Inspection visit
Inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0689
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
Level of Harm - Actual harm
Residents Affected - Few
Based on observation, interview and record review the facility failed to ensure a resident (R1) was
transported safely in a shower chair. This failure resulted in R1 sustaining a bimalleolar fracture of the right
ankle. This affects 1 of 3 residents (R1) reviewed for accidents in the sample of 3. This past non-compliance
occurred from 2/11/26 to 2/19/26. The findings include:R1's Facesheet shows R1 has diagnoses that
include, but are not limited to: osteoarthritis of the right and left shoulders, atherosclerotic heart disease,
history of poliomyelitis, dementia, and chronic kidney disease stage three. R1's Brief Interview for Mental
Status dated 2/6/26 shows R1 is cognitively intact.On 2/23/26 at 9:08 AM, R1 had two wheelchair footrests
with R1's name written on it. One footrest was on the seat of the wheelchair and the other was in a bag
attached to the back of the wheelchair. R1 was lying in bed with a green cast on R1's right ankle that went
up to the top of R1's right calf. R1 was not exhibiting any signs of pain. R1 said on the morning of 2/11/26,
V3 (Certified Nursing Assistant- CNA) woke R1 up to provide R1 with a morning shower. R1 said V3 put R1
into a chair without footrests and as V3 started to move the chair and bring R1 to the shower room, R1's
foot slipped off due to no footrests but doesn't recall exactly what happened. R1 recalls screaming out in
pain and R1's right foot getting injured. On 2/23/26 at 9:46 AM, V3 said on 2/11/26 around 7:35 AM, V3 and
V6 (CNA) got R1 up from bed to use the toilet. After using the toilet, V3 and V6 transferred R1 from the
toilet to a shower chair that did not have footrests. After V3 took approximately two steps, while still in R1's
room, R1 cried out in pain and said R1's right foot hurt. V3 immediately stopped pushing R1 in the shower
chair and stated R1's right foot had caught on the ground and rolled under the chair as V3 pushed the chair
forward. V3 notified V4 (Registered Nurse- RN) of the incident and V3 put R1 back into bed. R1 was
provided an as needed pain medication and an ice pack. V3 cared for R1 the remainder of the day shift on
2/11/26 and said R1 did not want to leave R1's bed. V3 also cared for R1 on 2/12/26 on the day shift and
stated R1 did not complain of pain throughout the duration of V3's shift, but R1 again did not want to leave
R1's bed. On 2/23/26 at 11:00 AM, V4 said during the initial assessment of R1 after the incident, V4 did not
see any swelling or bruising. V4 then notified V10 (Nurse Practitioner) who came and assessed R1. V4 said
V10 provided orders to leave R1 in bed, place R1 on non-weight bearing status of the right leg, and to
obtain an x-ray. V4 called to obtain an x-ray, which was completed on 2/11/26. On 2/23/26 at 11:16 AM, V9
(Licensed Practical Nurse- LPN) said V4 provided V9 with report at shift change of R1's injury and that an
x-ray was going to be completed. V9 said when the results came back from the x-ray company between
10:15 PM and 10:30 PM. V9 notified V10 of the initial results showing there was no fracture. V9 said R1 had
no complaints of pain during the evening shift on both 2/11/26 and 2/12/26.R1's Weights and Vitals
Summary dated 2/23/26 shows R1 exhibited no pain from 2/11/26 at 2:00 PM until 2/13/26 at 10:39 AM. On
2/23/26 at 10:28 AM, V5 (LPN) said on 2/13/26, V5 was notified by staff that R1 was expressing
excruciating pain. V5 provided R1 with as needed pain medication and immediately notified V10 who
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
145602
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145602
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/23/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Village at Victory Lakes, The
1055 East Grand Avenue
Lindenhurst, IL 60046
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
Level of Harm - Actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
was already enroute to the facility to complete rounds. V10 gave V5 orders to obtain a stat (immediate)
x-ray for R1's right ankle. R1's x-ray results from 2/13/26 shows R1 had minimally displaced acute or
subacute fractures of the medial [inner] and lateral [outer] malleoli [ankle bones].On 2/23/26 at 12:17 PM,
V10 said on 2/13/26, R1 was expressing excruciating pain in R1's right ankle upon an in-person
assessment, after the stat x-ray was completed. V10 ordered staff to send R1 to the emergency room
before receiving the results of the x-ray. V10 said R1's age and bone mineral density could have been
contributing factors to R1's fracture, but R1's foot getting caught on the floor and rolling under the chair
could have been a direct cause of R1's ankle fracture.On 2/23/26 at 12:06 PM, V2 (Assistant Director of
Nursing- ADON) said prior to the incident, the procedure of transporting residents to the shower room was
to bring a shower chair to the resident's room, disrobe the resident, transfer them to the shower chair, and
then wheel the shower chair from the resident's room to the shower room. However, V2 said after the
2/11/26 incident with R1, the facility changed the procedure for residents that utilize footrests. V2 said staff
will now use a wheelchair with footrests to bring the resident to the shower room, where staff will transfer
the resident from the wheelchair to a shower chair, provide the resident with a shower, place the resident
back into their wheelchair when finished with the shower, and take the resident back to their bedroom.
Facility provided in-service sign-in sheet dated 2/2026 shows nursing staff were educated on Shower chair
use- Shower chairs without foot support are to only be used within the shower room.On 2/23/26 at 1:38 PM,
V1 (Administrator) and V11 (Executive Director) said nursing staff had already changed the procedure and
began in-servicing staff on 2/14/26. During the weekly weights, falls, and wounds meeting on 12/19/26, the
interdisciplinary team gathered and discussed R1's incident and conducted a condensed quality assurance
meeting. V1 said staff are actively conducting weekly audits to ensure staff compliance with the updated
procedure. V1 said there were no similar accidents prior to R1's 2/11/26 incident and there have been no
additional accidents since the procedure change. Prior to the survey date of 2/23/26, the facility had taken
the following actions to correct the noncompliance:1. On 2/14/26, the facility updated their shower transfer
procedure and identified all residents that are affected.2. On 2/14/26, the facility began in-servicing V3 and
the rest of the nursing staff on the updated shower transfer procedure. The facility has also developed a
system to ensure all employees not yet in-serviced will receive the in-service information prior to the start of
their next shift at the facility.3. On 2/19/26, the facility conducted a quality assurance meeting to discuss the
incident, the updated procedure, and to devise ongoing auditing to ensure compliance with the new
procedure by nursing staff.
Event ID:
Facility ID:
145602
If continuation sheet
Page 2 of 2
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
FAQ · About this visit
Common questions about this visit
What happened during the February 23, 2026 survey of VILLAGE AT VICTORY LAKES, THE?
This was a inspection survey of VILLAGE AT VICTORY LAKES, THE on February 23, 2026. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at VILLAGE AT VICTORY LAKES, THE on February 23, 2026?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.