Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Victorian Village Hlth & Well during CMS and state inspections, most recent first.
A resident with deconditioning and a documented need for sit-to-stand mechanical lift transfers with two staff was manually transferred from a wheelchair to a bed by two CNAs who did not use the mechanical lift or a gait belt, contrary to the care plan and therapy recommendations. One CNA had the resident hold the bed rail and lifted under the resident’s armpits while the other stood behind the wheelchair and did not assist physically. During the stand-pivot, the resident’s leg apparently contacted the wheelchair, resulting in a large left lower leg laceration that required hospital evaluation and repair with multiple sutures. Facility policy required staff to follow the transfer method in the plan of care and identified equipment such as sit-to-stand lifts and gait belts as client movement equipment.
The facility did not maintain confidentiality of health information when two residents' personal medical records and medications were improperly disclosed to another resident and a home health provider. One resident's inhaler was sent home with another, and a therapy note for a different resident was included in discharge documents, resulting in breaches of privacy.
A resident discharged after short-term rehab did not receive all prescribed medications, specifically missing Metoprolol, and was sent home with a medication belonging to another resident. The facility's discharge process and policy require medication review and education, but these steps were not properly followed, resulting in the deficiency.
The facility failed to maintain kitchen sanitation standards, affecting all 46 residents receiving dietary services. Observations revealed improperly stored and labeled food items, dirty kitchenware, and unsanitary conditions in the main kitchen, freezers, and kitchenettes. The Director of Dining Services and the DON acknowledged the importance of proper food labeling and storage but failed to provide necessary kitchen logs, contributing to the deficiencies.
The facility failed to offer COVID-19 vaccines and education to its staff, as revealed by interviews and record reviews. The DON cited cost as a reason for not providing vaccines, and the Administrator confirmed no vaccines or clinics had been offered since November 2023. Staff members reported not being offered the vaccine, despite a sign indicating availability. The facility's policy only mentioned discussing future vaccination avenues, affecting a census of 46 residents.
A resident with type 2 Diabetes Mellitus received an inaccurate blood glucose reading due to a nurse's failure to allow alcohol to dry on the finger before testing. The facility's policy and manufacturer guidelines were not followed, leading to a deficiency in care quality.
The facility failed to provide adequate ADL care to three residents who were dependent on staff for personal hygiene. One resident had an itchy scalp and unkempt nails, another had dry skin, and a third had unclean nails with food residue. Despite care plans indicating the need for substantial assistance, these needs were not met.
A resident with chronic kidney disease had an indwelling urinary catheter reinserted due to urinary retention. The care plan required the catheter bag to be positioned below the bladder, but the resident was found in bed with a leg bag at bladder level, risking urine backflow and UTI. The RN and DON confirmed the improper use of the leg bag, and the facility lacked a specific policy on catheter maintenance.
A resident with a history of falling and leg contusion was administered 11 tablets of hydrocodone-acetaminophen in one day, exceeding the prescribed 3 grams of acetaminophen limit. The DON confirmed the error, noting the risk of kidney and liver toxicity. The facility lacked a policy to ensure adherence to physician orders.
Staff at the facility failed to maintain proper hand hygiene during incontinence care and a physical exam, affecting multiple residents. A CNA did not clean her hands between glove changes while assisting a resident with dementia. A Wound Nurse used the same gloves for cleaning and handling clean items, and a nurse examined a resident without cleaning his hands. Another CNA provided care without changing gloves or cleaning hands, moving from contaminated to clean areas. The facility's infection control policy emphasizes the importance of hand hygiene.
Improper Manual Transfer Causes Leg Laceration
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe transfer by not following the transfer method recommended by physical therapy and documented in the resident’s plan of care. A resident admitted with a primary diagnosis of disorder of muscle had a care plan initiated on 2/26/26 indicating an ADL self-care performance deficit related to deconditioning, with interventions specifying transfer with a sit-to-stand mechanical lift. As of 3/4/26, the physical therapy assistant stated that nursing staff were expected to transfer this resident using a sit-to-stand mechanical lift with two staff assisting. Therapy had not upgraded the resident’s transfer status to a one-person max assist and expected use of a gait belt for max assist transfers, noting that lifting under the armpits increases risk of injury. The facility’s Lifts and Safe Client Movement Program policy required employees to follow the transfer method indicated in the plan of care. On the date of the incident, two CNAs transferred the resident from a wheelchair to the bed without using the ordered sit-to-stand mechanical lift or a gait belt. One CNA reported that the wheelchair was positioned next to the bed, with the resident’s left leg next to the bed, and that she stood behind the wheelchair and did not touch the resident during the transfer. The other CNA instructed the resident to hold the bed rail with her left hand and then placed her arms under the resident’s armpits to assist her to stand, pivot to the left, and sit on the bed. Immediately after sitting, the resident reported leg pain, and the CNAs observed active bleeding from the left lower leg, which they believed had been scraped on the wheelchair during the transfer. The resident sustained a left lower leg laceration measuring approximately 12–13 cm in length and was transferred to the hospital, where the wound was repaired with 21 sutures.
