Inspection visit
Health inspection
3 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 3 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
Based on observation, interview, and record review, the facility failed to provide supervision during meals.
This applies to 1 of 1 resident (R201) reviewed for eating supervision in the sample of 13
Residents Affected - Few
The findings include:
R201's face sheet showed diagnoses including heart failure, asthma, chronic kidney disease, stage 2
(mild), diaphragmatic hernia without obstruction or gangrene, encounter for screening for respiratory
tuberculosis, complete rotator cuff tear or rupture of right shoulder, not specified as traumatic. R201's MDS
(minimum data set) dated June 20, 2025 showed that R201 needs substantial maximal assistance with
eating.
R201's POS (Physician Order Summary) June 13, 2025, showed diet order of CCHO [Carbohydrate
Controlled diet] Heart Healthy diet, Regular texture, Thin Liquids consistency. Fluid Restriction and
Maximum Supervision at meals.
On July 01, 2025, at 09:09 AM, R201 was lying in bed with the head of bed raised at about 30-45-degree
angle and eating breakfast from an over the bed table. R201's right arm was in a sling. R201 continued to
cough in between mouthfuls of food. Staff was not present in R201's room or in the immediate area.
On July 01, 2025, at 09:22 AM, V6 (Speech Therapist) was seen evaluating R201 while eating breakfast.
On July 01, 2025 at 1:17 PM, V6 stated that R201 should be eating with the head of bed at 90 degree
angle and should sit upright for 30 minutes after the meal. V6 added that R201 should have staff
supervision at meals. V6's treatment encounter progress notes dated July 01, 2025, included the following
information:
Patient is seen by skilled Speech Therapy to address dysphagia deficits. Educated patient verbally and
followed up with staff via email regarding recommendations from swallow evaluations, including Diet CCHO
Heart Healthy diet, Regular texture, Thin Liquids. Tray set up with assist. Meat /vegetables cut up into
approximately quarter sized pieces. Upright 90 degrees for all po [oral] intake. Supervision at meals. Cue
R201 to eat slowly, alternate one sip for every 3-4 bites of food. Small bites/small sips. Upright 90 degrees
and 30 minutes post po intake. Ensure oral cavity is clear following po intake
On July 2, 2025 at 10:48 AM, V2 (Assistant Director of Nursing) stated that R201 needs maximum
(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 6
Event ID:
146178
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
146178
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/03/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Victorian Village Hlth & Well
12525 W Renaissance Circle
Homer Glen, IL 60491
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
assistance with feeding. V2 stated that maximal assistance means that the resident needs more than 50%
assistance from staff with eating including supervision.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146178
If continuation sheet
Page 2 of 6
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
146178
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/03/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Victorian Village Hlth & Well
12525 W Renaissance Circle
Homer Glen, IL 60491
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 0808
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or
licensed dietitian, to the extent allowed by State law.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, interviews and record review, the facility failed to follow the planned menu plan for residents
on diabetic diets. This applies to 4 of 4 residents (R10, R198, R202, R248) reviewed for dining in the
sample of 13.
The findings include:
Daily menu spreadsheet for Monday June 30, 2025 lunch meal showed that dessert choice for all diets
except for CCHO (Carbohydrate Controlled diet) was #8 scoop or 1/2 cup Cherry Cobbler. The dessert
choice for the same meal for CCHO diets for diabetics included #8 scoop of spiced peaches.
On June 30, 2025 at 12:30 PM, the lunch meal service was observed in the facility 2nd floor dining room
with V8 CNA (Certified Nursing Assistant) and V9 (CNA) serving the meals from the server. V9 was noted
slicing Cherry Cobbler in the server and passing it out to the residents seated in the dining room for
dessert.
1.R10's face sheet had multiple diagnoses including Type 2 diabetes mellitus without complications,
gastro-esophageal reflux disease without esophagitis, personal history of transient ischemic attack (TIA),
and cerebral infarction without residual deficits.
R10's 5 day MDS (minimum data set) dated May 31, 2025 showed that R10 was cognitively intact.
R10's diet order on POS (Physician Order Summary) dated May 28, 2025 included CCHO, NAS [No added
salt] diet, Regular texture, Thin Liquids consistency.
On June 30, 2025 at 11:18 AM, R10 stated Food here is not diabetic friendly. My sugar goes up as I have to
eat what they serve me. I don't want any night time snacks. I try to pick things on the menu that is for
diabetics.
On June 30, 2025 at 12:45 PM, R10 was served cherry cobbler with her meal. R10 was seen eating the
cherry cobbler after she finished her meal. When asked R10 stated They gave it to me. They need to be
more careful.
