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Deficiency Records for Villa at Borgess Place
View the most recent health deficiencies and inspection results for Villa at Borgess Place. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Villa at Borgess Place. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide and implement an infection prevention and control program. | Health | 2026-04-21 | 2026-05-13 | Y |
| Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. | Health | 2026-03-26 | 2026-04-22 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2026-04-21 | 2026-04-22 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2026-04-21 | 2026-04-22 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2026-03-26 | 2026-04-22 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2026-03-26 | 2026-04-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2026-03-26 | 2026-04-22 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2025-12-10 | 2026-01-05 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2025-12-10 | 2026-01-05 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2025-12-10 | 2026-01-05 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2025-12-10 | 2026-01-05 | Y |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2025-12-10 | 2026-01-05 | Y |
| Provide and implement an infection prevention and control program. | Health | 2025-12-10 | 2026-01-05 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2025-08-13 | 2025-10-03 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2025-08-13 | 2025-10-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2025-08-13 | 2025-10-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-08-13 | 2025-10-03 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2025-08-13 | 2025-09-09 | N |
| Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. | Health | 2025-08-13 | 2025-09-09 | N |
| 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. | Health | 2025-08-13 | 2025-09-09 | N |
| Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. | Health | 2025-08-13 | 2025-09-09 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2025-08-13 | 2025-09-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2025-08-13 | 2025-09-09 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2025-08-13 | 2025-09-09 | N |
| 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. | Health | 2025-08-13 | 2025-09-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2025-08-13 | 2025-09-09 | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2025-08-13 | 2025-09-09 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2025-08-13 | 2025-09-09 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2025-08-13 | 2025-09-09 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2025-08-13 | 2025-09-09 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2025-08-13 | 2025-09-09 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2025-08-13 | 2025-09-05 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2025-08-13 | 2025-09-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2025-08-13 | 2025-09-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2025-08-13 | 2025-09-05 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2025-08-13 | 2025-09-05 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2025-08-13 | 2025-09-05 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2025-08-13 | 2025-09-05 | N |
| 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. | Health | 2025-06-09 | 2025-07-14 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2025-06-09 | 2025-07-14 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2025-06-09 | 2025-07-14 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2025-06-09 | 2025-07-14 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2025-06-09 | 2025-07-14 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2025-06-09 | 2025-07-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-06-09 | 2025-05-12 | Y |
| Provide and implement an infection prevention and control program. | Health | 2025-02-25 | 2025-03-21 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2025-02-11 | 2025-03-21 | Y |
| 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. | Health | 2025-02-11 | 2025-03-21 | Y |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2025-02-11 | 2025-03-21 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-09-18 | 2024-10-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-09-18 | 2024-10-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-09-18 | 2024-10-10 | Y |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2024-08-29 | 2024-10-04 | N |
| 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. | Health | 2024-08-29 | 2024-10-04 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-08-29 | 2024-10-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-08-29 | 2024-10-04 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2024-08-29 | 2024-10-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-08-29 | 2024-10-04 | N |
| 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. | Health | 2024-08-29 | 2024-10-04 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-08-29 | 2024-10-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-08-29 | 2024-10-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-08-29 | 2024-10-04 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-08-29 | 2024-10-04 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-08-29 | 2024-10-04 | N |
| 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. | Health | 2024-08-29 | 2024-10-04 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2024-08-29 | 2024-10-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-08-29 | 2024-10-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-08-29 | 2024-10-04 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-08-29 | 2024-10-04 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-08-29 | 2024-10-04 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-08-29 | 2024-10-04 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-08-29 | 2024-10-04 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-03 | 2024-02-02 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-06 | 2023-10-13 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-07-12 | 2023-08-09 | Y |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-07-12 | 2023-08-09 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-07-12 | 2023-08-09 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-07-12 | 2023-08-09 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-07-12 | 2023-08-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-07-12 | 2023-08-09 | N |
| 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. | Health | 2023-07-12 | 2023-08-09 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-07-12 | 2023-08-09 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-07-12 | 2023-08-09 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-07-12 | 2023-08-09 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-07-12 | 2023-08-09 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-07-12 | 2023-08-09 | N |