Village At Victory Lakes, The
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Based on interview and record review the facility failed to ensure a resident was free from injury during a shower for 1 of 3 residents (Resident R1) reviewed for falls in the sample of 3. The findings include:Findings Include:Resident R1's face sheet shows she had diagnoses including artificial hip replacement surgery, difficulty walking, and osteoarthritis of the hip.Resident R1's care plan initiated on 12/17/24 shows she is at risk for falls due to unsteady gait, balance, and decreased strength and endurance. The care plan also shows she requires partial to moderate assist for showers, dressing, and transfers. Interventions added on 12/18/24 to Resident R1's care plan to help prevent a fall include keep personal items within easy reach and nursing staff should provide instructions on safety measures. Resident R1's incident note completed by V3 (Licensed Practical Nurse) on 1/7/25 shows that Resident R1 had a fall in the shower room and was very upset. A witnessed fall incident form completed by V3 on 1/7/25 shows that Resident R1 was lying on the floor in the shower room and had a skin tear to her right outer elbow and said she had hit her head and hurt her back during the fall. Resident R1 was sent to a local community hospital for evaluation.Resident R1's hospital records show on 1/7/25 she was brought through the emergency room and complained of head and back pain due to a fall at the facility. Resident R1's hospital records show she received medical tests including X-rays of her knee, hip and spine and scans of her head with no acute findings. Resident R1 was discharged from the emergency room on 1/8/25 and did not return to the facility.On 10/28/25 at 10:25 AM, V4 (Certified Nursing Assistant) said she was in the shower room with Resident R1 when she had a fall on 1/7/25. V4 said she had placed Resident R1's personal items on the top of the heater in the bathroom.
V4 said Resident R1 was still in the shower chair, and she was helping dry Resident R1's legs and back off and Resident R1 mentioned
she wanted to have lotion put on. V4 said she turned her back to Resident R1 and went to get her wheelchair to bring
it closer to Resident R1 and the next thing she knew the shower chair moved and Resident R1 fell out onto the floor. V4 said
she should have handed Resident R1 the lotion or had her seated closer to the items, so she did not have to reach for them. V4 also said sometimes the shower chair will move and Resident R1 was a tall lady so with her having her feet on the floor she thinks that maybe why the chair suddenly moved. V4 said Resident R1 was very upset with her
after this incident and would not let her care for her.On 10/28/25 at 11:22, V6 (Registered Nurse) said she was called to the bathroom to assist after Resident R1 fell. V6 said the shower chair can still move at times depending on the resident position so she would not walk away from a resident or turn their back to them in
the shower room.The facility provided Fall Prevention and Management Program policy last revised on 1/23/25 shows all staff are responsible to prevent resident falls and care plan interventions including personal items should be kept in their reach should be followed to minimize fall risk.
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
Event ID:
VILLAGE AT VICTORY LAKES, THE in LINDENHURST, IL inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in LINDENHURST, IL, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from VILLAGE AT VICTORY LAKES, THE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.