Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Town Of Vici Nursing Home during CMS and state inspections, most recent first.
A resident with diabetes did not receive prescribed insulin on several occasions when they did not eat breakfast, but there was no documentation that the physician was notified as required. An LPN confirmed that the physician should be notified and the event documented, but this was not done.
The facility did not ensure proper blood pressure monitoring for a resident prescribed PRN clonidine, as required by physician orders, with documentation missing for several months. Additionally, another resident with multiple health conditions experienced repeated unavailability of prescribed medications, resulting in missed doses. Staff confirmed that medication reordering and administration processes were not consistently followed, leading to these deficiencies.
A resident requiring substantial assistance for personal hygiene was found with unclean, jagged fingernails and reported not receiving nail care in the past week. Facility standards required nails to be clean and trimmed, but a CNA confirmed nail care was only done on shower days or when nails appeared dirty, acknowledging the resident's nails needed attention.
A resident who required a mechanical lift for transfers was manually transferred by a CNA, resulting in a fall and a fracture. Despite policies mandating the use of mechanical lifts, the CNA proceeded with a manual transfer due to a malfunctioning lift and the resident's refusal to use it. The administration was unaware of the resident's refusal, highlighting a communication lapse.
A facility failed to develop a comprehensive care plan for a resident admitted with pain and high blood pressure. The clinical health record lacked documentation of a completed care plan, and an LPN confirmed that only a care plan reference sheet was available.
Failure to Notify Physician When Insulin Held
Penalty
Summary
The facility failed to ensure that a physician was notified when insulin was held for a resident with diabetes mellitus. According to the resident's physician order, Lantus insulin was to be administered daily and held if the fingerstick blood sugar (FSBS) was below 120. Medication administration records showed that the insulin was not given on multiple dates because the resident did not eat breakfast, but there was no documentation that the physician had been notified of these omissions. An LPN confirmed that insulin would be held if a resident was not eating or if their blood sugar was low, and that the physician should be notified and the event documented in the progress notes. However, there was no evidence that this notification or documentation occurred for the resident in question.
Failure to Monitor BP for PRN Antihypertensive and Ensure Medication Availability
Penalty
Summary
The facility failed to ensure proper pharmaceutical services for its residents in two key areas. For one resident with hypertension and severe cognitive impairment, there was a physician's order for clonidine to be administered as needed based on systolic blood pressure (SBP) greater than 160. However, blood pressure monitoring was not performed or documented three times daily as required over several months, making it unclear whether the medication was administered appropriately according to the physician's parameters. Both the Certified Medication Aide (CMA) and the Director of Nursing (DON) confirmed that blood pressure should be checked every shift, but were unable to provide documentation of these checks in the electronic medical record. Another resident with multiple diagnoses, including psychosis, thyroid disorder, and atrial fibrillation, experienced multiple instances where prescribed medications were unavailable for administration. The medication administration records showed that Rexulti, levothyroxine, metoprolol, and midodrine were not available on several occasions, resulting in missed doses. The CMA explained that medications are reordered when supplies run low, but acknowledged that some medications were out of stock and that a prescription had to be resent to the pharmacy. These failures indicate that the facility did not ensure medications were consistently available and administered as ordered.
Failure to Provide Nail Care for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with diagnoses including congestive heart failure and intact cognition, who required substantial assistance for personal hygiene, was observed to have jagged fingernails and a brown substance under their fingernails. The facility's Nursing Care Standard required fingernails to be clean and trimmed. During interviews, the resident reported that staff had not provided nail care in the past week, and a CNA confirmed that nail care was typically provided only on shower days or when nails appeared long and dirty. The CNA acknowledged that the resident's fingernails looked bad and needed attention. These findings indicate that the facility failed to provide necessary nail care for a dependent resident as required.
Failure to Use Mechanical Lift Results in Resident Injury
Penalty
Summary
The facility failed to ensure the proper use of a mechanical lift for a resident who required assistance for transfers. On June 9, 2024, a CNA attempted a one-person transfer of a resident without using the mechanical lift, contrary to the care plan that required two staff members and a maxi lift for transfers. This resulted in the resident being lowered to the floor and subsequently complaining of leg pain. An X-ray conducted two days later revealed an oblique fracture of the left distal femur. The facility's policies, including a No-Lift Policy, mandated the use of mechanical lifting devices for non-ambulatory residents, except in life-threatening situations. Both CNAs involved had signed this policy, acknowledging their responsibility to use mechanical lifts. Despite this, the CNA proceeded with a manual transfer due to a malfunctioning lift and the resident's refusal to use it, which was not communicated to the administration. The Director of Nursing confirmed the care plan required the use of a maxi lift, and the resident had previously refused to use the lift, demanding manual transfers instead. The incident was documented in various nursing notes and reports, highlighting the resident's ongoing complaints of pain and the eventual discovery of the fracture. The facility's failure to adhere to the care plan and policies, along with inadequate communication regarding the resident's refusal to use the lift, contributed to the deficiency. The administration was unaware of the resident's refusal to use the lift, indicating a lapse in communication and adherence to established protocols.
Failure to Develop Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who was admitted with diagnoses including pain and high blood pressure. Upon review of the clinical health record, it was found that there was no documentation of a comprehensive care plan being completed for this resident. During an interview, an LPN confirmed that the comprehensive care plan had not been completed and only a care plan reference sheet was available.
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What surveyors actually found near you
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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 Vici
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Woodward Skilled Nursing And Therapy | 19 mi | ★★★★★ | 0 | 0 |
| Seiling Nursing Center | 21.3 mi | ★★★★★ | 4 | 0 |
| Shattuck Nursing Center | 32.7 mi | ★★★★★ | 0 | 0 |
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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.