Inspection Reports for Villas of Holly Brook & Reflections Springfield
IL, 62711
Back to Facility ProfileInspection Report Summary
The most recent inspection on November 17, 2025, found the facility in compliance with applicable assisted living regulations and no deficiencies were cited. Earlier inspections showed a generally compliant pattern, though a complaint investigation on September 25, 2025, identified deficiencies related to fall prevention and care plan revisions that resulted in harm to one resident. Prior complaint investigations and annual surveys found no violations, and most complaints were unsubstantiated. No fines, immediate jeopardy findings, or enforcement actions were listed in the available reports. The inspection history suggests improvement, with the most recent survey showing no cited deficiencies following earlier issues.
Deficiencies (last 2 years)
Deficiencies (over 2 years)
1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
71% better than Illinois average
Illinois average: 3.5 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Plan of Correction
Deficiencies: 0
Nov 17, 2025
Visit Reason
The survey was conducted following a facility reported incident IL198460 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 administrative codes during this survey.
Inspection Report
Complaint Investigation
Deficiencies: 2
Sep 25, 2025
Visit Reason
The inspection was conducted as an original investigation of Complaint 2548917/IL197576 and a facility reported incident investigation related to an incident on 08-10-25/IL197469.
Findings
The facility failed to revise service plans to address resident falls and implement fall prevention interventions for two residents (R1 and R3) after falls. Additionally, the facility failed to implement interventions specified in the service plan for one resident (R2) at risk for falls, resulting in harm including a vertebral compression fracture.
Complaint Details
Original investigation of Complaint 2548917/IL197576 found no findings. The complaint investigation focused on falls and related service plan deficiencies for residents R1, R2, and R3.
Severity Breakdown
Type 2 Violation: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to revise care plans to address resident falls and interventions following falls for two residents (R1 and R3). | Type 2 Violation |
| Failed to implement interventions specified in the Service Plan for one resident (R2) at risk for falls. | Type 2 Violation |
Report Facts
Fall Investigation Dates: 3
Severity of Injuries: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Executive Director | Verified no staff member was present to assist resident R2 during fall and confirmed injury details. |
| E2 | Wellness Director | Confirmed service plans for residents R1 and R3 were not revised after falls and no new fall prevention interventions were implemented. |
Inspection Report
Complaint Investigation
Deficiencies: 0
May 1, 2025
Visit Reason
The visit was conducted as an original complaint investigation #IL190757.
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 #IL190757; establishment found in compliance.
Inspection Report
Annual Inspection
Deficiencies: 0
Feb 10, 2025
Visit Reason
Annual Licensure Survey and Incident Report Investigation 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
No violations were cited during the annual licensure survey or the incident report investigation. The establishment was found to be in compliance with applicable assisted living regulations.
Inspection Report
Plan of Correction
Deficiencies: 0
Dec 17, 2024
Visit Reason
The document is a plan of correction following an incident investigation at the assisted living facility.
Findings
The incident investigation could not be substantiated and no violations were cited. The facility was found to be in compliance with the applicable Illinois Assisted Living and Shared Housing regulations.
Complaint Details
Incident cannot be substantiated.
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 11, 2024
Visit Reason
The inspection was conducted as an incident report investigation related to a complaint identified as IL 179713.
Findings
The allegation could not be substantiated and no violations were cited. The facility was found to be in compliance with the applicable Illinois Assisted Living and Shared Housing regulations.
Complaint Details
Allegation cannot be substantiated. No violations cited.
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