harm 2024-08-29

F623 · Resident Rights Deficiencies

Health

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

Corrected 2024-10-04