Village At Victory Lakes, The

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

62.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 704 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 46.1% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 310 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.56 therapist hours per resident per day in 2026Q1 — more than 86% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 15% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 120 beds and averages 81.7 residents a day — about 68% occupied, or roughly 38 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.13 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.31 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.16 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.70 hrs/resident/day on weekends vs 4.30 on weekdays — 14% thinner on weekends. RN hours go from 1.43 to 1.01 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 35% is below the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

27 citations, most serious first. The 16 most serious are shown; the remaining 11 are one tap away and print in full.

• Immediate jeopardy · J2026-03-12 · tag F0678 — failed to provide CPR when needed — isolated
  Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to immediately identify the code status and initiate Cardiopulmonary Resuscitation (CPR) to a resident (R96) who had elected to be a full code. This failure resulted in an approximate 2 - 4 minute delay in initiating CPR to R96 who was pronounced deceased on [DATE] at the facility. This applies to 1 of 3 residents (R96) reviewed for resident death in the sample of 18. This failure resulted in an Immediate Jeopardy on [DATE] when V5 Certified Nursing Assistant (CNA) found R96 without a pulse or respirations, V5 did not begin CPR, she exited R96's room and went to find V3 Registered Nurse (RN). V3 and V5 both returned to R96s room and V3 confirmed that R96 was not breathing and did not have a pulse, both staff without starting CPR or calling a code again left R96s room to inform V6 (RN) that R96 had passed away. V1 (Administrator) and V19 (Assistant Director of Nursing) were informed of the Immediate Jeopardy on [DATE] at 1:19 PM. This surveyor confirmed by…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2026-05-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff used a resident transfer device in a safe manner for 2 of 5 residents (R1, R2) reviewed for safe transfers in the sample of 5. This failure led to R1 being transferred unsafely and dislocating R1's hip.The findings include:R1's Facility Final Report dated 5/8/26 showed on 5/8/26, R1 was being transferred with a assistive transfer device (ATD). R1 was unable to be adjusted safely onto the toilet, was lowered to the floor, and 911 was called to transfer R1 to the hospital.R1's Facility assessment dated [DATE] showed R1 has moderate cognitive impairment. R1 was admitted to the facility on [DATE] with diagnoses which include right femur fracture, post right artificial hip joint replacement, muscle wasting and atrophy, and dislocation of internal right hip prostheses. This assessment showed R1 is a fall risk. This assessment showed R1 is dependent on staff with toileting and bed to chair transfers.On 5/14/26 at 9:00 AM, R1 stated…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2026-02-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  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…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Actual harm · Gcited before2025-01-29 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review the facility failed to follow the Wound Physician's recommendations, failed to identify, report, and obtain treatment for wounds and failed to provide pressure relieving intervention to prevent the development of pressure ulcers for 4 of 9 residents (R73, R45, R135, R35) reviewed for pressure ulcers in the sample of 20. This failure resulted in R73's MASD-Moisture Acquired Skin Disease to the left and right gluteal area developing into a left gluteal Stage 3 and right gluteal Stage 4 pressure ulcer. The findings include: 1. R73 Predicting Pressure Ulcer score risk dated 10/12/2024 (admission) shows, High Risk On 01/28/25 at 11:11 AM, V2 DON-Director of Nurse changed the dressing for R73's Stage 4 pressure wound to the left buttock and the Stage 4 pressure wound to the left heel. On 01/28/25 at 11:11 AM, V2 DON-Director of Nursing said, R73 did have redness to the right butt cheek upon admission but developed the pressure ulcer in the facility. R73 admission assessment dated , 05/10/24 at 7:18 PM, shows, Skin MASD in buttocks - very…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-02-07 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure residents were transferred in a safe manner. This failure resulted in R432 being sent to the hospital for 8 days due to increased pain after a transfer. The facility also failed to ensure a resident with a diagnosis of dyspagia was supervised during meals and failed to ensure a resident was provided nectar thick liquids as ordered. This applies to 4 of 18 residents (R5, R7, R44 and R432) reviewed for safety in the sample of 18. The findings include: 1. R432's Face Sheet shows that he originally admitted to the facility on [DATE]. R432's Physical Therapy Evaluation dated 1/8/24 shows that he was referred to therapy for strengthening and decrease level of assistance in bed mobility and transfer. The report shows, Patient exhibiting difficulty performing bed mobility, transfer, sitting balance and ability to stand. The assessment shows that he needs maximum assistance of 2 people for transfer and is dependent on staff for bed-to-chair…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-01-03 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assess and identify a resident's pressure injury to her right lower leg until it was a stage 3 acquired pressure injury from a medical device. This applies to 1 of 3 residents (R2) reviewed for acquired pressure injuries in the sample of 3. This resulted in R2 sustaining a facility acquired stage 3 pressure injury. The findings include: R2's face sheet shows R2 is [AGE] year old who was originally admitted to the facility on [DATE], with diagnoses that include right femur fracture that had undergone hip surgery, history of falling, and diabetes. , R2's Braden scale (predicting pressure score risk), dated 10/30/23, shows R2 is at risk for developing pressure. R2's skin admission assessment, dated 10/11/23, shows R2 had no pressure injury except a surgical incision to right hip. R2's hospital Discharge summary, dated [DATE], shows an order for R2's right lower extremity to be non weight bearing, and the knee immobilizer to be on at all…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2026-03-12 · tag F0761 — failed to label and store drugs safely — widespread
