Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Villa Health Care East during CMS and state inspections, most recent first.
A resident with unsteadiness, history of falls, macular degeneration, depression, anxiety, and progressive confusion was repeatedly documented as wandering, impulsive, and exit‑seeking, packing belongings, talking about going home, and frequently going to exit doors. Although she was later identified on an elopement list and staff observed her pushing on exit doors and at least once setting off an exit alarm, these behaviors were not consistently reported to management, and her care plan initially lacked specific exit‑seeking interventions. On the night of the incident, the resident was left sleeping in a wheelchair at the nurse’s station next to an alarmed exit while the CNA showered another resident and the RN passed meds on another hall; she awoke, self‑propelled to the door, exited through two doors, fell onto the concrete, and then scooted through the parking lot until bystanders from a nearby highway found her alone, bleeding, and yelling for help. Police and EMS were called by the bystanders, and staff only came outside minutes later, demonstrating a failure to provide adequate supervision and timely response to alarms to prevent elopement.
A resident with Alzheimer’s disease, aphasia, and other comorbidities, who was ordered a pureed diet with moderately thick (honey) liquids, was observed receiving diced pears instead of fully pureed fruit. A CNA stated the pears were pureed and continued to serve them despite visible chunks, and the resident was seen removing a piece of pear from their mouth. The Food Services Supervisor confirmed that pureed items should be baby-food consistency with no chunks, and facility policy requires use of guest tickets at each meal to ensure diet accuracy.
Two residents with cognitive impairment and high fall risk were not adequately supervised, despite care plan interventions requiring staff presence during transfers and toileting. Both residents attempted to ambulate or perform personal hygiene independently, resulting in one sustaining a left hip fracture and the other a head laceration, with both requiring hospitalization. Staff interviews and documentation revealed that alarms and call lights were not effectively used or accessible, and staffing levels were insufficient to provide the necessary supervision.
The facility did not provide enough nursing staff on certain shifts, resulting in residents not receiving timely assistance and supervision, including a resident who fell in the bathroom while unattended despite care plan instructions. Multiple residents and staff reported inadequate staffing, especially at night, and facility records confirmed minimal nurse and CNA coverage during these times.
The facility did not consistently update or revise care plans for several residents after they experienced falls, despite documented histories of cognitive impairment, physical limitations, and repeated incidents. In some cases, required interventions such as alarms and supervision were not implemented or followed, and care plans were not adjusted to address new risk factors or incidents, contrary to facility policy.
Staff did not ensure privacy for a resident during incontinence care, leaving the door, curtain, and blinds open while a person was present outside the window. Additionally, several staff members, including CNAs, an RN, and the DON, were observed standing while feeding residents with severe cognitive impairment or dementia, rather than sitting with them as expected for dignified dining assistance.
A resident with significant fall risk factors was left unsupervised on the side of her bed by a CNA, resulting in a fall and femur fracture requiring surgery. The care plan required dependent staff assistance with transfers and did not document all necessary fall interventions, such as gripper socks, despite facility policy and the resident's high-risk status.
A resident with dementia and high fall risk was left unattended on the toilet, resulting in a fall and hip fracture. Despite care plans and visual reminders, staff failed to provide necessary supervision. The facility's policy emphasized monitoring high-risk residents, but the deficiency in supervision led to the incident.
The facility failed to securely store and properly label medications, with open bottles of eye drops and ointments lacking open dates, and expired Pantoprazole found in storage. An unlocked medication cart was also observed. Additionally, expired blood glucose control liquids were used for diabetic residents, with staff unclear on responsibility for checking expiration dates.
The facility failed to implement proper infection control practices, with staff not adhering to PPE protocols and inadequate disinfection of equipment. An LPN did not sanitize hands before donning gloves and inadequately disinfected a glucometer used on a COVID-19 positive resident. A resident with symptoms was not tested timely, leading to a positive result after hospital admission. Staff, including a CNA and an LPN, were observed not wearing required PPE when entering COVID-19 positive rooms, breaching infection control protocols.
A resident with enterocolitis due to C. difficile did not receive prescribed vancomycin doses because the medication was unavailable from the pharmacy. The LPN and DON confirmed the missed doses, which violated the facility's medication administration policy.
The facility failed to educate and document the COVID-19 vaccination status for three residents. The Infection Preventionist LPN admitted the absence of educational materials and declination refusals for the COVID-19 vaccine. The facility's policy requires education on the vaccine, but it lacks guidance on documenting acceptance or refusal. The EMRs for these residents do not show evidence of education or vaccine offers, indicating a deficiency in policy adherence and documentation.
