Villa at Borgess Place

In the surveyor’s words

From the most serious findings on record at Villa at Borgess Place, in the surveyor’s own words.

• Actual harm, isolatedF686Apr 21, 2026

  This citation pertains to intake 2988571Based on observation, interview, and record review the facility failed to promote the healing of an existing pressure ulcer and to prevent pressure ulcer development for one resident (#3) out of three residents reviewed resulting in a stage 2 pressure ulcer (partial-thickness skin injury) developing to an unstageable pressure ulcer(a full-thickness tissue loss where the depth is covered by eschar or slough tissue), the development of a new unstageable pressure ulcer, and the resident experience a pain level of 9 out of 10 (pain scale 1 - least pain and 10 being the most pain).Findings Included:Resident #3 (R3)Review of the medical record demonstrated that R3 was admitted to the facility on [DATE] with diagnoses that included encounter for surgical… […]

• Actual harm, isolatedF689Mar 26, 2026

  This citation pertains to Intake #2799926.Based on interview, and record review, the facility failed to ensure that interventions for increased supervision and assistance were implemented for residents at high risk for falls for 1 resident (Resident #101) of 3 residents reviewed for fall prevention, resulting in an unwitnessed fall with laceration to the head and subsequent hospitalization for SAH (subarachnoid hemorrhage) and SDH (subdural hematoma). Findings include:Review of an admission Record revealed Resident #101 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: sepsis (life threatening condition cause by an infection), weakness, cognitive deficit (impaired mental processes), insomnia (unable to sleep) and repeated falls. […]

• Actual harm, isolatedF656Aug 13, 2025

  Based on observation, interview and record review, the facility failed to develop a person-centered care plan for the prevention of pressure ulcers for 1 (Resident #47) of 18 residents reviewed for person centered care plans resulting in Resident #47 developing an open wound on his coccyx (tail bone area) and a pressure ulcer on his left heel.Findings include:Review of an admission Record revealed Resident #47 was a male who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: CVA (cerebral vascular accident/ stroke), hemiplegia of the left side (inability to move the left side of the body), peg-tube (percutaneous endoscopic gastrostomy tube- a tube inserted into the stomach to provide artificial nutrition) and aphasia (a disorder that affect show a… […]

• Actual harm, isolatedF686Aug 13, 2025

  Based on observation, interview, and record review the facility failed to provide adequate care to prevent the development of pressure ulcers in 1 (Resident #47) of 5 residents reviewed for pressure ulcers resulting in Resident #47 developing pressure ulcers in the coccyx (the tailbone area of the body) and the left heel.Findings include:Resident #47Review of an admission Record revealed Resident #47 was a male who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: CVA (cerebral vascular accident/ stroke), hemiplegia of the left side (inability to move the left side of the body), peg-tube (percutaneous endoscopic gastrostomy tube- a tube inserted into the stomach to provide artificial nutrition) and aphasia (a disorder that affect show a person… […]

• Actual harm, isolatedF689Jun 9, 2025

  This citation pertains to intake MI00153113.Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent falls for 1 (Resident #105) of 3 residents reviewed for falls, resulting in a fall with major injury requiring hospitalization and surgical intervention for Resident #105 and potential for additional falls with injury. Findings include: Resident #105 Review of an admission Record revealed Resident #105 was originally admitted to the facility on [DATE] with pertinent diagnoses which included unspecified abnormalities of gait and mobility and muscle weakness.Review of a Minimum Data Set (MDS) assessment for Resident #105, with a reference date of 2/18/25 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated… […]