Below average — CMS composite of the measures below.
The next survey window likely opens 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 Vandalia Healthcare & Senior Living during CMS and state inspections, most recent first.
A resident with intact cognition and Medicaid coverage reported ongoing tooth pain and a cavity for about a year, with physician notes repeatedly documenting the need for a dental appointment. Staff interviews showed confusion over who was responsible for scheduling and confirming the visit, and multiple appointment attempts were delayed or canceled. The resident later developed acute dental pain, gum swelling, broken and carious teeth, and a periapical abscess requiring antibiotics and PRN acetaminophen.
Wound dressing care was not provided per orders for a resident with right leg cellulitis and skin impairment. An RN cleansed the wound with normal saline instead of Dakins solution and applied barrier cream directly in the wound bed rather than to intact skin around the wound, then placed calcium alginate over the barrier cream before wrapping the leg with an elastic compression wrap.
Failure to obtain MD orders for newly identified open wounds: a resident with severe cognitive impairment and skin integrity impairment had an order for the right hip only, while open areas were observed on the right hip and right upper buttocks/back with drainage. The RN confirmed both wounds were open and that there were no new documentation or dressing change orders for the additional areas; the corporate nurse stated new wounds should be measured and the MD contacted for orders by the end of the shift.
A resident with a central line, surgical wounds, and IV antifungal therapy did not have enhanced barrier signage or PPE available at the door or in the room. An RN administered IV micafungin through a double-lumen chest line using gloves only, did not don a gown, did not change gloves during the procedure, and did not aspirate for blood return before infusion, despite facility policy requiring blood return prior to each infusion.
Medication Left at Bedside Instead of Being Administered Directly: A resident with multiple chronic conditions and intact cognition was scheduled to receive several morning meds, but an LPN left a cup of pills on the bedside table while the resident was sleeping. The resident said he was not awakened and did not know how long the pills had been there. The LPN stated she usually leaves meds at the bedside if the resident is asleep, while the DON stated meds should be given directly to the resident rather than left on the table.
Failure to follow enhanced barrier precautions occurred for two residents. One resident with severe cognitive impairment and devices including a feeding tube had EBP documented, but staff did not wear gowns during wound care or a feeding tube flush, and one nurse did not perform hand hygiene. Another resident with a midline and pseudomonas had EBP in the care plan, but there was no EBP sign or PPE at the door, and an RN administered IV micafungin and flushed the line without changing gloves or wearing a gown.
A resident with severe cognitive impairment and a history of falls experienced multiple unwitnessed falls, some resulting in injuries. Despite these incidents, the care plan was not updated with new interventions, and staff did not implement additional fall prevention strategies as required by facility policy.
The facility did not maintain adequate nursing staff to meet residents' needs in a timely manner, resulting in delays in care such as toileting and call light response. Multiple staff and residents reported that call lights often went unanswered for extended periods, especially during evening and night shifts, due to insufficient CNA coverage. Administrative staff were aware of the staffing shortages but were not always able to secure additional help, leading to ongoing delays in essential resident care.
The facility did not provide bedtime snacks as required, instead serving them with the evening meal, leaving residents without food options until breakfast. Staff reported that snack availability was reduced due to budget cuts, and the kitchen was locked after supper, preventing access to additional snacks. Observations confirmed that designated snack areas were inadequately stocked, affecting all residents, including those with significant medical needs.
Two residents requiring assistance with toileting experienced significant delays in call light response, with one reporting waits of up to 45 minutes, particularly during evening and overnight shifts. Multiple staff members, including CNAs and LPNs, confirmed that call lights were not always answered promptly due to insufficient staffing, especially during shift changes or when only one CNA was present per unit. Resident Council minutes and the facility ombudsman also documented ongoing concerns about untimely call light responses.
The facility failed to provide consistent showers for three residents requiring assistance, with gaps in documentation and adherence to the shower schedule. Residents with severe cognitive impairment and those needing partial assistance did not receive showers as scheduled, and staff cited staffing issues as a reason for missed showers. The facility's policy requires at least weekly showers, but incomplete records suggest this standard was not met.
The facility failed to maintain a safe and clean environment for residents, with issues such as leaking toilets, missing tiles, and unsecured fixtures affecting five residents. Some residents were unable to use their bathrooms for months, leading to inconvenience and frustration. Staff shortages and a lack of maintenance budget contributed to the deficiencies, with the maintenance man quitting and using his own money for repairs.
The facility failed to maintain safe water temperatures, with readings between 116 and 122.5 degrees Fahrenheit, exceeding the policy of 100-110 degrees. Several residents, including those cognitively impaired, were affected. Maintenance issues, such as a hole in the pipe leading to the hot water heater, contributed to the problem. The DON and Maintenance Assistance/Therapy Assistant were aware of the policy but did not ensure compliance.