Elopement of Confused Exit‑Seeking Resident Through Alarmed Exit Door
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and timely response to alarms to prevent the elopement of a confused, exit‑seeking resident. The resident was admitted for short‑term rehabilitation with diagnoses including unsteadiness on feet, history of falling, macular degeneration, depression, anxiety, and diabetes, and was repeatedly documented by staff as having much confusion, poor safety awareness, impulsivity, and wandering behaviors. Social services and nursing notes described the resident as alert/oriented with much confusion, forgetfulness, poor reasoning skills, and no safety awareness, with frequent attempts to get up unsafely, wandering up and down hallways, going in and out of other residents’ rooms, and seeking exits while looking for family or a dog. Multiple notes and interviews documented that the resident packed belongings several times, made statements about going home or meeting family, and was recognized by staff as a wanderer with potential to be exit‑seeking, yet the facility initially scored her as not able to physically leave the facility and did not document early interventions for exit‑seeking on the care plan. Over time, staff documented escalating behaviors, including exit‑seeking and attempts to use exit doors. Nursing and social service notes recorded that the resident was crying, seeking elopement, attempting to stand despite being wheelchair‑bound, and that staff had to provide continuous redirection, sometimes keeping her at the nurse’s station or providing 1:1 supervision informally. An Exit Seeking/Wandering Screener was later completed indicating that the resident was physically able to leave the building, disoriented to place, had impaired decision‑making, made statements about going home, and displayed persistent anger, and she was added to the facility’s wander/elopement list. Subsequent care plan updates added general redirection strategies (calm communication, snacks, drinks, bathroom use, activities, reassurance), but there were no documented specific interventions addressing her repeated exit‑seeking at doors. Staff interviews revealed that several nurses and CNAs observed the resident self‑propelling to exit doors, looking out, pushing on doors, and in at least one instance setting off an exit door alarm, yet these behaviors were not reported to management or the DON, and some staff stated they did not see the importance of reporting because the resident had not yet gotten out or been hurt. On the night of the elopement, surveillance footage and staff interviews showed that the resident was left sleeping in her wheelchair at the nurse’s station near an alarmed exit door while the assigned CNA went to shower another resident and the assigned RN was administering medications on another hall. At 7:12 PM, the resident awoke, self‑propelled from behind the nurse’s station to the exit door next to it, pushed through the first door, then opened the second exit door, had difficulty getting her wheelchair through, attempted to stand, and fell onto the concrete outside the second door. She then log‑rolled into the parking lot, used a handicap sign to sit up, and scooted on her buttocks through the parking lot until two bystanders driving on the adjacent busy four‑lane highway saw her alone, bleeding, and yelling for help. The bystanders reported that no staff were outside with the resident, that an initial staff member they notified did not follow them out, and they ultimately called 911. A police officer arrived to find the resident alone, confused, and bleeding from her hands/wrists, with nursing staff coming outside only minutes later. Facility leadership and the DON later acknowledged that they had not been informed of the resident’s prior exit‑seeking behaviors, that no enhanced monitoring such as frequent checks or formal 1:1 supervision had been implemented, and that the resident, who lacked safety awareness and was on a wander/elopement list, was able to elope through an alarmed exit door without timely staff response, resulting in Immediate Jeopardy. The resident was transported to a local hospital, where ED documentation listed dementia in her medical history and noted that she had eloped from the nursing home and fallen, with complaints of right knee and hip pain. The resident’s long‑term PCP, who had followed her for over 20 years, stated that although she had not been formally diagnosed with dementia previously, her cognitive decline over the past year was evident, and she had no insight or safety awareness. He stated that no facility staff had contacted his office to report exit‑seeking behaviors and that he expected such behaviors to be documented and addressed with interventions to prevent elopement. Throughout the record and interviews, multiple staff, including social services, the ADON, and the DON, described the resident as very confused, a wanderer, and not appropriate for the non‑secured setting, yet there was a lack of consistent recognition and communication that she was an elopement risk, and staff failed to respond promptly to the exit door alarm at the time she left the building, allowing her to be found outside by bystanders rather than facility staff.
