Villa Health Care East
Inspection Findings
F-Tag F0657
F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some
FORM CMS-2567 (02/99) Previous Versions Obsolete
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.
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
10/15/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Villa Health Care East
100 Marian Parkway Sherman, IL 62684
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0689
F 0689 Level of Harm - Actual harm
difficulties with tasks, she will constantly check on them. V5 stated Resident 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.
Residents Affected - Few
On 10/9/25 at 11:40 AM, V7 (CNA) stated Resident R2 would frequently get up to go to the bathroom without calling for help. V7 stated Resident 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 Resident 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 Resident 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.
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
10/15/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Villa Health Care East
100 Marian Parkway Sherman, IL 62684
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0725
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.
VILLA HEALTH CARE EAST in SHERMAN, IL inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
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.