Failure to Protect Resident Health Information Confidentiality
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' personal and medical records as required by their own policies and procedures. In one instance, a 77-year-old resident who was discharged from the facility did not receive all of his prescribed medications, and instead, another resident's inhaler was mistakenly sent home with him. The error was discovered when the discharged resident's daughter found the inhaler while sorting through the medications provided by the facility and subsequently notified the facility. In a separate incident, a home health physical therapist evaluating the discharged resident at home found a therapy note in the electronic medical record that belonged to a different resident who was still admitted at the facility. The therapy note included personal information such as the resident's name, date of birth, and plan of care. The facility's own documentation confirmed that a page of another resident's therapy notes was included in the discharge documents sent to the home health agency. These events demonstrate that the facility did not ensure that only the appropriate resident's information was released, resulting in breaches of confidentiality for at least two residents.
Failure to Provide Prescribed Medication at Discharge
Penalty
Summary
A 93-year-old resident admitted for short-term rehabilitation was discharged to his daughter's home. Upon review of the electronic medical record and interviews, it was found that the resident was prescribed multiple medications, including Metoprolol Succinate ER 12.5 mg twice daily. After discharge, the resident's daughter discovered that the Metoprolol was missing from the medications sent home, and also found a medication belonging to another resident mixed in with the discharge medications. Interviews with facility staff revealed that the discharge process includes reviewing and itemizing medications with the resident or their representative to ensure accuracy. The facility's policy requires complete client and family education about treatments and medications, as well as arranging for medication needs at home. Despite these procedures, the resident did not receive all prescribed medications at discharge, and an incorrect medication was included among those provided.
Facility Fails to Maintain Kitchen Sanitation Standards
Penalty
Summary
The facility failed to maintain its kitchen in a manner that prevents foodborne illness, affecting all 46 residents receiving dietary services. During a tour of the main kitchen, it was observed that dust covered the vents over the stove while open pots of food were cooking. The large refrigerator contained improperly stored food items, such as hot dogs, ham, raw ground beef, and various cheeses, all of which were either not labeled with use-by dates or were improperly wrapped, leading to potential contamination. Additionally, the pantry contained dented cans, which the Director of Dining Services acknowledged could develop bacteria if used. Further inspection revealed that the facility's freezers contained numerous unlabeled and improperly stored food items, including chicken cordon bleu, omelets, sweet potato fries, hash browns, and cookie dough, many of which showed signs of freezer burn and frost. Kitchen drawers were found to be dirty, with utensils and pans crusted with dried spills and grease. The second-floor kitchenette and Faith house kitchen also exhibited similar issues, with improperly stored and labeled food items, dirty kitchenware, and unsanitary conditions. The Director of Dining Services and the Director of Nursing acknowledged the importance of proper food labeling and storage to prevent serving expired or contaminated food. They also recognized the need for daily cleaning and sanitization of kitchen areas. However, the facility failed to provide requested kitchen logs for the small houses and the second floor, which would have documented the maintenance of dishwashers, refrigerators, freezers, and sanitization procedures. The facility's policies on food storage and machine ware washing were not adhered to, contributing to the observed deficiencies.
Failure to Offer COVID-19 Vaccines and Education to Staff
Penalty
Summary
The facility failed to offer COVID-19 vaccines to its staff members and did not provide education regarding the benefits, risks, and potential side effects associated with the COVID-19 vaccine. This deficiency was identified through interviews and record reviews, revealing that the facility had not offered the vaccine or related education to staff in the past year. The Director of Nursing (DON) admitted that there was no documentation to show that the facility was offering the vaccine or education, citing cost as a reason for not providing it. The Administrator, who has been with the facility since November 2023, confirmed that no COVID-19 vaccines or clinics had been offered to staff during her tenure. Several staff members, including a nurse, a housekeeping staff member, and a wound nurse, reported that they had not been offered the COVID-19 vaccine by the facility. Despite a sign at the facility's entrance indicating that opportunities for staff vaccination were available, the facility's policy only mentioned discussing future vaccination avenues for unvaccinated employees. At the time of the survey, the facility had a census of 46 residents, and the lack of vaccine offerings and education had the potential to affect all residents.
Failure to Follow Blood Glucose Monitoring Guidelines
Penalty
Summary
The facility failed to adhere to manufacturer guidelines for blood glucose monitoring, resulting in a deficiency in the quality of care provided to a resident diagnosed with type 2 Diabetes Mellitus. The resident, identified as R35, had a physician's order to check blood glucose levels twice daily. During an observation, a registered nurse (RN), identified as V18, was seen performing a blood glucose test on R35. The RN cleaned the resident's finger with an alcohol wipe and did not allow sufficient time for the alcohol to dry before obtaining the blood sample. This led to an inaccurate blood glucose reading of 153, which the resident noted was higher than their usual readings in the low 100s. The Director of Nursing (DON), identified as V2, confirmed that the procedure should include allowing the alcohol to dry to prevent inaccurate readings. The facility's policy on blood glucose monitoring, last reviewed in January, also specifies that the manufacturer's instructions should be followed, which includes allowing the finger to dry after swabbing with alcohol. This oversight in following proper procedures resulted in a failure to meet professional standards of quality in the care provided to the resident.
