Above average — CMS composite of the measures below.
The next survey window likely opens around December 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 Fayette County Hospital during CMS and state inspections, most recent first.
An LPN failed to follow hand hygiene and glove-use practice during blood glucose monitoring for a resident with diabetes, applying gloves before gathering supplies and then proceeding with the fingerstick. A CNA also failed to follow infection control practice during Foley/peri care for another resident, repeatedly removing gloves and keeping replacement gloves in her scrub pocket while providing care. The DON and IP stated staff should not gather supplies with gloves on or keep gloves in pockets, and facility policies required handwashing and proper glove changes during these procedures.
The facility failed to provide the required RN coverage for 8 hours a day, 7 days a week, on several occasions. The DON confirmed the absence of a policy for RN coverage, and the administrator cited nurse call-offs as a contributing factor. This deficiency affected all 29 residents in the facility.
The facility failed to document monthly Medication Regimen Reviews (MRR) for five residents with various diagnoses, including major depressive disorder and Alzheimer's. Despite the facility's policy requiring monthly MRRs, there was no evidence of MRRs for several months. The Consultant Pharmacist claimed to have conducted the reviews but did not document them due to a switch to a new electronic medical records system and the discontinuation of paper forms previously used for documentation.
A resident with cognitive impairments and a history of falls did not receive new fall interventions after multiple incidents. Despite having a chair alarm and being on hourly rounds, the resident continued to fall, and the care plan was not updated with new strategies. The facility's fall prevention policy, which requires post-fall assessments and care plan changes, was not adequately followed.
Hand Hygiene and Glove Use During Blood Glucose and Catheter Care
Penalty
Summary
The facility failed to follow infection control standard of practice for hand hygiene during blood glucose monitoring for a resident with chronic kidney disease, type 2 diabetes mellitus, iron deficiency anemia, a disorder of the kidney and ureter, cardiac murmur, and sepsis. The resident’s record showed an order for blood glucose monitoring before meals and at bedtime, and the resident was cognitively intact with a BIMS score of 15. During observation, an LPN applied gloves before gathering supplies from the medication cart, removed the gloves, sanitized hands, and then continued preparing for the blood glucose check before entering the resident’s room and obtaining the fingerstick sample. The LPN cleaned the resident’s finger with an alcohol wipe, performed the fingerstick, and then exited the room to clean and wrap the blood glucose monitoring machine. When interviewed, the LPN stated she usually puts her gloves on prior to doing the blood glucose check and usually does not wear gloves while gathering supplies. The DON stated nurses should not put gloves on and gather supplies before completing blood glucose testing, and that the expected process was to gather supplies, sanitize hands, place gloves on, and then obtain the blood glucose sample. The facility policy for the blood glucose monitoring system directed staff to clean the patient’s finger with an alcohol wipe and allow it to dry completely after gloves are on. The facility also failed to follow infection control practice during catheter care for another resident with chronic obstructive pulmonary disease, heart failure, essential hypertension, chronic kidney disease, and urinary retention with an indwelling Foley catheter. The resident’s care plan included Foley catheter care every shift and as needed, and the resident was cognitively intact with a BIMS score of 15. During observation, a CNA repeatedly removed gloves and retrieved new gloves from her scrub pocket while performing peri care and catheter care, and at one point gloves fell on the floor before she obtained more gloves from the box and placed them in her pocket. The CNA stated she did this because she was being observed. The DON and Infection Preventionist stated staff should not keep gloves in their pockets while providing care, should sanitize hands before placing new gloves on, and should place gloves on the bedside so they are available during care. The facility policy for perineal/catheter care required handwashing before and after care, removal of soiled gloves, placement of clean gloves before touching bedside items, and handwashing at the end of care.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for 8 consecutive hours per day, 7 days a week, as required. This deficiency was identified through interviews and record reviews, revealing that the facility lacked RN coverage on specific dates: 5/11/24, 5/19/24, 5/27/24, 6/9/24, and 6/30/24. The Director of Nursing (DON) acknowledged the absence of a policy for RN coverage and confirmed the lack of required RN hours on these dates. The facility's administrator attributed the deficiency to nurses calling off, which contributed to the gaps in RN coverage. The facility's nursing schedule for May and June 2024 corroborated the absence of the required RN coverage on the specified dates, affecting all 29 residents living in the facility.
Failure to Document Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to document the findings of monthly Medication Regimen Reviews (MRR) for five residents who were reviewed for unnecessary medications. These residents had various diagnoses, including major depressive disorder, Alzheimer's, anxiety, and insomnia, and were on multiple oral medications. Despite the facility's policy requiring monthly MRRs and documentation of any irregularities, there was no evidence of MRRs being completed for the months of June, July, August, and September 2024 for these residents. Interviews and record reviews revealed that the Consultant Pharmacist claimed to have conducted the MRRs at the pharmacy but did not document them in the residents' medical records. The pharmacist had previously documented MRRs in the medical records before the facility switched to a new electronic medical records system. After the switch, the pharmacist used a paper form, which eventually ran out and could not be reordered due to discontinuation. This led to a lack of documentation for the specified months. The facility's policy mandates that the Consultant Pharmacist maintain a log of all visits and activities and submit written reports monthly. The policy also requires the pharmacist to document the review of each resident's drug regimen monthly and report any irregularities. However, the facility was unable to produce any resident-specific documentation to show that the medications were reviewed or that charts were signed during the months in question.
Failure to Implement New Fall Interventions for Resident
Penalty
Summary
The facility failed to implement new fall interventions for a resident with a history of falls and cognitive impairments. The resident, who has diagnoses including legal blindness, hallucinations, delusional disorders, and major depressive disorder, experienced multiple falls without new interventions being added to their care plan. Despite having a chair alarm and being on hourly rounds, the resident continued to fall, as documented in the Long Term Care Fall Log. The resident's care plan was not updated with new interventions following falls on specific dates, and the Director of Nursing confirmed that no new interventions were implemented. The resident's care plan noted a previous fall resulting in a fracture, and the family declined surgery for the fracture. The resident has poor balance, an unsteady gait, and experiences hallucinations and delusions, contributing to their fall risk. Despite these factors, the facility continued with existing interventions without making necessary adjustments to the care plan after subsequent falls. The facility's policy on fall prevention requires post-fall assessments and care plan changes, which were not adequately followed in this case.
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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 Vandalia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Vandalia Healthcare & Senior Living | 1.1 mi | ★★★★★ | 7 | 0 |
| The Haven Of St. Elmo | 14.1 mi | ★★★★★ | 8 | 0 |
| Greenville Nursing & Rehab | 17.8 mi | ★★★★★ | 2 | 0 |
| Lutheran Care Center | 19.4 mi | ★★★★★ | 7 | 1 |
| Montgomery Nursing & Rehab Ctr | 22.4 mi | ★★★★★ | 1 | 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.