ElderGrade

Inspection citations at Villa At Borgess Place

70 citations on record, 5 of which inspectors scored at actual harm or immediate jeopardy. Each one is the state surveyor's own finding, not our summary.

Reading the scope & severity code

A–C

No harm, minimal potential

D–F

No harm, potential for harm

G–I

Actual harm to a resident

J–L

Immediate jeopardy

The letter also encodes how many residents were affected — isolated, a pattern, or widespread. Full explainer.

Citations by survey year

Year Citations Involving harm or jeopardy
2026 7 2
2025 35 3
2024 19 0
2023 9 0
D April 21, 2026 Tag F0880 Complaint investigation Corrected May 2026

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

D April 21, 2026 Tag F0677 Complaint investigation Corrected Apr 2026

Quality of Life and Care Deficiencies

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

No actual harm, potential for more than minimal harm

G April 21, 2026 Tag F0686 Complaint investigation Corrected Apr 2026

Quality of Life and Care Deficiencies

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

Actual harm to a resident

D March 26, 2026 Tag F0658 Complaint investigation Corrected Apr 2026

Resident Assessment and Care Planning Deficiencies

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

No actual harm, potential for more than minimal harm

D March 26, 2026 Tag F0655 Complaint investigation Corrected Apr 2026

Resident Assessment and Care Planning Deficiencies

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

No actual harm, potential for more than minimal harm

D March 26, 2026 Tag F0627 Complaint investigation Corrected Apr 2026

Resident Rights Deficiencies

Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.

No actual harm, potential for more than minimal harm

G March 26, 2026 Tag F0689 Complaint investigation Corrected Apr 2026

Quality of Life and Care Deficiencies

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

Actual harm to a resident

D December 10, 2025 Tag F0880 Complaint investigation Corrected Jan 2026

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

D December 10, 2025 Tag F0694 Complaint investigation Corrected Jan 2026

Quality of Life and Care Deficiencies

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

No actual harm, potential for more than minimal harm

D December 10, 2025 Tag F0690 Complaint investigation Corrected Jan 2026

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.

No actual harm, potential for more than minimal harm

D December 10, 2025 Tag F0658 Complaint investigation Corrected Jan 2026

Resident Assessment and Care Planning Deficiencies

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

No actual harm, potential for more than minimal harm

D December 10, 2025 Tag F0655 Complaint investigation Corrected Jan 2026

Resident Assessment and Care Planning Deficiencies

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

No actual harm, potential for more than minimal harm

D December 10, 2025 Tag F0550 Complaint investigation Corrected Jan 2026

Resident Rights Deficiencies

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

No actual harm, potential for more than minimal harm

D August 13, 2025 Tag F0880 Corrected Oct 2025

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

D August 13, 2025 Tag F0761 Corrected Sep 2025

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.

No actual harm, potential for more than minimal harm

D August 13, 2025 Tag F0756 Corrected Sep 2025

Pharmacy Service Deficiencies

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

No actual harm, potential for more than minimal harm

D August 13, 2025 Tag F0677 Corrected Oct 2025

Quality of Life and Care Deficiencies

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

No actual harm, potential for more than minimal harm

D August 13, 2025 Tag F0655 Corrected Sep 2025

Resident Assessment and Care Planning Deficiencies

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

No actual harm, potential for more than minimal harm

D August 13, 2025 Tag F0628 Corrected Sep 2025

Resident Rights Deficiencies

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

No actual harm, potential for more than minimal harm

D August 13, 2025 Tag F0609 Complaint investigation Corrected Sep 2025

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

No actual harm, potential for more than minimal harm

D August 13, 2025 Tag F0605 Corrected Sep 2025

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

No actual harm, potential for more than minimal harm

D August 13, 2025 Tag F0600 Complaint investigation Corrected Sep 2025

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.

No actual harm, potential for more than minimal harm

D August 13, 2025 Tag F0578 Corrected Sep 2025

Resident Rights Deficiencies

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.

No actual harm, potential for more than minimal harm

E August 13, 2025 Tag F0921 Corrected Sep 2025

Environmental Deficiencies

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

No actual harm, potential for more than minimal harm

E August 13, 2025 Tag F0847 Corrected Sep 2025

Administration Deficiencies

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

No actual harm, potential for more than minimal harm

E August 13, 2025 Tag F0842 Complaint investigation Corrected Sep 2025

Resident Assessment and Care Planning Deficiencies

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

No actual harm, potential for more than minimal harm

E August 13, 2025 Tag F0689 Complaint investigation Corrected Oct 2025

Quality of Life and Care Deficiencies

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

No actual harm, potential for more than minimal harm

E August 13, 2025 Tag F0550 Corrected Sep 2025

Resident Rights Deficiencies

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

No actual harm, potential for more than minimal harm

F August 13, 2025 Tag F0812 Corrected Sep 2025

Nutrition and Dietary Deficiencies

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

No actual harm, potential for more than minimal harm

G August 13, 2025 Tag F0686 Corrected Oct 2025

Quality of Life and Care Deficiencies

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

Actual harm to a resident

G August 13, 2025 Tag F0656 Corrected Sep 2025

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.

Actual harm to a resident

D June 9, 2025 Tag F0677 Complaint investigation Corrected Jul 2025

Quality of Life and Care Deficiencies

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

No actual harm, potential for more than minimal harm

D June 9, 2025 Tag F0658 Complaint investigation Corrected Jul 2025

Resident Assessment and Care Planning Deficiencies

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

No actual harm, potential for more than minimal harm

D June 9, 2025 Tag F0607 Complaint investigation Corrected Jul 2025

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

No actual harm, potential for more than minimal harm

D June 9, 2025 Tag F0550 Complaint investigation Corrected Jul 2025

Resident Rights Deficiencies

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

No actual harm, potential for more than minimal harm

E June 9, 2025 Tag F0806 Complaint investigation Corrected Jul 2025

Nutrition and Dietary Deficiencies

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

No actual harm, potential for more than minimal harm

F June 9, 2025 Tag F0803 Complaint investigation Corrected Jul 2025

Nutrition and Dietary Deficiencies

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.

No actual harm, potential for more than minimal harm

G June 9, 2025 Tag F0689 Complaint investigation Corrected May 2025

Quality of Life and Care Deficiencies

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

Actual harm to a resident

D February 25, 2025 Tag F0880 Complaint investigation Corrected Mar 2025

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

D February 11, 2025 Tag F0940 Complaint investigation Corrected Mar 2025

Administration Deficiencies

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

No actual harm, potential for more than minimal harm

Citations are published by CMS from state survey agency findings. A citation describes what an inspector observed on a specific date; homes are required to submit a correction plan, and many findings are resolved long before you read them. Ask the administrator what happened and what changed.