Villa Health Care East
VILLA HEALTH CARE EAST in SHERMAN, IL — inspection on January 29, 2026.
Found 1 citation. 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
Based on observation, interview, and record review, the facility failed to prepare and provide food according to physician orders for 1 of 3 residents (R3) reviewed for diet consistency in the sample of 9.
Findings Include:R3's admission Record document, print date of 1/22/26, documented R3 has diagnoses including Alzheimer's disease, atrial fibrillation, gastro-esophageal reflux disease, hypertension, spinal stenosis, aphasia following cerebral infarction, and glaucoma.R3's MDS (Minimum Data Set), dated 12/4/25, documented R3 is moderately cognitively impaired and requires setup assistance with meals. R3's Physician Order Summary Report, print date of 1/22/26, documented R3's physician order for a pureed texture diet with moderately thick (honey) consistency liquids. On 1/22/26 at 12:39 PM R3 was observed during the lunch meal. R3 was served pureed meat, peas, and carrots in a 3-compartment divided plate. R3 was also served pears with whipped topping in a small plastic bowl.
The pears appeared to be diced rather than pureed. On 1/22/26 at 1:00 PM V9 CNA (Certified Nurse Assistant) was observed sitting next to R3 and was cutting R3's pears up with a butter knife.
Surveyor asked V9 if the pears were pureed and V9 stated yes.
Surveyor then requested V9 to get a scoop of the pears onto a spoon.
Chunks of pear pieces were observed on the spoon which V9 continued to leave for R3. On 1/22/26 at 1:05 PM R3 was observed reaching into her mouth and then R3 placed a piece of pear on her plate. On 1/22/26 at 1:47 PM V8 Food Services Supervisor stated a pureed diet is to be the consistency of baby food and there should not have been any chunks in R3's pears. On 1/28/26 at 1:51 PM V1 Administrator stated she expects the residents to be served food according to each resident's physician's orders.
The facility's Menus and Meal Service policy, dated 11/22, documented guest tickets should be printed for each resident at every meal to ensure diet accuracy. A system needs to be established to ensure each resident receives their food at every meal.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
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