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The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Village At Victory Lakes, The during CMS and state inspections, most recent first.
A resident who was documented as full code was found without a pulse or respirations, but a CNA did not start CPR and instead went to find an RN. The RN confirmed the resident was pulseless and apneic, and both staff left the room to notify the primary nurse before CPR was started, resulting in an approximate 2 to 4 minute delay. Staff interviews showed uncertainty about the resident’s code status even though it was available in the chart and report sheets, and the resident was later pronounced deceased at the facility.
Unauthorized Access to Medication Room: A Restorative CNA obtained keys from an RN, opened the medication room, and entered the room even though the RN later stated only nurses could enter. The ADON identified the medication room as a secure area for resident meds, including narcotics and OTC meds, and the facility policy states access is limited to licensed nursing personnel, pharmacy personnel, or other staff lawfully authorized to administer meds.
A dietary aide wore the same gloves throughout meal service while handling multiple food items and kitchen tasks. The aide picked a green bean out of mashed potatoes, used gloved hands to place a hamburger patty on a bun, picked up and plated sandwiches, handled meal cards, plates, utensils, trays, and plated dinner rolls without changing gloves. The GM later stated the aide should have used utensils or changed to clean gloves to prevent contamination of other food.
A resident with dementia, prior hip arthroplasty, and high fall risk status fell out of bed during incontinent care when a CNA turned the resident side to side and the resident rolled over the edge of the bed. The CNA said she knew another staff member was needed on the opposite side of the bed for safety but continued alone because other staff were busy. A PT later noted the resident should be properly positioned in bed and have staff on each side during care.
Catheter Drainage Bag Left on Floor: A resident with hemiplegia/hemiparesis after a cerebral infarction and an indwelling catheter for urine retention was observed in bed with the catheter drainage bag resting directly on the floor. The resident said staff position the bag because he is stuck in bed. The ADON/Infection Prevention nurse stated this is not acceptable due to infection control issues, and the facility policy requires the bag be kept off the floor.
Failure to obtain and verify resident weights: one resident on tube feeding was not weighed on admission/readmission as required, and another resident's admission weight was later struck through without verification despite documented weight loss and poor PO intake. The dietitian and RN stated admission weights are used to monitor weight gain/loss, and the ADON said weight serves as a baseline and should remain in the record.
A resident was not documented as being offered and/or receiving the annual influenza vaccine. The resident’s immunization record showed the last flu shot was given in 11/2024, while the ADON/IP nurse stated flu vaccines are offered annually and on admission/readmission and that the facility held a vaccine clinic in the fall. The facility could not provide documentation that the resident was offered or given the vaccine during the relevant period, despite its policy requiring residents to either consent to or decline flu immunization in writing.
A resident with multiple chronic conditions and intact cognition was transferred by two CNAs from the toilet to a shower chair that lacked footrests, even though the resident used wheelchair footrests. As the chair was pushed out of the room, the resident’s right foot slipped, caught on the floor, and rolled under the chair, causing immediate pain. Initial RN and NP assessments and an x-ray did not show a fracture, and the resident remained in bed with minimal reported pain. Later, the resident reported excruciating right ankle pain, a stat x-ray revealed minimally displaced fractures of the medial and lateral malleoli, and the NP linked the injury to the incident where the foot was caught and rolled under the shower chair.
A resident with a history of mobility issues and a high risk for falls was injured during a shower when a CNA placed personal items out of reach and turned away to retrieve a wheelchair. The resident attempted to access the items, causing the shower chair to move and resulting in a fall with injury. Staff interviews confirmed that care plan interventions to keep items within reach and provide supervision were not followed.
The facility failed to follow wound care recommendations and provide adequate pressure ulcer care, resulting in the development and worsening of pressure ulcers for several residents. A resident developed Stage 3 and Stage 4 pressure ulcers due to the lack of recommended interventions, while another developed a Stage 4 ulcer after a delay in receiving a pressure-reducing mattress. Additionally, a resident was found without a protective dressing on an open sacral area, and another had an air mattress pump turned off, despite orders for pressure-relieving interventions.
