Villa at Beecher Place

In the surveyor’s words

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

• Immediate jeopardy, isolatedF578May 20, 2026

  This citation pertains to Intake Number 299655.Based on interviews and record review, the facility failed to ensure that wishes for no life-sustaining treatment (Do-Not-Resuscitate) were followed for one resident (Resident #101) of 4 sampled residents reviewed for advance directives, resulting in an unwanted resuscitation and prolonged suffering.Immediate Jeopardy:The Immediate Jeopardy (IJ) began on [DATE].The Immediate Jeopardy (IJ) was identified on [DATE].The Administrator was notified of the Immediate Jeopardy (IJ) on [DATE] at 3:10 PM. […]

• Immediate jeopardy, isolatedF695Apr 25, 2023

  This Citation contains two Deficient Practice Statements (DPS). Deficient Practice Statement #1: Based on observation, interview and record review, the facility is placed in Immediate Jeopardy for its 1) Failure to provide extra Tracheostomy (TRACH) tubes at bedside for three residents (Resident #37, Resident #48, and Resident #101) out of three residents reviewed for Tracheostomy care; 2) Failure to ensure that Trachesotomy follow-up care was provided and ensure a person-centered care plan for one resident (Resident #37), 3) Failure to ensure that competent nursing staff could provide Tracheostomy care, 4) Failure to store and clean respiratory equipment for two residents (Resident #30 and Resident #101), and 5) Failure to ensure that oxygen was provided and managed per physician's order… […]

• Immediate jeopardy, isolatedF684Jan 10, 2022

  This Citation pertains to Intake Number MI 959 Based on interview and record review the facility is placed in Immediate Jeopardy for its failure to comprehensively assess, treat and monitor the circulation and skin conditions of Resident #13's right leg, including not having a Wound Care Physician assess the resident's leg for 2 1/2 months, which resulted in Resident #13 requiring a right leg, above-the-knee amputation. This deficient practice placed 107 residents at significant risk of not being comprehensively and competently assessed, monitored, and treated by facility staff for their skin issues, which could result in loss of limb or other life-threatening health conditions. […]

• Actual harm, patternF603Dec 7, 2022

  This Citation pertains to Intake Number MI00131037. Based on observation, interview and record review, the facility failed to develop, implement, and operationalize policies and procedures to ensure that eight residents (Resident #701, Resident #702, Resident #703, Resident #704, Resident #705, Resident #706, Resident #707, and Resident #708) of eight residents reviewed and 32 additional Residents residing on the third floor of the facility were assessed for appropriate placement in a locked unit of the facility and provided immediate access for visitation. […]

• Actual harm, isolatedF686Jun 24, 2026

  Based on observation, interview and record review, the facility failed to follow care-planned interventions, implement the interventions timely, and assess, monitor, and prevent the new development of pressure ulcers for five residents (Resident #2, Resident #6, Resident #13, Resident #34 and Resident #38) of five residents reviewed for pressure ulcers, resulting in delayed assessment, new pressure injuries, and pain. Findings include. Resident #13: On 6/15/2026, at 9:32 AM, Resident #13 was sitting in their wheelchair. There was a dressing to their right heel with a date of 6/14. Their feet were resting on the foot pedals. On 6/15/2026, at 12:45 PM, Resident #13 was sitting in their wheelchair and declined a skin observation. […]