Failure to Provide Ordered Pureed Diet Consistency
Penalty
Summary
The deficiency involves the facility’s failure to provide food in the prescribed texture and consistency according to a physician’s diet order for one resident. The resident had multiple diagnoses, including Alzheimer’s disease, atrial fibrillation, GERD, hypertension, spinal stenosis, aphasia following cerebral infarction, and glaucoma, and was documented on the MDS as moderately cognitively impaired and requiring setup assistance with meals. The physician’s order specified a pureed texture diet with moderately thick (honey) liquids. During a lunch meal observation, the resident was served pureed meat, peas, and carrots, but the pears with whipped topping appeared diced rather than pureed. A CNA was observed sitting next to the resident and cutting the pears with a butter knife, and when asked if the pears were pureed, the CNA stated they were. At the surveyor’s request, the CNA placed a scoop of pears on a spoon, which showed visible chunks of pear that the CNA continued to leave for the resident. The resident was then observed reaching into her mouth and placing a piece of pear onto her plate. The Food Services Supervisor later stated that a pureed diet should be the consistency of baby food and that there should not have been any chunks in the pears. The facility’s Menus and Meal Service policy documented that guest tickets should be printed for each resident at every meal to ensure diet accuracy and that a system needs to be established to ensure each resident receives their food at every meal.
Failure to Supervise High Fall Risk Residents Resulting in Serious Injuries
Penalty
Summary
The facility failed to provide adequate supervision and maintain an environment free from accident hazards for two residents, resulting in significant injuries and hospitalizations. One resident, with diagnoses including Alzheimer's disease and a history of falls, was found sitting unsupervised on the side of her bed with the bed not in the lowest position, the bed alarm not sounding, and her call light out of reach. This resident later fell in the bathroom while attempting to ambulate independently, despite care plan interventions requiring staff supervision during transfers and toileting. Staff interviews confirmed that the resident was known not to use her call light and required supervision, but she was left unattended, leading to a left hip fracture. Another resident, also with a history of repeated falls, cognitive impairment, and hemiplegia, experienced multiple falls over a period of time, including a significant incident where she fell off the toilet while attempting to clean herself, resulting in a right frontal laceration that required hospitalization and sutures. The resident's care plan specified that staff should remain with her in the bathroom and not leave her unattended, but documentation and staff interviews revealed that she was left alone or given privacy, contrary to these interventions. The resident's fall risk assessments consistently rated her as high risk, and her medical records documented frequent reminders and interventions that were not consistently followed. Staff interviews indicated that both residents rarely used their call lights and often attempted to perform tasks independently despite their high fall risk and care plan requirements for supervision. Staffing levels were noted to be low, with only one CNA for a hallway of 23 residents during certain shifts, making it difficult to provide the required supervision. The facility's own falls policy required individualized care planning and consistent implementation of fall prevention interventions, which were not adhered to in these cases, directly contributing to the residents' injuries.
Insufficient Nursing Staff to Meet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by multiple incidents and staff/resident interviews. One resident, who was moderately cognitively impaired and required supervision for activities of daily living, experienced a fall in the bathroom after becoming dizzy and was found on the floor by a CNA. The resident's care plan specifically required that she not be left unattended in the bathroom or while sitting on the side of the bed, and that her call light be kept within reach with prompt response to requests for assistance. On the night of the fall, there was only one nurse and one CNA assigned to the hallway where this resident and others resided. Other residents and staff reported that there was not enough help on the night shift, with only one nurse and one CNA typically assigned to certain halls, making it difficult to provide timely care and supervision. Residents who were dependent on staff for transfers and mobility, and those at risk for falls, expressed concerns about insufficient staffing, particularly during evening and night shifts. Staff assignment sheets confirmed that on several reviewed dates, only one nurse and one CNA were assigned to the relevant hallways during overnight hours. Additional documentation, including grievance forms and resident council meeting minutes, indicated ongoing concerns about call lights not being answered promptly and the need for CNAs to check on residents every two hours. The facility's staffing plan referenced CMS minimum staffing guidelines and described a methodology for determining staffing needs, but interviews with the scheduler and administrator revealed that staffing decisions were based on these minimums and the facility assessment, without a specific policy for nursing staff levels.