The facility failed to ensure staff wore required PPE in isolation rooms and did not change gloves during incontinence care, affecting infection control for several residents. A CNA entered a resident's room without PPE despite MRSA precautions, and another did not change gloves after cleaning a soiled area, touching multiple surfaces afterward.
A resident with intact mental status was transferred to a hospital for abdominal pain without being informed of the facility's bed hold policy. The LPN responsible for the transfer confirmed that the policy was not provided, despite the facility's requirement to inform residents prior to or upon transfer.
The facility failed to reassess the PASRR for two residents after they were newly diagnosed with mental illnesses. The Director of Admission/Community Outreach admitted that the facility had not been performing PASRR reassessments when residents were diagnosed with a mental illness after admission. One resident was diagnosed with an anxiety disorder and another with a delusional disorder, but their PASRRs were not updated accordingly.
Delay in CPR Initiation for Full-Code Resident
Penalty
Summary
The facility failed to immediately identify the code status and initiate CPR for a resident who had elected to be a full code. The resident was admitted with diagnoses including a left below-the-knee amputation, pneumonia, and malignant neoplasm of the bladder and prostate. His physician order summary and care plan both documented that he was a full code and that staff were to follow that code status. On the morning of the event, a CNA found the resident without a pulse or respirations and did not begin CPR. Instead, she left the room to find an RN. The RN returned to the room, confirmed the resident was not breathing and did not have a pulse, and then both staff left the room again to inform the primary nurse that the resident had passed away. CPR was not started during this interval, and the report states there was an approximate 2 to 4 minute delay before CPR was initiated. Staff interviews indicated that the CNA was unsure of the resident’s code status, and the RN also did not immediately start CPR or call a code. The resident’s nursing notes show that CPR was eventually initiated after another RN was alerted, EMS was contacted, and the resident was pronounced deceased at the facility. The facility’s staff interviews confirmed that the involved CNA, RN, and primary nurse were CPR certified and that code status information was available in report sheets and the EMR. The medical director stated that if a resident is found down, CPR should be initiated immediately, and the facility identified the event as an Immediate Jeopardy.
Unauthorized Access to Medication Room
Penalty
Summary
The facility failed to ensure that only authorized personnel entered the medication room. During observation on 03/10/2026 at 9:11 AM, a Restorative CNA approached an RN and asked for the keys to the medication room, and the RN handed over the keys. The Restorative CNA then opened the medication room and went inside. The RN stated that the CNA was not a nurse but could enter because she was the CNA manager; otherwise, only nurses could enter the medication room. Later that morning, the ADON stated that the medication room is a secure room where residents’ medications, including narcotics and over-the-counter medications, are stored, and that only authorized personnel, which would be nurses, are allowed to enter. The facility policy on medication storage states that medication supplies are accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications, and that medication rooms and medication supplies are locked when not in use or in direct view of an authorized person.
Cross Contamination During Meal Service
Penalty
Summary
Food was not served in a manner to prevent cross contamination during the noon meal service in the kitchen. During observation from 10:56 AM through 12:01 PM, a dietary aide wore the same gloves throughout the entire meal service while handling multiple food items and meal service tasks. The aide picked a green bean out of mashed potatoes with gloved hands and continued using the same gloves to plate the potatoes, used gloved hands to pick up a hamburger patty and place it on a bun, picked up and plated two sandwiches, handled residents’ meal cards, plates, utensils, trays, and removed additional items from the warmer, and plated all dinner rolls with the same gloves. The general manager later stated the aide had used her hands to pick up meal items and should have used utensils or changed gloves and put on clean gloves to prevent contamination of other food after doing so. The facility’s sanitation policy stated gloves should be changed and hands washed when moving between tasks or when gloves are dirty.
