Inspection Reports for Villas of Holly Brook Chatham
825 E Walnut St, Chatham, IL 62629, United States, IL, 62629
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Inspection Report
Complaint Investigation
Deficiencies: 3
Sep 18, 2025
Visit Reason
Original investigation of Complaint 2548497/IL197391 regarding failure to revise service plans and address resident care needs.
Findings
The facility failed to revise service plans to accurately reflect residents' needs, particularly for two residents (R1 and R2). R1 experienced a significant decline during a respite stay, including confusion, medication noncompliance, and a fall that was not properly investigated or documented. The facility neglected to address R1's declining condition, failed to document changes in medical records, and did not update the service plan to reflect care needs or fall risk. R1 was hospitalized and later died. R2's service plan also lacked documentation of needed assistance with several ADLs.
Complaint Details
Complaint investigation of alleged neglect and failure to update service plans and document resident condition changes, including a fall and medication issues for resident R1.
Severity Breakdown
Type 1 Violation: 1
Type 2 Violation: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to revise service plan to reflect resident's needs and ADL assistance for two residents. | Type 2 Violation |
| Neglected to address and investigate a resident fall and declining condition causing severe harm. | Type 1 Violation |
| Failed to maintain accurate documentation of significant changes in resident's condition in medical records. | — |
Report Facts
Fall Risk Assessment Score: 22
Dates of R1 stay: Admitted 2025-08-16, discharged 2025-09-02.
Incident Log Dates: Incident log from 07/2025 to 09/2025 showed no incidents reported for R1.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Executive Director | Conducted initial assessment on R1 and verified lack of documentation and awareness of fall. |
| E2 | Wellness Director | Created inaccurate service plan focus for R1, denied fall occurred, and provided communication logs. |
| E3 | Care Partner | Cared for R1, reported medication noncompliance and UTI symptoms, unaware of fall. |
| E4 | Care Partner | Cared for R1, observed progressive decline, unaware of fall. |
| E5 | Certified Nursing Assistant | Found R1 on floor after fall, notified Wellness Director, denied seeing R1 sitting on floor. |
| E6 | Business Office Manager | Assisted in getting R1 off floor after fall, did not complete incident report. |
| Z1 | R1's Sister | Reported R1's condition before and after respite stay, denied R1 sat on floor voluntarily. |
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