Health inspection·August 21, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to provide privacy while performing incontinence care and failed to provide dignity during dining assistance for 5 of 24 residents (R7, R9, R40, R60, R64) reviewed for resident privacy and dignity in the sample of 48. Findings include: 1. R9's admission Record, dated 8/20/25, documents R9 was admitted to the facility on [DATE] with diagnosis of Type 2 Diabetes Mellitus (DM), Malnutrition, Congestive Heart Failure (CHF), Atherosclerotic heart Disease (ASHD), Osteoarthritis, Spinal Stenosis, Falls, Hypertension (HTN). R9's Minimum Data Set, dated [DATE], documents R9 is cognitively intact. On 8/20/25 at 11:20 AM, V22, CNA, provided incontinence care to R9. V22 failed to close the door to the room, pull the curtain around the bed, or close the blinds to the window. R9's bed was close to the window with a courtyard outside her window. There was a person walking around watering flowers while incontinent care was going on with R9 being exposed to the window. R9 stated I did not know there was someone outside the window because normally there isn't. I wouldn't like anyone to see me naked through the window, it's embarrassing and it is nothing the public should see. On 8/21/25 at 1:10 PM, V22 stated that Anytime I am doing resident care, the door, the curtain, and the blinds should be closed to maintain the resident's privacy. I did not think about it when I was taking care of (R9) and had thought I at least closed the door. On 8/21/25 at 9:25 AM, V1, Administrator, stated I would expect staff to provide privacy for the resident while performing care, including closing the door, pulling the curtain, and closing the blinds. The Facility's Resident Rights booklet, dated 3/2017, documents You have the right to Privacy: Your medical and personal care are private. 2. On 8/18/25 at 12:57 PM, V10, Registered Nurse, (RN) is standing feeding R64 lunch. On 8/19/25 at 9:10 AM V12, Certified Nurse Aide, (CNA) is standing while feeding R64 lunch. R64’s admission Record, print date of 8/21/25, documents R64 was admitted on [DATE] and has a diagnosis of Alzheimer’s Disease. R64’s MDS, dated [DATE], documents R64 is severely cognitively impaired and is dependent on Page 1 of 2 145721 145721 08/21/2025 Villa Health Care East 100 Marian Parkway Sherman, IL 62684

F 0550 staff for dining. Level of Harm - Minimal harm or potential for actual harm 3. On 8/18/25 at 12:57 PM, V11, CNA is standing feeding R40 lunch. Residents Affected - Some R40’s admission Record, print date of 8/20/25, documents R40 was admitted on [DATE] and has a diagnosis of Severe Dementia. R40’s MDS, dated [DATE], documents R40 is severely cognitively impaired and dependent on staff for eating. 4. On 8/19/25 at 12:52 PM, V2, Director of Nurses, (DON), is standing while feeding R7. R7’s admission Record, print date of 8/20/25, documents R7 was admitted on [DATE] and has a diagnosis of Dementia. R7’s MDS, dated [DATE], documents R7 is severely cognitively impaired and requires set up clean up assistance. On 8/20/25 at 1:47 PM, V1, Administrator, stated the facility does not have a policy on feeding residents, but staff should sit with the resident instead of standing over them. 5. On 08/18/2025 at 1:08PM V9, CNA standing up and feeding R60 his meal in main dining room. R60's face sheet documents in part a diagnosis of unspecified Dementia, unspecified severity with agitation. R60's care plan dated 6/7/2025 documents R60 at risk for nutritional problems related to potential weight loss, poor intake, hypertension and UTI. R60's care plan documents interventions; R60 prefers to eat in dining room for meals, staff is available to assist if needed. 145721 Page 2 of 2