Unsafe Bedside Care for a High Fall-Risk Resident
Penalty
Summary
The facility failed to ensure a resident was safe during care for one resident who had diagnoses including status post left hip arthroplasty, dementia with agitation, depression, and hypertension, and who was documented as severely cognitively impaired and high risk for falls. The resident was being monitored closely in the common area because of fall risk. Review of the fall incident report showed the resident fell out of bed while being changed by a CNA during incontinent care. The CNA stated she was turning the resident side to side to apply an incontinent pad, noted the resident was very close to the edge of the bed, and the resident rolled out of bed. The CNA stated she needed another staff member on the opposite side of the bed for the resident's safety but proceeded alone because other staff were busy. A PT who attended daily meetings said the resident was a fall risk and that staff should ensure proper positioning in bed and have a staff member on each side of the bed during care for the resident's safety.
Catheter Drainage Bag Left on Floor
Penalty
Summary
The facility failed to ensure a urinary catheter drainage bag was kept off the floor for one resident reviewed for catheters. On 3/9/26 at 12:07 PM, the resident was observed lying in bed with the catheter drainage bag resting directly on the floor to the left side of the bed. The resident stated that staff position the catheter bag because he is stuck in bed. The resident’s admission record dated 3/10/26 shows hemiplegia and hemiparesis following a cerebral infarction affecting his left, non-dominant side. The order summary dated 3/10/26 shows active orders written on 3/3/26 for an indwelling catheter for urine retention and catheter site care every shift. On 3/10/26 at 1:10 PM, the ADON/Infection Prevention nurse stated it is not acceptable for a catheter drainage bag to be on the floor due to infection control issues, and the facility’s Foley Catheter Management Policy states the catheter drainage bag is to be kept off the floor.
Failure to Obtain and Verify Resident Weights
Penalty
Summary
The facility failed to ensure that a resident was weighed upon admission and readmission. One resident with dysphagia and aftercare following surgery on the digestive system, including a feeding tube, was admitted, discharged to a local hospital, and then readmitted, but the weights record showed no weights from the time of discharge through several days after readmission, and the resident was not weighed until about a month later. The dietitian stated residents on tube feeding are at risk for weight loss and that weights should be done on admission so weight gain or loss can be monitored and interventions placed as needed. The RN stated residents are weighed 3 days in a row then as ordered. The facility policy stated all new admissions and readmissions should be weighed within 24 hours of admission. The facility also failed to verify the accuracy of a resident's weight for a resident with potential for weight loss. Another resident, who was severely cognitively impaired and had osteoporosis and hypertension, had a documented admission weight of 114 lbs., followed by weights of 100 lbs. and 95.7 lbs. The nutritional assessment documented significant weight loss and recommendations for Boost three times a day and medication to help with appetite due to poor oral intake, with intervention to be approved by family. The admission weight of 114 lbs. was later struck through by an RN as incorrect documentation, but the RN stated she did not speak to any staff or verify who weighed the resident before removing it. The dietitian stated the resident continued to be at risk for weight loss and that the weight should not be removed without verification, and the ADON stated weight serves as a baseline for comparison and should remain in the medical record.
Failure to Document Influenza Vaccine Offer or Administration
Penalty
Summary
The facility failed to ensure that a resident was offered and/or received an influenza vaccination for 1 of 5 residents reviewed for immunizations. The resident’s admission record showed admission to the facility on [DATE], and the immunizations list showed the last influenza vaccination was administered on 11/4/24. During an interview on 3/11/26 at 1:00 PM, the ADON/Infection Prevention Nurse stated that influenza vaccines are offered to all residents annually and on admission/readmission, and that the facility had an influenza vaccine clinic that past fall. However, the facility was unable to provide documentation that an influenza vaccine was offered and/or administered to the resident between 10/2025 and 3/10/26 when asked about the resident’s immunization status. The facility’s Immunization Program Policy states that the facility offers immunizations against seasonal influenza to all residents and requires residents to either consent to receive or decline the vaccine in writing on the appropriate form.
