Inspection Reports for Villas of Holly Brook Assisted Living & Memory Care: Bloomington Towanda Barnes
1815 N Towanda Barnes Rd, Bloomington, IL 61704, IL, 61704
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Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 2, 2025
Visit Reason
The inspection was conducted as an original complaint investigation identified by case number 2569242/197763.
Findings
The establishment was found to be in compliance with Part 295 Assisted Living and Shared Housing Establishment Administrative Code and 210 ILCS 9/1 Assisted Living and Shared Housing Act.
Complaint Details
Original complaint investigation 2569242/197763 resulted in compliance with applicable assisted living regulations.
Inspection Report
Complaint Investigation
Deficiencies: 6
Sep 25, 2025
Visit Reason
The inspection was conducted as a complaint investigation related to allegations concerning the care of a resident's indwelling urinary catheter and related care practices.
Findings
The facility failed to ensure proper catheter care including hand hygiene after glove removal, lacked a urinary catheter care policy, did not include catheter care instructions or physician orders in the resident's service plan, and failed to maintain resident dignity by allowing the resident to carry an uncovered catheter bag in public areas.
Complaint Details
The complaint investigation involved two complaint investigations IL197660 (no violations) and IL197694 (Type 1 violation) related to catheter care and resident dignity issues.
Severity Breakdown
Type 1 Violation: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure thorough indwelling urinary catheter care with hand hygiene after glove removal. | Type 1 Violation |
| Failed to include the amount, type, frequency, and staff responsible for catheter care in the resident's service plan. | — |
| Failed to ensure a physician order for the indwelling urinary catheter with care instructions. | — |
| Failed to secure proper placement/positioning of catheter bag; catheter bag was found lying on the floor and hung from resident's waistband. | — |
| Failed to include Home Health interventions in clinical record and follow these interventions. | — |
| Failed to ensure resident dignity by allowing the resident to carry an uncovered catheter bag in the dining room. | — |
Report Facts
Residents reviewed for incontinent care: 4
Residents reviewed for Resident Rights: 4
Residents reviewed for catheter care: 3
Catheter size: 16
Catheter balloon size: 10
Catheter change frequency: 14
Date of last catheter change: 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E4 | Certified Nursing Assistant/CNA | Observed performing catheter care without hand hygiene after glove removal and stated lack of catheter care procedure |
| E10 | Regional Clinical Director | Provided information on catheter care training and Home Health involvement |
| E1 | Executive Director | Unable to provide catheter care policy and confirmed dignity issue with resident carrying uncovered catheter bag |
| E3 | Licensed Practical Nurse/LPN | Unable to locate physician order or catheter care instructions and confirmed catheter bag positioning requirements |
Inspection Report
Plan of Correction
Deficiencies: 0
Sep 2, 2025
Visit Reason
The survey was conducted as a facility reported incident IL197182 to assess compliance with Part 295 Assisted Living and Shared Housing Establishment Administrative Code and 210 ILCS 9/1 Assisted Living and Shared Housing Act.
Findings
The establishment was found to be in compliance with the applicable assisted living and shared housing regulations during this survey.
Inspection Report
Annual Inspection
Deficiencies: 2
Jul 3, 2025
Visit Reason
The inspection was conducted as an Annual Licensure Survey to assess compliance with health and safety regulations for direct care and food service employees, including initial health evaluations and background checks.
Findings
The facility failed to ensure that two of five employees had initial health evaluations, tuberculin skin tests, and healthcare worker background checks completed upon hire as required by regulations.
Deficiencies (2)
| Description |
|---|
| Failure to ensure an initial health evaluation and tuberculin skin test was conducted upon date of hire for two employees. |
| Failure to ensure a healthcare worker background check was completed prior to hire for two employees. |
Report Facts
Employees reviewed: 5
Employees non-compliant: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E3 | Dietary Aide | Named in findings for lacking initial health evaluation, tuberculin skin test, and background check. |
| E4 | Certified Nursing Assistant | Named in findings for lacking initial health evaluation, tuberculin skin test, and background check. |
| E1 | Executive Director | Confirmed the lack of initial health evaluations, tuberculin skin tests, and background checks for E3 and E4. |
Inspection Report
Complaint Investigation
Deficiencies: 0
May 31, 2025
Visit Reason
Original investigation of Complaint 2564481 /IL192701.
