Inspection Reports for
Villas of Holly Brook Assisted Living & Memory Care: Bloomington Towanda Barnes

Facility Reported Incidents IL202490 and IL202544 cited violations of 295.6000a)13) and 295.4060h)3)A).

The establishment failed to keep a wandering, exit-seeking resident from leaving the Memory Care unit unsupervised, resulting in a substantial probability of severe harm. Additionally, the facility substantiated verbal and emotional abuse by a former Dietary Director towards a resident and took corrective action by terminating employment.

Complaint IL202290: unsubstantiated.

The establishment failed to conduct tornado drills on each shift in February, did not ensure all required members signed service plans for four residents, and had a dishwasher sanitizer that was not working properly.

Original Complaint Investigation IL198697: Violations cited 295.6000 a)1)2)6)7)8). Facility Reported Incident IL198749: Violations cited 295.4060 h)3) and 295.6010 a)2).

The establishment failed to follow fall policies causing injury to one resident and failed to implement Resident Rights policies resulting in increased agitation for another resident. Additionally, the facility did not submit a final investigation report to the State Agency for an incident involving a resident's fall.

Complaint Investigation 25610954/IL198489

The establishment failed to obtain a physician assessment after admission to hospice services and did not update the service plan after a significant change for one resident. Additionally, the facility failed to have adequate staff present to care for memory care residents, creating a substantial probability of severe harm.

Complaint IL198349: Section 295.4010 d)e) cited. Facility Reported Incident IL198403: Section 295.4010 d)e) cited.

The establishment failed to revise service plans to include recent falls and related interventions for three residents, causing or creating a substantial probability of harm.

Complaint 2569242/197763: no violations cited.

The establishment was found in compliance with all applicable regulations during this complaint investigation.

Complaint Investigation IL197660: No violations. Complaint Investigation IL197694: Type 1 violation cited for 295.3000a). General violations cited for 295.4010g)1)A)2)3), 295.4060b), and 295.6000a)1).

The establishment failed to provide thorough urinary catheter care with hand hygiene, maintain an adequate service plan for catheter care, secure appropriate catheter supplies and physician orders, and ensure resident dignity by allowing a resident to carry an uncovered catheter bag in the dining room.

Facility Reported Incident IL197182: no violations cited.

The establishment was found in compliance with all applicable regulations for this facility reported incident.

The facility failed to ensure initial health evaluations, tuberculin skin tests, and healthcare worker background checks were completed upon hire for two employees.

Complaint 2564481 /IL192701: Complaint cannot be substantiated. No violations cited.

The establishment was found in compliance with all applicable regulations during the complaint investigation.

Original Complaint #2563493/IL190629: Sections 295.2000 a)c)3)4)5)d), 295.4000 c), 295.4010 c)d) cited. Facility Reported Incident IL190968: Section 295.4010 c)d) cited. Facility Reported Incident IL189974: Section 295.4010 c)d) cited.

The establishment failed to terminate residency when a resident no longer met residency requirements, failed to obtain a physician's assessment after a significant change in condition, and failed to update the service plan after a change of condition for one resident.

Complaint 24610231 / IL 182604: Violation 295.2000 c) 4) cited. Complaint 24610337 / IL 182867: No violations cited.

The establishment failed to ensure one of two sampled residents met the residency requirements for Assisted Living, specifically that the resident required more than one paid caregiver at any given time for activities of daily living.

FRI IL 181370: The incident can be substantiated. No violations cited.

The establishment was found in compliance with all applicable regulations during this investigation.

The establishment was found in compliance with all applicable regulations; no violations were cited.

The establishment was found in compliance with Part 295 Assisted Living and Shared Housing Establishment Administrative Code and 210 ILCS 9/1 Assisted Living and Shared Housing Act. No deficiencies were cited.