Villa Health Care East

In the surveyor’s words

From the most serious findings on record at Villa Health Care East, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Apr 14, 2026

  Based on interview and record review, the facility failed to ensure R3 was adequately supervised and respond in a timely manner to alarms to prevent elopement for 1 of 1 (R3) resident reviewed for supervision. This failure resulted in R3 who is confused, has a history of exit seeking and wandering at the facility eloped into unknown and unsafe conditions that include exiting the facility, falling onto the concrete, log rolling to a handicap parking sign then sitting up and scooting on her buttocks through the facility parking lot alone until two bystanders observed R3 laying in the facility parking lot and stopped to assist her. […]

• Actual harm, isolatedF689Oct 15, 2025

  Based on observation, interview and record review, the facility failed to supervise 2 of 4 (R2 and R3) residents, reviewed for accidents in a sample of 7. This failure resulted in R3 sustaining a left hip fracture. R2 sustaining a right frontal laceration to her head. Both incidents resulted in hospitalization.Findings include: 1.On 10/14/2025 at 9:07 AM, R3 was sitting on the side of her bed, 1 foot on the floor and the other dangling off the bed and the bed was not in the lowest position. No staff were in the room. The bed alarm was underneath the bed pad but was not sounding. R3 was barefoot. R3's call light was on the nightstand out of R3's reach. […]

• Actual harm, isolatedF689Jul 17, 2025

  Based on record review and interview the facility failed to ensure adequate supervision, and precautions in place for falls for 1 of 3 residents (R2) reviewed for accidents in the sample of 8. This failure resulted in R2 falling off bed fracturing her femur and requiring surgical repair. Findings include: R2's Order Summary Report, undated, documented she had the following diagnoses: unilateral primary osteoarthritis, dependence on wheelchair, muscle weakness, unsteadiness on feet, unspecified lack of coordination, abnormal posture. R2's initial report to Illinois Department of Public Health (IDPH) dated 6/24/2025 documents R2 slid off the bed on 6/23/2025 at 8:00AM. […]

• Actual harm, isolatedF689Jan 28, 2025

  Based on interview and record review, the facility failed to provide supervision for 1 of 4 (R2) residents, reviewed for falls in a sample of 4. This failure resulted in R2 sustaining a left hip fracture. Findings include: R2's Diagnosis list, dated 1/14/2025, documented diagnoses of high risk for injury related to falls, Dementia, and Lewy Body Dementia. R2's Morse Fall Scale, dated 1/8/2025, documented that she was a high fall risk. R2's Minimum Data Set, dated dated [DATE], documented that her cognition was severely impaired, that she was occasionally incontinent of urine and that she required substantial to maximum assistance with toilet transfers. R2's Care Plan, dated 1/8/2025, documented, Anticipate and meet the resident's needs. […]

• Actual harm, isolatedF686Aug 11, 2022

  Based on observation, interview and record review, the facility failed to identify, monitor and provide treatments as ordered to prevent the worsening or formation of pressure ulcers for 3 of 4 residents (R41, R6 and R22) reviewed for pressure ulcers in the sample of 37. This failure resulted in R41's Stage III pressure ulcer worsening to an unstageable pressure ulcer. Findings include: 1. R41's Current Face Sheet Documents R41 was readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R41's Minimum Data Set (MDS) dated [DATE] documents R41 is cognitively intact and requires extensive assistance of one staff member for transfer, dressing, toileting and personal hygiene. R41's Care Plan dated 8/4/22 documents to provide wound care per treatment order. […]