VILLAGE AT VICTORY LAKES, THE Nursing Home


VILLAGE AT VICTORY LAKES, THE (CCN: 145602) is a Non profit - Corporation facility located in LINDENHURST, IL (60046). The facility has an overall rating of 5/5, health inspection rating of 4/5, and a staffing rating of 4/5. It offers 120 certified beds and maintains an average of 85.5 residents per day. The nursing staff includes Nurse Aides, LPNs, and RNs working 4.10604 total hours per resident per day. It has been certified since February 2, 1989 and the last listed health inspection was on April 5, 2023, The facility is located in Lake county and provides senior and nursing home care.

VILLAGE AT VICTORY LAKES, THE Summary


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Provider Name: VILLAGE AT VICTORY LAKES, THE

Address: 1055 EAST GRAND AVENUE, LINDENHURST, IL 60046

Phone: (847) 356-5900

County: Lake (570)

Ownership Type: Non profit - Corporation

Certified Beds: 120

Average Residents Per Day: 85.5 ()

Provider Type: Medicare and Medicaid, Resides in Hospital: No

Legal Business Name: FRANCISCAN COMMUNITIES, INC

First Approved Date: February 2, 1989

Affiliated Entity: FRANCISCAN COMMUNITIES (227)

Retirement Community: Y, Special Focus Status:

Ownership Change in Last 12 Months: N

Resident Family Council: Resident

Sprinkler System Status: Yes

Overall Rating: 5 ()

Health Inspection Rating: 4 ()

QM Rating: 5 ()

Long Stay QM Rating: 5 ()

Short Stay QM Rating: 4 ()

Staffing Rating: 4 ()

Staffing Report Note:

PT Staffing Note:

Nurse Aide Staff Hours Per Day, per resident: 2.24675, LPN Staff Hours Per Day: 0.5413, RN Staff Hours Per Day: 1.3179, Licensed Staff Hours Per Day: 1.8592

Total Nurse Staff Hours Per Day, per resident: 4.10604

Weekend Nurse Staff Hours: 3.68394, Weekend RN Staff Hours: 0.9393

PT Staff Hours Per Day, per resident: 0.1415

Nurse Staff Turnover: 50.5, Nurse Turnover Note:

RN Turnover: 51.6, RN Turnover Note:

Admin Left Number: 1, Admin Turnover Note:

Case Mix Nurse Aide Hours Per Day, per resident: 2.2827, Case Mix LPN Hours Per Day: 0.7342, Case Mix RN Hours Per Day: 0.3754

Adjusted Nurse Aide Hours Per Day, per resident: 2.00513, Adjusted LPN Hours Per Day: 0.5440, Adjusted RN Hours Per Day: 1.3227

Total Adjusted Nurse Hours Per Day, per resident: 3.81503

Adjusted Weekend Nurse Hours Per Day, per resident: 3.42285

Health Survey Dates and Scores: Cycle 1: 2023-04-05 (Score: 64), Cycle 2: 2022-06-23 (Score: 72), Cycle 3: 2021-08-11 (Score: 12)

Total Weighted Health Score: 58.000

Reported Incidents: 1, Substantiated Complaints: 3

Infection Control Citations:

Fines and Penalties: Number of Fines: 0, Total Fines in Dollars: 0.00, Payment Denials Number: 0, Total Penalties Number: 0

Location and GPS: 1055 EAST GRAND AVENUE,LINDENHURST,IL,60046 (42.4096, -88.033)

Process Date: 2024-03-01


Health Inspection Citations Details

Each record details specific health deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:

Citation on 2024-01-03

Type: Health, Deficiency: Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Severity: G - Level 3: Actual harm that is not immediate jeopardy. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2024-01-19

Citation on 2023-04-05

Type: Health, Deficiency: Provide care and assistance to perform activities of daily living for any resident who is unable.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-04-21

Citation on 2023-04-05

Type: Health, Deficiency: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-04-21

Citation on 2023-04-05

Type: Health, Deficiency: Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-04-21

Citation on 2023-04-05

Type: Health, Deficiency: Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-04-21

Citation on 2023-04-05

Type: Health, Deficiency: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-04-21

Citation on 2023-04-05

Type: Health, Deficiency: Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-04-21

Citation on 2023-04-05

Type: Health, Deficiency: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-04-21

Citation on 2023-04-05

Type: Health, Deficiency: Provide and implement an infection prevention and control program.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-04-21

Citation on 2022-12-21

Type: Health, Deficiency: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-12-31

Citation on 2022-12-15

Type: Health, Deficiency: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Severity: G - Level 3: Actual harm that is not immediate jeopardy. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-12-27

Citation on 2022-09-28

Type: Health, Deficiency: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-10-07

Citation on 2022-06-23

Type: Health, Deficiency: Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-07-15

Citation on 2022-06-23

Type: Health, Deficiency: Provide care and assistance to perform activities of daily living for any resident who is unable.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-07-15

Citation on 2022-06-23

Type: Health, Deficiency: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-07-15

Citation on 2022-06-23

Type: Health, Deficiency: Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-07-15

Citation on 2022-06-23

Type: Health, Deficiency: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-07-15

Citation on 2022-06-23

Type: Health, Deficiency: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-07-15

Citation on 2022-06-23

Type: Health, Deficiency: Provide and implement an infection prevention and control program.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-07-15

Citation on 2021-08-11

Type: Health, Deficiency: Provide care and assistance to perform activities of daily living for any resident who is unable.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-09-03