Failure to Safely Transport Resident in Shower Chair Without Footrests
Penalty
Summary
The deficiency involves the facility’s failure to safely transport a cognitively intact resident with multiple medical conditions, including osteoarthritis, atherosclerotic heart disease, a history of poliomyelitis, dementia, and chronic kidney disease stage three, in a shower chair. On the morning in question, two CNAs transferred the resident from bed to the toilet and then from the toilet to a shower chair that did not have footrests, despite the resident having wheelchair footrests labeled with the resident’s name. Shortly after the transfer, as the CNA began to push the shower chair out of the resident’s room, the resident’s right foot slipped off due to the lack of footrests, caught on the floor, and rolled under the chair, causing the resident to cry out in pain and report right foot pain. Following the incident, the CNA immediately stopped pushing the chair, notified an RN, and the resident was returned to bed. The RN’s initial assessment did not reveal swelling or bruising, and a nurse practitioner was notified and ordered that the resident remain in bed, be placed on non-weight-bearing status for the right leg, and receive an x-ray. The x-ray was obtained the same day, and the initial results reported to the LPN and nurse practitioner indicated no fracture. During the remainder of that day and the following day, staff reported that the resident did not complain of pain but did not want to get out of bed. Subsequently, staff documented that the resident exhibited no pain until a later date when the resident began expressing excruciating right ankle pain. An LPN administered as-needed pain medication and notified the nurse practitioner, who ordered a stat x-ray of the right ankle. The x-ray showed minimally displaced acute or subacute fractures of the medial and lateral malleoli. Upon in-person assessment, the nurse practitioner noted the resident’s excruciating ankle pain and ordered transfer to the emergency room. The nurse practitioner stated that while the resident’s age and bone mineral density could have been contributing factors, the resident’s foot getting caught on the floor and rolling under the shower chair could have been a direct cause of the ankle fracture.
Resident Fall Due to Inadequate Supervision and Failure to Follow Fall Prevention Interventions
Penalty
Summary
A deficiency occurred when a resident with a history of artificial hip replacement, difficulty walking, and osteoarthritis of the hip, who was identified as being at risk for falls due to unsteady gait, balance issues, and decreased strength, sustained a fall during a shower. The resident's care plan required partial to moderate assistance for showers, dressing, and transfers, and included interventions such as keeping personal items within easy reach and providing safety instructions. However, during the shower, a Certified Nursing Assistant (CNA) placed the resident's personal items on top of a heater, out of the resident's immediate reach. While the CNA was assisting with drying and turned away to retrieve the resident's wheelchair, the resident attempted to access her personal items, causing the shower chair to move and resulting in a fall. The resident suffered a skin tear, reported hitting her head and hurting her back, and was subsequently sent to the hospital for evaluation. Staff interviews confirmed that the CNA recognized the error in not keeping personal items within the resident's reach and acknowledged that the shower chair could move, especially given the resident's height and positioning. Another nurse stated that the shower chair can move depending on the resident's position and emphasized the importance of not leaving or turning away from a resident in the shower room. The facility's Fall Prevention and Management Program policy required staff to follow care plan interventions, including keeping personal items within reach, to minimize fall risk. These actions and inactions led to the resident's fall and injury during the shower.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to follow the Wound Physician's recommendations and did not provide adequate pressure ulcer care for several residents, leading to the development and worsening of pressure ulcers. Resident R73, who was admitted with high risk for pressure ulcers, developed a Stage 3 and Stage 4 pressure ulcer on the left and right gluteal areas, respectively, due to the facility's failure to implement recommended interventions such as floating heels and using pressure off-loading boots. Additionally, R73 did not receive the prescribed antibiotic treatment for a wound infection, as the order was not processed by the responsible staff. Resident R45, who was at risk for pressure ulcers, developed a Stage 4 pressure ulcer on the sacrum after the facility delayed providing a pressure-reducing mattress. Despite being care planned to prefer lying on her back, the facility did not implement necessary interventions to prevent skin breakdown, resulting in the development of a severe pressure ulcer. Similarly, Resident R135 was observed with an open area on the sacrum without a protective dressing, despite having a physician's order for daily dressing changes, indicating a lapse in wound care management. Resident R35 was found with an air mattress pump turned off, despite having an order for a pressure-relieving mattress due to the risk of developing pressure injuries. The facility's failure to ensure the air mattress was functioning properly contributed to inadequate pressure ulcer prevention. These deficiencies highlight the facility's failure to adhere to its own Nursing Skin Integrity policy and ensure timely and appropriate interventions for residents at risk of or suffering from pressure ulcers.