Findings
The establishment was found to be in compliance with Part 295 Assisted Living and Shared Housing Establishment Administrative Code and 210 ILCS 9/1 Assisted Living and Shared Housing Act.
Complaint Details
Investigation of Complaint 2564481 /IL192701 resulted in compliance with applicable assisted living regulations.
Inspection Report
Complaint Investigation
Deficiencies: 3
May 7, 2025
Visit Reason
The inspection was conducted as a complaint investigation related to Original Complaint #2563493/IL190629 and facility reported incidents IL190968 and IL189974, focusing on residency requirements, physician assessments, and service plans.
Findings
The facility failed to terminate residency for a resident (R3) who no longer met residency requirements, failed to obtain a comprehensive physician assessment after a significant change in condition for R3, and failed to update R3's service plan after changes in condition. R3 required increased assistance with transfers, ambulation, and toileting, which was not reflected in assessments or service plans.
Complaint Details
The investigation was based on Original Complaint #2563493/IL190629 and facility reported incidents IL190968 and IL189974. The complaint was substantiated by findings related to residency termination, physician assessment, and service plan updates for resident R3.
Deficiencies (3)
| Description |
|---|
| Failed to terminate residency when a resident no longer met residency requirements. |
| Failed to obtain a comprehensive physician assessment after a significant change in condition. |
| Failed to update the service plan after a change in the resident's condition. |
Report Facts
Resident sample size: 3
Dates of progress notes: 18
Fall dates: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E3 | Regional Director of Operations | Verified lack of readmission nursing assessment and failure to update physician assessment and service plan for resident R3. |
| E4 | Registered Nurse | Provided statements regarding resident R3's increased assistance needs after hospital return. |
| E6 | Resident Assistant | Reported on resident R3's care needs and private caregiver presence. |
| E7 | Resident Assistant | Reported on resident R3's care needs and private caregiver presence. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Dec 23, 2024
Visit Reason
The inspection was conducted as an original investigation of two complaints (24610231 / IL 182604 and 24610337 / IL 182867) regarding compliance with assisted living residency requirements.
Findings
The facility failed to ensure that one of two sampled residents (R1) met the residency requirements for Assisted Living, specifically that the resident required assistance from more than one paid caregiver at any given time for activities of daily living, which is not permitted.
Complaint Details
Complaint IL 182604 was substantiated with a violation of Section 295.2000 c) 4). Complaint IL 182867 had no violations cited.
Deficiencies (1)
| Description |
|---|
| Failure to ensure one resident met assisted living residency requirements due to need for two-person assist with activities of daily living and transfers. |
Report Facts
Complaint numbers: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Towanda Barnes | Named as part of facility name, no employee role stated | |
| E1 | Executive Director | Confirmed awareness of resident's condition and family situation |
| E2 | Regional Clinical Director | Received new certification regarding resident's status |
| E3 | Certified Nursing Assistant (CNA) | Reported resident requires two-person assist for transfers and showers |
| E4 | Regional Director of Operations | Confirmed resident requires two-person assist and does not meet assisted living residency requirements |
Inspection Report
Original Licensing
Deficiencies: 0
Nov 26, 2024
Visit Reason
Original investigation of facility FRI IL 181370 to determine compliance with Part 295 Assisted Living and Shared Housing Establishment Administrative Code and 210 ILCS 9/1 Assisted Living and Shared Housing Act.
Findings
The establishment was found to be in compliance with the applicable Illinois Assisted Living and Shared Housing regulations during this survey.
Inspection Report
Annual Inspection
Deficiencies: 0
Aug 15, 2024
Visit Reason
Annual Licensure Survey to assess compliance with Part 295 Assisted Living and Shared Housing Establishment Administrative Code and 210 ILCS 9/1 Assisted Living and Shared Housing Act.
Findings
The establishment was found to be in compliance with the applicable assisted living regulations and licensing requirements.
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