R10's nutritional care plan revised May 28, 2025 showed to provide, serve CCHO NAS diet as ordered.
2. R202's face sheet had multiple diagnoses including Type 2 diabetes mellitus with hyperglycemia, other
specified noninfective gastroenteritis and colitis.
R202's diet order on POS dated June 24, 2025 included CCHO/NAS diet, Regular texture, Thin Liquids
consistency.
On June 30, 2025 at 12:46 PM, R202 was seated at the dining room and eating her lunch which included
cherry cobbler.
R202's nutritional care plan initiated June 25, 2025 showed to provide, serve diet (CCHO, NAS) as
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146178
If continuation sheet
Page 3 of 6
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
146178
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/03/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Victorian Village Hlth & Well
12525 W Renaissance Circle
Homer Glen, IL 60491
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 0808
ordered.
Level of Harm - Minimal harm
or potential for actual harm
3. R248's face sheet had multiple diagnoses including type 2 diabetes mellitus without complications,
unspecified atrial fibrillation, unspecified dementia, unspecified severity, without behavioral disturbance,
psychotic disturbance, mood disturbance, and anxiety.
Residents Affected - Some
R248's diet order on POS dated June 20, 2025 included CCHO/Heart Healthy diet, Regular texture, Thin
Liquids consistency.
On June 30, 2025 at 12:46 PM, was seated at the dining room and eating his lunch which included cherry
cobbler.
R248's care plan initiated June 23, 2026 showed provide, serve diet (CCHO Heart Healthy) as ordered.
4. R198's face sheet had multiple diagnoses including including Type 2 Diabetes Mellitus with Diabetic
Polyneuropathy.
R198's 5 day MDS dated [DATE] showed that R198 was moderately impaired in cognition.
R198's diet order on POS dated June 23, 2025 included CCHO diet for management of Diabetes Mellitus.
On June 30, 2025 at 1:10 PM, R198 was eating from a room tray in his room. R198 received cherry cobbler
in his room which R198 ate 100%. When asked whether he ordered the cherry cobbler, R198 stated that he
was served the same.
R198's care plan revised June 23, 2025 showed to provide CCHO Heart Healthy, Mechanical Soft as
ordered.
On June 30, 2025 at 12:59 PM when V5 (Director of Dining) was asked what dessert the Diabetics were
supposed to receive, V5 stated that the residents were supposed to have received peaches as it was on the
meal tickets. V5 then brought forward a container of peaches that was covered in a plastic wrap and kept at
the corner of the counter in the 2nd floor dining room server.
On June 30, 2025 at 1:18 PM, V4 (Dietitian) stated that it was an error on the staffs part and the residents
on CCHO diets should have received spiced peaches instead of cherry cobbler.
Facility 'Resident Diet Information' dated June 30, 2025 included that R10, R198, R202 and R248 were on
CCHO diets.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146178
If continuation sheet
Page 4 of 6
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
146178
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/03/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Victorian Village Hlth & Well
12525 W Renaissance Circle
Homer Glen, IL 60491
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 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Face sheet
showed R21 is 73 years-old who has multiple medical diagnoses including aftercare following joint
replacement surgery and infection and inflammatory reaction due to internal right knee prosthesis,
subsequent encounter. Care plan dated June 9, 2025, shows R21 is receiving intravenous (IV) antibiotic
therapy for 35 days related to prosthetic joint infection after a total knee arthroplasty (TKA).
Residents Affected - Some
R21 was in his room on June 30, 2025, from 12:14PM until 12:40PM receiving care from V13 (Nurse).
R21's room was noted with a sign showing, Enhanced Barrier Precautions and a set-up was noted outside
R21's room door. During this time, V12 provided care to R21 (flushing an IV line, applying compression
socks and changing dressing to the wound) without wearing an isolation gown.
3. R2 is 76 years-old who has multiple medical diagnoses including displace comminuted fracture of shaft
of right femur, subsequent encounter for closed fracture with routine healing.
On July 1, 2025, at 11:12 AM, V16 (Certified Nursing Assistant/CNA) provided personal care and hygiene
to R2. V16 cleaned R2's perineum from front to back, she put a pair of shorts on to R2 and a pair of
sneakers on his feet. V16 helped R2 to reposition and placed new sheet on the bed. V16 changed her
gloves in between tasks, however, she did not perform hand hygiene throughout the provision of care.
