Inspection Reports for Villas of Holly Brook Chatham
825 E Walnut St, Chatham, IL 62629, United States, IL, 62629
Back to Facility ProfileInspection Report Summary
The most recent inspection on September 18, 2025, identified deficiencies related to service plan revisions, documentation, and investigation of a resident’s fall and declining condition. Earlier inspections were not provided for comparison, so broader inspection patterns cannot be determined from the available information. The main issues involved failure to update service plans to reflect residents’ needs, inadequate documentation of medical changes, and lack of investigation into a fall that resulted in hospitalization and subsequent death. There were no fines, immediate jeopardy findings, or license actions listed in the available reports. The substantiated complaint investigation focused on neglect related to resident care planning and documentation.
Deficiencies (last 1 years)
Deficiencies are regulatory violations found during state inspections.
Deficiencies per year
| 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. | — |
| 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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