Failure to Revise Care Plans After Resident Falls
Penalty
Summary
The facility failed to update and revise care plans for multiple residents after they experienced falls, as required by both facility policy and regulatory standards. For example, one resident with a history of repeated falls, cognitive impairment, and physical limitations experienced several falls on specific dates, but her fall risk care plan was not updated after at least two of these incidents. Another resident, who was severely cognitively impaired and required assistance for transfers, also experienced multiple falls, yet his care plan was not revised following at least two of these events. In one instance, it was documented that the resident was wearing inappropriate footwear at the time of a fall, and a family grievance noted that required alarms were not consistently in place, despite being care planned interventions. A third resident, who was cognitively intact but required supervision for transfers and used a wheelchair, reported that staff did not provide assistance to prevent falls and that she often had to manage on her own. The care plan for this resident included interventions to prevent her from being left unattended, but these were not consistently followed. Additionally, a fourth resident with a history of hip fracture and Alzheimer's disease fell after losing balance while leaving the bathroom, and although recommendations were made for reeducation on call light use, the care plan was not updated with new interventions following the fall. Facility policies require that care plans be reviewed and revised by the interdisciplinary team after each assessment and after any fall, with input from caregivers and consideration of environmental hazards. Despite these requirements, the care plans for these residents were not consistently updated or revised after falls, and interventions were not always implemented or adjusted in response to incidents, as documented in interviews, observations, and record reviews.
Failure to Provide Privacy During Care and Dignity During Dining Assistance
Penalty
Summary
Staff failed to provide privacy and dignity during care for several residents. In one instance, a CNA provided incontinence care to a cognitively intact resident with the door, curtain, and blinds left open, exposing the resident to potential view from outside, where a person was present in the courtyard. The resident expressed embarrassment about the possibility of being seen naked through the window. The facility's Resident Rights booklet states that medical and personal care are private, and both the CNA and Administrator acknowledged that privacy should have been maintained by closing the door, curtain, and blinds during care. Additionally, multiple staff members, including CNAs, an RN, and the DON, were observed standing while feeding residents who were dependent on staff for eating due to severe cognitive impairment or dementia. These actions occurred in the dining room and involved residents with diagnoses such as Alzheimer's disease and severe dementia. The Administrator confirmed that there was no facility policy on feeding residents but stated that staff should sit with residents rather than stand over them during feeding.
Failure to Provide Adequate Supervision and Fall Precautions
Penalty
Summary
A deficiency occurred when a resident with multiple high-risk factors for falls, including muscle weakness, impaired gait, dependence on a wheelchair, and a history of falls, was left unsupervised sitting on the side of her bed by a CNA. The CNA left the resident momentarily to retrieve a sit-to-stand lift, during which time the resident slid off the bed and sustained a distal femoral shaft fracture, later requiring surgical repair. The resident's care plan indicated a need for dependent staff assistance with transfers using a mechanical lift and substantial/maximal assistance for bed mobility, but these interventions were not followed at the time of the incident. Additionally, the care plan failed to document the use of gripper socks as an intervention, despite this being identified in the fall investigation. Interviews with facility leadership confirmed that the resident was considered a high fall risk and should not have been left sitting on the bedside unsupervised. The facility's fall policy required individualized care planning and implementation of interventions for high-risk residents, which was not adequately executed in this case.
Failure to Supervise High Fall Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision for a resident, identified as R2, who was at high risk for falls due to her medical conditions, including dementia and Lewy Body Dementia. R2's care plan emphasized the need for anticipating and meeting her needs, ensuring her call light was within reach, and responding promptly to her requests for assistance. Despite these precautions, R2 attempted to walk back to her bed from the toilet without assistance, resulting in a fall that led to a left hip fracture. The incident was unwitnessed, and the root cause was identified as R2 being new to the facility and attempting to move without calling for help. Interviews with facility staff revealed that R2 was known to be a high fall risk, and there were visual reminders such as a whiteboard and a 'call don't fall' sign in her room. However, it was noted that R2 might not have understood how to use the call light due to her cognitive impairment. Staff members, including LPNs and CNAs, acknowledged that R2 should not have been left unattended on the toilet, given her fall risk and cognitive limitations. The CNA who assisted R2 on the day of the fall did not return a call for further clarification on the incident. The Director of Nurses confirmed that R2 should not have been left alone on the toilet and that interventions such as bed and chair alarms and clear communication during shift changes were standard for high fall risk residents. The facility's policy on fall assessment and management emphasized the need for an interdisciplinary approach to care planning and monitoring. R2's physician indicated that the injury could have been prevented if staff had stayed with her, highlighting the deficiency in supervision and adherence to care protocols.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure the secure storage and proper labeling of medications, as well as the use of non-expired medical supplies. During an observation, a medication cart was found with several open bottles of eye drops and ointments that were not labeled with the date they were opened, including Timolol eye drops and Durezol for specific residents. Additionally, an open tube of Systane eye lubricant was found unlabeled, and an expired bottle of Pantoprazole Oral Suspension was discovered in the medication storage room. Furthermore, a medication cart was left unlocked and unattended, which was confirmed by the staff present. The facility also failed to ensure the use of non-expired blood glucose control liquids, which were found to be expired for several diabetic residents. The staff, including an LPN and the Infection Preventionist, indicated that checking the expiration dates of these control liquids was not their responsibility, and the facility's policy did not adequately address the quality control measures for blood glucose monitoring. The Director of Nursing acknowledged the expectations for medication labeling and disposal of expired medications, but the facility's policy did not cover these aspects comprehensively.