4. Face sheet showed R149 is 73 years-old who has multiple medical diagnoses including enterocolitis due
to clostridium difficile, not specified as recurrent. Active care plan shows R149 is on isolation for Clostridium
Difficile (C. diff).
On July 1, 2025, at 1:41 PM, V12 (CNA) and V17 (Nurse) rendered peri-care to R149. V12 cleaned R149
from front to back, she changed the incontinence brief, opened R149's vanity drawer multiple times and
help reposition R149. V12 changed her gloves in between tasks, however, she did not perform hand
hygiene all throughout the provision of care.
On July 2, 2025, at 1:50 PM, V2 (Assistant Director of Nursing/ADON) stated that every time a staff provide
patient direct contact care to a resident on EBP, the staff must put on gloves and gown as protection
between staff and resident. When the staff provide incontinence or peri-care, the staff must change gloves
and perform hand hygiene from dirty to clean tasks, or in between tasks to prevent cross contamination and
the spread of infection.
The Facility's Enhance Barrier Precautions (EBP) Policy and Procedure dated March 21, 2024, shows:
Policy: Facility employs Enhanced Barrier Precautions in effort to reduce the transmission of novel or
targeted multi drug resistant organisms (MDRO) and infection risk for residents with open wounds or
indwelling medical devices.
Enhance Barrier Precautions (EBP) refers to an infection control intervention designed to reduce
transmission of multidrug- resistant organisms that employs targeted gown and glove use during high
contact resident care activities.
Procedure:
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146178
If continuation sheet
Page 5 of 6
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
146178
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/03/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Victorian Village Hlth & Well
12525 W Renaissance Circle
Homer Glen, IL 60491
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 0880
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
1. Enhance Barrier Precautions (EBP) are used in conjunction with standard precautions and require the
use of gown and glove during high contact resident care activities that provide opportunities for transfer of
MDROs to staff hands and clothing.
Based on observation, interview and record review, the facility failed to ensure that hand hygiene was
performed during perineal care and failed to ensure that a gown was donned during wound care for a
resident identified on (EBP) Enhanced Barrier Precaution.
This applies to 4 of 4 residents (R2, R20, R21, and R149) reviewed for infection control in the sample of 13.
1. R20's face sheet showed multiple diagnoses including, dementia, Alzheimer's disease and failure to
thrive.
R20's (MDS) Minimum Data Set, dated [DATE] showed the resident had severe cognitive impairment,
urinary and bowel incontinence, and was dependent on staff for toileting.
On July 1, 2025 at 11:22 am, V14 (CNA/Certified Nurse Assistant) provided incontinence care to the R20.
R20's incontinence brief was soiled with urine and bowel movement. After provision of incontinence care,
V14 touched R20's thigh and right hand to assist the resident to grab the bed rail, adjusted the pillow and
the lift pad under the resident while using the same soiled gloves. V14 then took off the soiled gloves, pulled
out two gloves from her pocket, wore the gloves and then applied a clean incontinence brief to the resident
without performing hand hygiene (hand washing or use of hand sanitizer).
On July 2, 2025 at 11:18 am, V2 (ADON/ Assistant Director of Nursing) stated while performing
incontinence care, the CNA should remove gloves after cleaning the resident's urine and stool, and perform
hand hygiene using hand sanitizer or soap and water. She also stated that the CNA should re-apply clean
gloves before touching the resident or touching clean surfaces. V2 stated that hand hygiene and application
of clean gloves should be performed in between dirty and clean tasks to prevent cross-contamination and
ensure infection control.
The facility's nursing policy and procedure regarding infection control last reviewed by the facility on April
2024 showed under types of precautions . 3. employees must wash their hands for twenty (20) seconds
using soap and water under the following conditions: .d. after removing gloves. 4. In most situations, the
preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an
alcohol-based hand rub containing 60-95% ethanol or isopropanol for all of the following situations: a.
before and after direct contact with residents; b. before donning gloves; . f. before moving from a
contaminated body site to a clean body site during resident care; g. after contact with a resident's intact
skin; . j. after removing gloves.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146178
If continuation sheet
Page 6 of 6
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Back to topCitations
3 citations 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.
F808 - Therapeutic Diets
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
F880 - Infection Control
Provide and implement an infection prevention and control program.
FAQ · About this visit
Common questions about this visit
What happened during the July 3, 2025 survey of VICTORIAN VILLAGE HLTH & WELL?
This was a inspection survey of VICTORIAN VILLAGE HLTH & WELL on July 3, 2025. The surveyor cited 3 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at VICTORIAN VILLAGE HLTH & WELL on July 3, 2025?
Yes, 3 deficiencies were 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.