  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.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review, the facility failed to ensure that only authorized personnel entered the medication room.This has the potential to affect all the residents residing at the facility.The findings include:The form CMS 671 dated 3/9/26 show there are 86 residents residing at the facility.On 03/10/2026 at 9:11 AM, V12 (Restorative Certified Nursing Assistant-CNA) approached V16 (Registered Nurse-RN) and asked for the keys for the medication room. V16 (RN) handed V12 (Restorative CNA) the set of keys. V12 opened the medication room and went inside the medication room. V16 (RN) said V12 is not a Nurse but she is the CNA manager so she can enter the medication room, otherwise only Nurses can enter the medication room. On 3/10/26 at 9:35 AM, V9 (Assistant Director of Nursing-ADON) said the Medication room is a secure room where resident's medications including narcotics and over the counter medications were stored. Only authorized personnel which would be the nurses are the only ones allowed to enter a medication room to ensure safety and proper handling of…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2026-03-12 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review the facility failed to ensure food was served in a manner to prevent cross contamination. This failure has the potential to affect all 85 residents residing in the facility and receiving food from the kitchen. The findings include: On 3/9/26 The noon meal service line in the facility kitchen was observed continuously from 10:56 AM though 12:01 PM. At 11:11 AM, V8 (Dietary AIde) put on gloves and during the entire meal service V8 wore the same gloves. At 11:18 AM, a green bean had fallen into the mashed potatoes and V8 picked it out with her gloved hands and continued to wear the same gloves and plated to serve the mashed potatoes to residents. At 11:23 AM, V8 used her gloved hands to pick up a hamburger patty and place it on a bun and plated it to be served to a resident. At 11:43 AM, V8 picked up 2 sandwiches and plated and served them to residents. During the meal service V8 handled residents meal cards, plates, utensils, trays and took additional items out of the warmer when needed. V8 plated all dinner rolls using the same gloves…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-03-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation interview and record review the facility failed to ensure a resident was safe during care to 1 of 18 residents (R86) reviewed for safety in the sample of 18.The findings include:R86's face sheet show R86 has diagnoses that include s/p (status post) left hip arthroplasty, dementia with agitation, depression and hypertension.R86's facility assessment dated [DATE] shows R86 is severely cognitively impaired.R86's fall risk assessment dated [DATE] shows R86 is high risk for falls.On 3/8/25 at 11 AM, R86 was in the common area being monitored closely. V15 (Registered Nurse) said R86 was kept in the common area due to being a high fall risk.Review of R86's fall incident report show R86 fell on: 2/16/26- fell out of bed while being changed by a CNA (Certified Nurse Assistant) during care. On 3/5/26 at 9:12 AM, V11 (CNA) said she was R86's CNA last 2/16/26 when R86 fell out of bed. V11 (CNA) said she provided incontinent care to R86. V11 said she was applying R86's incontinent pad, turning R86 in bed…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-03-12 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
  Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to ensure urinary catheter bags were kept from resting on the floor for 1 of 5 residents (R102) reviewed for catheters in the sample of 18.The findings include:On 3/9/26 at 12:07 PM, R102 was lying in bed in his room. R102's catheter drainage bag was resting directly on the floor to the left side of his bed. R102 said staff position his catheter bag since he's stuck in bed.R102's admission Record dated 3/10/26 shows R102 has hemiplegia and hemiparesis following a cerebral infarction affecting his left, non-dominant side. R102's Order Summary Report dated 3/10/26 shows current, active orders written on 3/3/26 for an indwelling catheter for a diagnosis of (urine) retention and catheter site care to be performed every shift.On 3/10/26 at 1:10 PM, V19, Assistant Director of Nursing/Infection Prevention nurse, said it is not acceptable for a catheter drainage bag to be on the floor due to infection control issues.The facility's Foley Catheter Management Policy (effective 9/1/23) under the heading of Infection Control…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-03-12 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  Provide enough food/fluids to maintain a resident's health.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident was weighed upon admission and readmission and failed to verify the accuracy of a resident's weight for a resident with potential for weight loss which applies to 2 of 7 residents (R1, R14) reviewed for weight loss in a sample of 18.The findings include:1.) R1's Facility assessment dated [DATE] showed R1 is a [AGE] year-old cognitively intact resident with diagnoses which include: dysphagia and aftercare following surgery on the digestive system (feeding tube). R1's Census Sheet printed on 3/12/26 showed R1was admitted to the facility on [DATE], discharged on 1/10/26 (to local hospital), and readmitted to the facility on [DATE]. R1's Weights and Vitals Summary printed on 3/10/26 showed R1 had no weights recorded from 1/7/26 through 1/10/26 and was not weighed until 2/9/26 after being readmitted to the facility on [DATE]. On 3/9/26 at 1:35 PM, V13 Dietitian stated residents who are on tube feeding are at risk for weight…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-03-12 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
