Villa Health Care East
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
The facility's policy, Care Plan Process, dated 11/2017, All plans of care must be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly assessment.
The facility's policy, Fall Assessment and Management, dated 6/2024, documented, C.
Care planning after a fall: 1. A licensed nurse will consult with the resident's care givers and other interdisciplinary team members in regard to future intervention, and resident specific risk factors. 2.
Potential environmental hazards will be reported to the Environmental Services Department.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/15/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Villa Health Care East
100 Marian Parkway Sherman, IL 62684
SUMMARY STATEMENT OF DEFICIENCIES
difficulties with tasks, she will constantly check on them. V5 stated R2 always has her call light in reach but rarely uses it. V5 stated after a resident falls, she doesn't move them, goes to get a nurse, they will assess the resident and then will either call 911 or transfer the resident to the bed or chair with a full body mechanical lift. V5 stated we find out updates on interventions in reports each shift.
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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/15/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Villa Health Care East
100 Marian Parkway Sherman, IL 62684
SUMMARY STATEMENT OF DEFICIENCIES
Federal health inspectors cited VILLA HEALTH CARE EAST in SHERMAN, IL for a deficiency under regulatory tag F-F0725 during a complaint investigation conducted on 2025-10-15.
Category: Nursing and Physician Services Deficiencies
The facility was found deficient in the following area: Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 3 deficiencies cited during this inspection of VILLA HEALTH CARE EAST.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-11-04.