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Complaint Investigation

Villa Health Care East

October 15, 2025 · Sherman, IL · 100 Marian Parkway
Citations 3
CMS Rating 1/5
Beds 109
Provider ID 145721
Healthcare Facility
Villa Health Care East
Sherman, IL  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

VILLA HEALTH CARE EAST in SHERMAN, IL — inspection on October 15, 2025.

Found 3 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0657
Resident Assessment and Care Planning Deficiencies

revised by the interdisciplinary team after each assessment, including both the comprehensive and

The facility's policy, Fall Assessment and Management, dated 6/2024, documented, C.

Care planning

team members in regard to future intervention, and resident specific risk factors. 2.

Potential environmental hazards will be reported to the Environmental Services Department.

145721 10/15/2025

Villa Health Care East 100 Marian Parkway Sherman, IL 62684

with tasks, she will constantly check on them. V5 stated R2 always has her call light in reach but

assess the resident and then will either call 911 or transfer the resident to the bed or chair with a full

On 10/9/25 at 11:40 AM, V7 (CNA) stated R2 would frequently get up to go to the bathroom without calling for help. V7 stated R2's hall has a lot of confused residents at risk for falls. V7 stated after 2:00 PM they only have 1 CNA for 23 residents now and they really need 2, it's hard to keep up.

On 10/9/25 at 11:42 AM, V6 LPN stated her main concern for R2 is falling. V6 stated she does regular checks on her and makes sure her alarms are on. V6 stated there is only 1 nurse working from 10:00 PM to 6:00 AM with 3 CNAs. V6 stated R2 was always getting up to go to the restroom without calling for help but now she has a urinary catheter and doesn't get out of bed. V6 stated after a fall occurs, they document, go over new interventions and the care plan. V6 stated new updates on falls are discussed during daily shift reports. V6 stated falls are always a concern.

On 10/14/25 at 11:40 AM, V10 (Medical Director) stated a resident showing urinary tract infection symptoms or a change in mental status would be at an increased risk for falls and he would expect staff to put in place fall precautions. V10 stated he would expect staff to be following the resident's care plan.

On 10/14/25 at 1:30 PM, in a joint interview with V1 (Administrator) and V2 (Director of Nursing), V2 stated she would expect to be notified of a significant change. V1 and V2 stated it is the resident's right to have privacy. V1 and V2 both stated they would expect the care plans to be followed.

The facility's Falls policy dated 6/2024 documented it is the policy of this facility to assess each resident's fall risk on admission, quarterly, and with each fall.

The policy continued to document each resident will be assessed using the MDS upon admission, quarterly and with any significant change assessment.

The potential for falls will be care planned when appropriate, based on the results of the Fall Risk Assessment.

The Interdisciplinary care plan will be person centered to reflect the specific needs and risk factors of the resident.

145721 10/15/2025

Villa Health Care East 100 Marian Parkway Sherman, IL 62684

  • Multiply the total number of hours by 10% to get the minimum number of registered nurse hours. It

were 96 residents that reside in the facility.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in SHERMAN, IL, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from VILLA HEALTH CARE EAST or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


More Reports

About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.