  Develop and implement policies and procedures for flu and pneumonia vaccinations.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a resident was offered and/or received an influenza vaccination for 1 of 5 residents (R18) reviewed for immunizations in the sample of 18.The findings include:R18's admission Record dated 3/11/26 shows she was admitted to the facility on [DATE]. R18's Immunizations list dated 3/11/26 shows R18's last influenza vaccination was administered on 11/4/24.On 3/11/26 at 1:00 PM, V19, Assistant Director of Nursing/Infection Prevention Nurse, said influenza vaccines are offered to all residents annually and on admission/readmission. V19 said the facility had an influenza vaccine clinic this past fall.The facility was not able to provide documentation that an influenza vaccine was offered and/or administered to R18 between 10/2025 and 3/10/26 when inquired about R18's immunization status.The facility's Immunization Program Policy (effective 9/1/23) shows the facility offers immunizations against seasonal influenza to all residents. Residents are encouraged…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-10-30 · tag F0809 — failed to serve meals on a reasonable schedule — isolated
  Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review the facility failed to ensure a resident was served the noon meal at the scheduled time. This applies to 1 of 5 residents (R1) reviewed for dietary services in the sample of 5. The findings include: On 10/30/25 at 10:20 AM, V9 (R1's spouse) said on 10/26/25, R1 did not fill out the meal ticket form and this was his 2nd time he missed a meal. She had to alert the staff R1 did not receive the lunch meal. On 10/30/25 at 12:02 PM, V6 (Certified Nursing Assistant-CNA) said on 10/26/25, she was R1's CNA. That day it was really busy, V9 came up to her after the noon meal was served and said R1 did not get a noon meal tray. V6 said she called the kitchen, and they said his tray should have gone out, she looked and looked and could not find his tray. She went to the kitchen between 1:00 PM to 1:30 PM to get a meal tray for R1 and the kitchen had closed up and did not have any food remaining for the noon meal. V6 said she got R1 a grilled cheese sandwich. V6 said PM staff delivers meal tickets for the following day, the residents choose their meals, and…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-10-28 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  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 (R1) reviewed for falls in the sample of 3. The findings include:Findings Include:R1's face sheet shows she had diagnoses including artificial hip replacement surgery, difficulty walking, and osteoarthritis of the hip.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 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. R1's incident note completed by V3 (Licensed Practical Nurse) on 1/7/25 shows that 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 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…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-01-29 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review the facility failed to ensure staff wore the required PPE (Personal Protective Equipment) in a contact isolation and enhanced barrier precaution room, and failed to ensure gloves were changed during incontinence care to prevent cross contamination. This applies to 4 of 10 residents (R24, R54, R63, R135) reviewed for infection control in the sample of 20. The findings include: 1.) On 1/27/25 at 9:35 AM, outside of R24's open door were two isolation signs, one for Contact Isolation indicating gloves and gowns must be applied when entering the resident room. The second sign was for Enhanced Barrier precautions that showed when providing cares such as dressing, bathing, transferring, providing hygiene, changing briefs or assisting with toileting staff must wear gloves and gowns. Outside of R24's doorway was also a cart containing PPE including gowns, gloves, and masks as well as a bin to place linens and garbage. At 9:37 AM, V7 (Certified Nursing Assistant/CNA) went into the room of R24 without applying a gown or gloves, she proceeded…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-01-29 · tag F0625 — isolated
  Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review the facility failed to provide a resident with the bed hold policy when transferring a resident to a hospital for 1 of 2 residents (R23) reviewed for transfers in the sample of 20. The findings include: A facility assessment done on 12/13/24 showed R23's mental status was intact. R23's Progress Note dated 1/10/25 showed R23 was sent to the hospital because he was having abdominal pain. R23's SNF/NF to Hospital Transfer Form dated 1/10/25 showed R23 was being transferred to a local hospital for evaluation of abdominal pain. The same document showed R23 was capable of making decisions. On 01/27/25 at 11:43 AM, R23 stated when he was sent to the hospital on 1/10/25 he was not given the bed hold policy or informed what the facility's bed hold policy was. On 01/28/25 at 12:44 PM, V5 (Licensed Practical Nurse) said she was the nurse that sent R23 to the hospital on 1/10/25. V5 said she did not provide or inform R23 of the facility's bed hold policy on transfer. The facility's Bed Hold Notices policy dated 5/1/19 showed the facility support the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

$93,506 in federal fines across 5 penalties.

• $11,480 — penalty dated 2026-05-14
• $26,685 — penalty dated 2026-03-12
• $19,135 — penalty dated 2026-02-23
• $20,253 — penalty dated 2025-01-29
• $15,953 — penalty dated 2024-02-07

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to FRANCISCAN COMMUNITIES — 6 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 15 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted.

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

This home reported $1.0M paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in IL