Inadequate PPE Use and Glove Changes in Isolation Rooms
Penalty
Summary
The facility failed to ensure proper use of Personal Protective Equipment (PPE) in rooms designated for contact isolation and enhanced barrier precautions. In one instance, a Certified Nursing Assistant (CNA) entered a resident's room without wearing the required gown and gloves, despite the presence of signs indicating the need for such precautions due to the resident's MRSA infection. The CNA was unaware of the resident's isolation status, and the Director of Nursing confirmed that staff should have been wearing gowns and gloves. Additionally, another CNA failed to change gloves during incontinence care, leading to potential cross-contamination. Further observations revealed that staff did not adhere to enhanced barrier precautions for other residents. CNAs provided care without wearing gowns and failed to change gloves after cleaning soiled areas, touching multiple surfaces afterward. The facility's policies on transmission-based precautions and perineal care were not followed, as staff did not consistently use PPE or change gloves as required, potentially compromising infection control measures.
Failure to Provide Bed Hold Policy During Hospital Transfer
Penalty
Summary
The facility failed to provide a resident with the bed hold policy when transferring the resident to a hospital. The resident, who had an intact mental status, was transferred to a hospital for evaluation of abdominal pain. During the transfer, the resident was not informed of the facility's bed hold policy, as confirmed by both the resident and the Licensed Practical Nurse (LPN) responsible for the transfer. The facility's policy, dated 5/1/19, requires that residents be informed of the bed hold policy prior to or upon transfer to a hospital. However, this policy was not followed in the case of this resident, leading to the deficiency.
Failure to Reassess PASRR After New Mental Illness Diagnoses
Penalty
Summary
The facility failed to reassess the PASRR (Preadmission Screening and Resident Review) for two residents, R36 and R54, after they were newly diagnosed with mental illnesses. The Director of Admission/Community Outreach, V12, acknowledged that the facility had not been performing PASRR reassessments when residents were diagnosed with a mental illness after admission. V12 stated that PASRR is typically completed at the hospital before admission or as part of the admission process if the resident comes from out of state or their home. However, the facility was not aware of the need for reassessments with changes in medications and mental health diagnoses until recently. R36 was admitted to the facility with a primary diagnosis of Parkinson's Disease and was later diagnosed with an anxiety disorder. R36's PASRR was last dated before the diagnosis of the anxiety disorder. Similarly, R54 was admitted with a primary diagnosis of hemiplegia and hemiparesis following a cerebral infarction and was later diagnosed with a delusional disorder. R54's PASRR was also dated before the diagnosis of the delusional disorder. The facility's PASRR policy indicates that individuals with a sole diagnosis of dementia are excluded from further evaluations, but those with both dementia and another psychiatric condition require confirmation of dementia as the primary diagnosis.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lindenhurst
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hillcrest Retirement Village | 3.4 mi | — | 2 | 0 |
| Libertyville Manor Ext Care | 7.8 mi | — | 0 | 0 |
| The Terrace | 9.3 mi | — | 2 | 1 |
| Elevate Care Waukegan | 9.4 mi | — | 3 | 0 |
| Allure Of Zion | 9.4 mi | — | 16 | 0 |
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