Inadequate Infection Control Practices in LTC Facility
Penalty
Summary
The facility failed to implement proper infection control practices, as evidenced by multiple instances of staff not adhering to PPE protocols and inadequate disinfection of multi-use equipment. A Licensed Practical Nurse (LPN) was observed not sanitizing hands before donning gloves and inadequately disinfecting a blood glucose glucometer after use on a COVID-19 positive resident. The facility's policy required dedicated medical equipment for COVID-19 positive residents, which was not followed, as the glucometer was not dedicated and was inadequately disinfected. The facility also failed to conduct timely COVID-19 testing for residents showing symptoms. One resident, who was admitted with congestive heart failure and hypertension, exhibited symptoms consistent with COVID-19 but was not tested between specific dates, leading to a positive test result only after being taken to the hospital by a family member. This indicates a lapse in the facility's testing protocol, which required symptomatic residents to be tested immediately. Additionally, staff members, including an agency CNA and an LPN, were observed not wearing the required PPE when entering rooms of COVID-19 positive residents. The CNA did not perform hand hygiene consistently and failed to wear eye protection or a gown while delivering meal trays to COVID-19 positive residents. Similarly, the LPN entered a COVID-19 positive resident's room with only a mask, disregarding the requirement for full PPE. These actions demonstrate a significant breach in infection control protocols, contributing to the spread of infection within the facility.
Medication Administration Failure
Penalty
Summary
The facility failed to administer medications as prescribed to a resident diagnosed with enterocolitis due to Clostridium difficile. The resident was on contact/droplet isolation precautions and had a physician's order for vancomycin oral suspension, to be administered four times a day. However, the Medication Administration Record (MAR) indicated that the vancomycin doses were not administered on specific dates and times. An LPN confirmed that the doses were missed because the medication did not arrive from the pharmacy, and the convenience box did not contain any vancomycin. The Director of Nursing corroborated this explanation, noting that the medication was unavailable from the pharmacy on the specified dates. The facility's policy on medication administration requires accurate administration per doctor's orders, which was not adhered to in this instance.
Failure to Educate and Document COVID-19 Vaccination Status
Penalty
Summary
The facility failed to provide education or document refusal for the COVID-19 vaccine for three residents, identified as R44, R51, and R231, out of a sample of 55 residents reviewed for immunizations. On August 5, 2024, the Infection Preventionist LPN, identified as V2, acknowledged that the facility lacked educational materials and declination refusals for the COVID-19 immunization. V2 confirmed that R44, R51, and R231 were the only residents in the building who had not been vaccinated for COVID-19. The facility's COVID-19 Vaccination Policy for Residents, dated February 1, 2022, mandates that education be provided to all residents or their responsible parties regarding the COVID-19 vaccination. However, the policy does not specify how acceptance or refusal of the vaccine should be documented. The admission records for R51, R44, and R231, printed on August 12, 2024, indicate that these residents were admitted on unspecified dates. Their electronic medical records (EMRs) lack documentation showing that they were educated about and offered the COVID-19 vaccine. This omission highlights a deficiency in the facility's adherence to its vaccination policy and documentation procedures.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Sherman
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Arcadia Care On The Hill | 6.9 mi | — | 30 | 2 |
| Regency Care | 8 mi | — | 1 | 0 |
| Avenues At Springfield | 8.6 mi | — | 0 | 0 |
| Arc At Sangamon Valley | 8.9 mi | — | 4 | 0 |
| Springfield Suites Rehab And Nursing | 9.6 mi | — | 15 | 0 |
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