Health inspection·January 28, 2025

F 0689 Level of Harm - Actual harm On 1/21/2025 at 2:20 PM, V6, LPN, stated that she knew R2 had a fall history and was a high fall risk. She continued to state that her shift, day shift, did not leave her on the toilet alone because they all knew she was a high fall risk and that there was a white board in R2's room that had written on it that she was a high fall risk. Residents Affected - Few On 1/22/2025 at 9:43 am V7, Licensed Practical Nurse (LPN), stated that she was the nurse who assessed R2 after her fall. V7, stated, The CNA, (V11), came and got me because (R2) was on the floor in the bathroom. She was lying on her right side on the floor. She had a scrape above her right eyebrow and had no complaints of pain. V7 continued to state that she did active and passive range of motion of her legs and arms and there was no issues. V7 stated that she spoke with R2's granddaughter because her power of attorney did not answer the phone. V7 stated that her granddaughter told her that her grandmother falls all the time. V7 was asked, if she knew R2 was a high fall risk and she stated yes and that there was a call don't fall sign in her room and that all rooms have these signs. V7 also stated she did not think R2 knew how to use the call light or what it was for because of her dementia. V7 stated that she did not know why V11, Certified Nurse Assistant (CNA), put her on the toilet and then left the room, maybe to help another resident. On 1/22/2025 at 9:45 am V9, CNA, stated that on 1/14/2025, she went to get R2 up for the day, she assisted her with sitting on the side of her bed, because she wasn't sitting up very well. She was able to transfer R2 into her wheelchair, into the bathroom and on to the toilet with R2 using the assistance bar in the bathroom because R2 was having trouble standing up that day and usually she transferred pretty good. Once R2 was finished using the toilet, V9 stated that she assisted her back into her wheelchair, got her dressed and took her to the dining room for breakfast. V9 stated that R2's appetite was poor that morning, only taking in about 75% of her meal when she usually eats 100%. V9 stated that R2 told her that she was having pain in both of her hips and in her back. V9 stated that she let the nurse know (V10, LPN), they laid her down and (V10, LPN) checked her out. V9 stated that R2 was in pain and had facial grimacing when she transferred her. V9 stated that R2 was a high fall risk but she never tried to get up on her own. V9 stated that she would not leave R2 unattended on the toilet nor would she never depended on R2 using her call light when she needed to get off of the toilet and that she would stay with her until she was finished. On 1/22/2025 at 10:30 am V10, LPN, stated that R2 never asked for pain medication usually but said her hips and back hurts. V10, stated, The CNA (V9) was putting the footrest on (R2's) wheelchair, and her left leg was rotated outwardly, The CNA (V9) and myself, laid (R2) down in bed and I assessed her further. R2's left leg was rotated outward and shortened. I called her doctor for a stat Xray of those areas, and he wanted her sent to the ER immediately. V10 stated that R2 was a high fall risk by just looking at her diagnosis. V10 stated that she told her CNA's who she works with and the oncoming shift not to leave her alone when on the toilet and she should have never been left alone on the toilet. V10 also stated that with R2's dementia she would not know when or how to use the call light. On 1/22/2025 at 9:30 AM, V8, Licensed Physical Therapy Assistant, (LPTA), stated that she worked with R2 on 1/13/2025, the day after she fell, she did not complain of any pain. V8 also stated that R2 could not safely transfer herself on or off of the toilet. V8 stated that R2 could hold a call light but did not think she would understand how to use it. V8 stated that from a safety standpoint someone should have stayed in the bathroom with her. On 1/22/2025 at 9:45 am, a phone call was placed, and a message was left for V11, CNA, to return call. V11, did not return phone call. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145721 If continuation sheet Page 2 of 3 Printed: 05/15/2026 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 145721 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/28/2025 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 0689 Level of Harm - Actual harm Residents Affected - Few On 1/22/2025 at 11:00 am V2, Director of Nurses, when asked since R2 was a high risk for falls, should she have been left unattended on the toilet? V2 stated no. When asked if a resident, who is a high risk of falls, what type of interventions would be put immediately into place when they are admitted with a history of falls, she stated that some time a bed and chair alarm, and a call don't fall sign. V2 was asked how does the staff know, agency staff included, who is a high risk for falls and interventions? V2 stated that agency should check the residents care plan and also when they get report from the previous shift, they should be let known. An electronic mail document from V12, R2's Physician, containing questions from the state agency and his responses regarding R2's fall, cognition and safety, dated 1/27/2025, documented, 1. Could a fall from the toilet, onto the floor, possibly cause a left hip fracture even though she was found on her right side? Possibly. 2. Do you think that this injury could have been prevented if the facility staff would have stayed with her until she was ready to get off the toilet and not leave her unattended due to her severely impaired cognition and dementia? Yes. 3. Do you think (R2) could understand how to use a call light with her cognition being impaired? Unable to determine at this time. The facility's policy, Subject: Fall Assessment and Management 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. this will help facilitate an interdisciplinary approach for care planning to appropriately monitor, assess and ultimately reduce injury risk. Factors related to the risk will be addressed and care planned. It continues, D. All staff providing care for the resident will have access to the care plan and/or [NAME]. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145721 If continuation sheet Page 3 of 3