Citation on 2021-08-11

Type: Health, Deficiency: Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-09-03

Citation on 2021-08-11

Type: Health, Deficiency: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-09-03


Fire Safety Citations Details

Each record details specific fire safety deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:

Citation on 2023-04-20

Type: Fire Safety, Tag: 0006, Version: New

Description: Conduct risk assessment and an All-Hazards approach.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-05-12

Citation on 2023-04-20

Type: Fire Safety, Tag: 0018, Version: New

Description: Establish procedures for tracking staff and patients during an emergency.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-05-12

Citation on 2023-04-20

Type: Fire Safety, Tag: 0023, Version: New

Description: Establish policies and procedures for medical documentation.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-05-12

Citation on 2023-04-20

Type: Fire Safety, Tag: 0041, Version: New

Description: Implement emergency and standby power systems.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-05-12

Citation on 2023-04-20

Type: Fire Safety, Tag: 0324, Version: New

Description: Provide properly protected cooking facilities.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-05-12

Citation on 2023-04-20

Type: Fire Safety, Tag: 0346, Version: New

Description: Follow proper procedures when the fire alarm was out of service for more than 4 hours.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-05-12

Citation on 2023-04-20

Type: Fire Safety, Tag: 0354, Version: New

Description: Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-05-12

Citation on 2023-04-20

Type: Fire Safety, Tag: 0355, Version: New

Description: Properly select, install, inspect, or maintain portable fire extinguishes.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-05-12

Citation on 2023-04-20

Type: Fire Safety, Tag: 0712, Version: New

Description: Have simulated fire drills held at unexpected times.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-05-12

Citation on 2023-04-20

Type: Fire Safety, Tag: 0914, Version: New

Description: Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-05-12

Citation on 2023-04-20

Type: Fire Safety, Tag: 0920, Version: New

Description: Ensure proper usage of power strips and extension cords.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-05-12

Citation on 2022-07-12

Type: Fire Safety, Tag: 0001, Version: New

Description: Establish an Emergency Preparedness Program (EP).

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-07-27

Citation on 2022-07-12

Type: Fire Safety, Tag: 0037, Version: New

Description: Establish staff and initial training requirements.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-08-05

Citation on 2022-07-12

Type: Fire Safety, Tag: 0133, Version: New

Description: Install a two-hour-resistant firewall separation.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-08-22

Citation on 2022-07-12

Type: Fire Safety, Tag: 0321, Version: New

Description: Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-07-27

Citation on 2022-07-12

Type: Fire Safety, Tag: 0324, Version: New

Description: Provide properly protected cooking facilities.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-07-28

Citation on 2022-07-12

Type: Fire Safety, Tag: 0345, Version: New

Description: Have approved installation, maintenance and testing program for fire alarm systems.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-08-01

Citation on 2022-07-12

Type: Fire Safety, Tag: 0351, Version: New

Description: Install an approved automatic sprinkler system.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-07-28

Citation on 2022-07-12

Type: Fire Safety, Tag: 0353, Version: New

Description: Inspect, test, and maintain automatic sprinkler systems.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-07-13

Citation on 2022-07-12

Type: Fire Safety, Tag: 0355, Version: New

Description: Properly select, install, inspect, or maintain portable fire extinguishes.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-07-19

Citation on 2022-07-12

Type: Fire Safety, Tag: 0363, Version: New

Description: Install corridor and hallway doors that block smoke.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-07-22

Citation on 2022-07-12

Type: Fire Safety, Tag: 0372, Version: New

Description: Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-08-22

Citation on 2022-07-12

Type: Fire Safety, Tag: 0511, Version: New

Description: Have properly installed electrical wiring and gas equipment.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-08-15

Citation on 2022-07-12

Type: Fire Safety, Tag: 0531, Version: New

Description: Have elevators that firefighters can control in the event of a fire.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Waiver has been granted on 2023-04-11

Citation on 2022-07-12

Type: Fire Safety, Tag: 0712, Version: New

Description: Have simulated fire drills held at unexpected times.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-08-01

Citation on 2022-07-12

Type: Fire Safety, Tag: 0754, Version: New

Description: Provide properly sized and located linen or trash receptacles.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-08-10

Citation on 2022-07-12

Type: Fire Safety, Tag: 0915, Version: New

Description: Have proper power supply for life support equipment.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-07-28

Citation on 2022-07-12

Type: Fire Safety, Tag: 0918, Version: New

Description: Have generator or other power source capable of supplying service within 10 seconds.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-08-01

Citation on 2021-09-07

Type: Fire Safety, Tag: 0007, Version: New

Description: Address patient/client population and determine types of services needed.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-09-24

Citation on 2021-09-07

Type: Fire Safety, Tag: 0291, Version: New

Description: Install emergency lighting that can last at least 1 1/2 hours.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-09-21

Citation on 2021-09-07

Type: Fire Safety, Tag: 0321, Version: New

Description: Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-09-30

Citation on 2021-09-07

Type: Fire Safety, Tag: 0351, Version: New

Description: Install an approved automatic sprinkler system.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-09-21

Citation on 2021-09-07

Type: Fire Safety, Tag: 0355, Version: New

Description: Properly select, install, inspect, or maintain portable fire extinguishes.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-09-21

Citation on 2021-09-07

Type: Fire Safety, Tag: 0363, Version: New

Description: Install corridor and hallway doors that block smoke.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-09-21

Citation on 2021-09-07

Type: Fire Safety, Tag: 0920, Version: New

Description: Ensure proper usage of power strips and extension cords.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-09-08