Deficiencies per Year
4
3
2
1
0
Low
Unclassified
Inspection Report
Annual Inspection
Census: 22
Deficiencies: 3
Nov 6, 2025
Visit Reason
Annual Licensure Survey conducted to assess compliance with resident rights, food service, and environmental requirements at Villas of Holly Brook Shelbyville.
Findings
The facility failed to provide housekeeping services for three resident rooms, resulting in unclean conditions including dirty floors, bathrooms, and foul odors. Menus were not made available at least 48 hours in advance and were inaccessible to residents. The establishment was not kept in a clean, safe, and orderly condition as confirmed by multiple observations and staff interviews.
Deficiencies (3)
| Description |
|---|
| Failed to provide housekeeping services for three resident rooms resulting in unclean conditions. |
| Menus were not planned and made available at least 48 hours in advance and were inaccessible to residents. |
| The establishment was not kept in a clean, safe, and orderly condition and in good repair. |
Report Facts
Residents: 22
Last housekeeper shift: Oct 13, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E11 | Housekeeper | Last employed housekeeper; last worked shift on October 13, 2025. |
| E2 Wellness Director | Wellness Director | Confirmed the building was dirty and no housekeeper had been employed for over a month. |
| E9 Caregiver | Caregiver | Reported the building had not been cleaned regularly since maternity leave in May. |
| E5 Dietary Manager | Dietary Manager | Stated the November menu was not posted because she did not know how to make copies. |
| E1 Executive Director | Executive Director | Confirmed menus were not posted as required and no working housekeeper was on staff as of 11/6/25. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Sep 15, 2025
Visit Reason
The inspection was conducted as an original complaint investigation (IL197382) regarding failure to meet residency requirements and other regulatory standards at Villas of Holly Brook Shelbyville.
Findings
The facility failed to meet residency requirements for one resident (R1), failed to update service plans for three residents (R1, R2, R3), and failed to provide adequate assistance with activities of daily living for one resident (R3). These failures created a substantial probability of harm to residents.
Complaint Details
This was an original complaint investigation (IL197382) triggered by concerns about residency requirements and care provision. The technical infraction regarding physician signature was noted with no violation imposed. The complaint was substantiated by findings of failure to meet residency requirements, update service plans, and provide adequate assistance.
Severity Breakdown
Technical Infraction: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| The establishment did not have a physician sign R1's physician assessment, resulting in a technical infraction with no violation imposed. | Technical Infraction |
| Failed to ensure residency requirements for one resident (R1), including appropriate level of care and assistance. | — |
| Failed to update service plans for three residents (R1, R2, R3) to reflect current care needs and conditions. | — |
| Failed to provide assistance with activities of daily living for one resident (R3), including hygiene and toileting needs. | — |
Report Facts
Residents reviewed for residency requirements: 3
Residents with deficiencies: 3
Residents requiring assistance: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E2 Wellness Director | Provided statements regarding residents' care needs and service plan inaccuracies. | |
| E4 Care Partner | Assisted residents with mobility and toileting; confirmed resident conditions. | |
| E5 Care Partner | Assisted residents with mobility and toileting. | |
| E4 CNA | Reported resident resistance to care and hygiene issues. |
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