Failure to Provide Adequate ADL Care to Dependent Residents
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADL) care to three residents who were dependent on staff for personal hygiene. One resident was observed scratching her head with jagged nails and a brown substance under them, indicating a lack of personal hygiene care. Her care plan noted she was dependent on staff for personal hygiene due to dementia, yet her needs were not met as evidenced by her dry hair and itchy scalp. Another resident was observed with dry skin, and her daughter expressed concerns about the staff's failure to address this issue. The resident's care plan required substantial assistance for personal hygiene due to dementia and deconditioning, but her skin condition suggested neglect in this area. A third resident was found with long, jagged nails and a reddish-brown substance on her thumb, which staff later identified as food residue. Despite her care plan indicating the need for dependent care and regular nail maintenance, these needs were not adequately addressed.
Improper Indwelling Catheter Maintenance
Penalty
Summary
The facility failed to maintain an indwelling urinary catheter according to best practices, which led to a deficiency in care for a resident with chronic kidney disease. The resident, who had intact cognition, had an indwelling urinary catheter reinserted due to urinary retention. The care plan specified that the catheter bag and tubing should be positioned below the level of the bladder and away from the entrance room door. However, during an observation, the resident was found lying in bed with a urinary catheter leg bag attached to her left leg, which was positioned at the same level as her bladder. This improper positioning of the leg bag could lead to urine backflow into the bladder, increasing the risk of a urinary tract infection (UTI). The resident reported discomfort in her lower abdomen and mentioned that the urine in the leg bag had not been emptied for a long time. The RN confirmed that the resident should not have been using a leg bag while lying in bed, as it could cause urinary reflux and potentially lead to a UTI. The Director of Nursing (DON) acknowledged that the CNA should have informed the nurse to switch the leg bag to a regular catheter drainage bag when the resident was assisted back into bed. Additionally, it was noted that the facility lacked a specific policy regarding indwelling catheter maintenance, although their existing policy on catheter insertion, removal, and changing emphasized maintaining the drainage bag below the bladder level to prevent UTIs.
Medication Error Due to Exceeding Prescribed Acetaminophen Limit
Penalty
Summary
The facility failed to adhere to physician medication orders for a resident, leading to a significant medication error. The resident, who has a history of falling and a contusion of the left lower leg, reported experiencing pain levels up to 8 on a scale of 0-10. The resident's physician order sheet included two orders for hydrocodone-acetaminophen to be administered as needed for moderate to severe pain, with a strict limit of not exceeding 3 grams of acetaminophen per day from all sources. However, on a specific day, the resident was administered a total of 11 tablets of hydrocodone-acetaminophen, resulting in a total intake of 3.575 grams of acetaminophen, which exceeded the prescribed daily limit. The Director of Nursing (DON) confirmed the administration of 11 tablets, acknowledging that this exceeded the physician's order and posed a risk of kidney and liver toxicity or damage to the resident. The facility did not have a policy in place to ensure adherence to physician orders, which contributed to the oversight. The resident's care plan, initiated shortly before the incident, included administering pain medication as per the physician's orders, highlighting a failure in executing the care plan effectively.
Failure to Maintain Proper Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to maintain proper hand hygiene during incontinence care and a physical exam, affecting several residents. A Certified Nurse's Assistant (CNA) was observed providing incontinence care to a resident without cleaning her hands between glove changes. The CNA handled various items and assisted the resident without performing hand hygiene, despite the resident's care plan indicating a need for dependent assistance due to dementia and impaired balance. A Wound Nurse also failed to perform hand hygiene while providing incontinence care to another resident. The nurse used the same gloves to clean the resident's perineal area and handle clean briefs, and then touched personal items and wound care equipment without cleaning her hands. The resident's care plan noted occasional bladder incontinence, and the nurse acknowledged the need for hand hygiene to prevent cross-contamination. Additionally, a nurse did not clean his hands before examining a resident with a reddish-brown substance on her thumb, later identified as dry blood. The nurse touched the resident's hands and face without performing hand hygiene. Another CNA provided incontinence care to a resident without changing gloves or cleaning hands, moving from contaminated to clean areas. The Director of Nursing confirmed the importance of hand hygiene to prevent contamination, as outlined in the facility's infection control policy.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Homer Glen
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aliya Of Palos Park | 2.7 mi | ★★★★★ | 6 | 0 |
| Lemont Nursing & Rehab Center | 3.4 mi | ★★★★★ | 27 | 0 |
| Warren Barr Orland Park | 3.8 mi | ★★★★★ | 3 | 0 |
| Franciscan Village | 4.3 mi | ★★★★★ | 14 | 0 |
| Alden Estates Of Orland Park | 4.3 mi | ★★★★★ | 7 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.