The facility failed to provide nutritional supplementation as recommended for three residents, resulting in significant weight loss for one. A resident with multiple medical conditions did not receive extra protein despite recommendations, and expressed dissatisfaction with food quality. Another resident on hospice care did not receive prescribed supplements at lunch due to staff oversight. A third resident did not receive a high calorie/protein supplement as ordered, with staff unaware of the requirement.
The facility failed to maintain a full-time DON and ensure RN coverage for 8 hours daily, affecting 33 residents. The DON worked as a floor nurse due to staffing shortages, neglecting administrative duties, and resigned due to these challenges. The facility's schedule showed several days without RN coverage, confirming the deficiency.
The facility failed to store and serve food safely, affecting all 33 residents. Opened food items lacked dates, and scoops were improperly stored in bins. A dietary staff member handled drinks by the rim after touching various surfaces. The Dietary Manager confirmed these practices were against professional standards.
The facility failed to provide an accessible call system in the shower room and community bathroom, affecting all 33 residents. Observations showed that call light boxes lacked pull cords, making them inaccessible from the toilet or floor. Additionally, shower stalls had no call system. Staff interviews revealed a lack of awareness and policy regarding call light systems.
The facility failed to provide the required 80 square feet per resident bed in multiple occupancy rooms, affecting several residents. Observations revealed that the rooms were certified for double occupancy but did not meet the required space, with measurements ranging from 71.31 to 74.48 square feet per resident. The Administrator acknowledged the issue and confirmed that residents were not informed during admission. Despite the space limitations, adequate space was determined to meet residents' needs, and no concerns were noted in Resident Council Minutes.
A resident with moderate cognitive impairments reported being handled roughly by a CNA during care, without explanation or time to assist, leading to distress and a feeling of being rushed. The facility acknowledged the incident as poor customer service, failing to promote the resident's dignity and independence.
A resident expressed dissatisfaction with being woken up too early and taken to the dining room, contrary to their preference to sleep longer. Staff confirmed the resident was typically in the dining room by 6:00 AM, and the facility administrator acknowledged residents should choose their waking times, but was unsure of a policy supporting this.
A facility failed to accurately code an MDS Assessment for a resident who experienced a significant weight loss of 15.61% over six months. The resident's weight log showed a decrease from 132 pounds to 111.4 pounds, but this was not documented on the MDS. The MDS/Care Plan Coordinator confirmed that such weight losses should be coded, as per the facility's policy.
A resident prone to skin tears was observed without the required protective skin sleeves on two occasions. CNAs admitted they were unaware of the sleeves' location, despite the care plan and physician orders mandating their use at all times. The Care Plan Coordinator confirmed the necessity for the resident to wear the sleeves consistently.
A facility failed to position a resident with dysphagia upright during meals, leading to choking episodes, and did not follow professional standards to prevent an open wound in another resident. The resident with dysphagia was fed while reclined, contrary to care plan instructions, resulting in coughing and choking. Another resident, at risk for pressure ulcers, was found with an open wound during incontinence care, with staff failing to apply barrier cream or notify the RN. These deficiencies indicate a need for improved adherence to care plans and professional standards.
A resident with a Stage III pressure ulcer did not receive adequate care as per professional standards. The facility failed to document pressure ulcer assessments and treatments in the resident's medical record. The Director of Nursing indicated that CNAs applied barrier cream, but the wound was not assessed weekly due to the resident being on hospice. Observations showed the ulcer was still open, and the MDS/CP Coordinator confirmed that hospice orders were not properly transcribed or completed.
A resident with multiple diagnoses, including dementia and muscle weakness, was not properly assessed or assisted after being found crawling on the floor and sliding out of a wheelchair. Despite being at high risk for falls, staff failed to notify a nurse or follow care plan interventions, such as offering ambulation with a walker. The facility's fall prevention policy was not followed, as no assessments or fall huddles were conducted after these incidents.
The facility failed to provide proper catheter and incontinence care for two residents. An LPN did not secure a suprapubic catheter as required and used improper hygiene practices. Two CNAs did not change gloves or perform hand hygiene during incontinence care for a resident on Enhanced Barrier Precautions. These actions violated the facility's infection control policies.
A facility failed to limit as-needed psychotropic medication to 14 days for a resident receiving Lorazepam for anxiety. Despite a pharmacy recommendation for a gradual dose reduction, the physician declined without providing a rationale. The facility's policy requires as-needed psychotropic medications to be limited to 14 days unless extended with documented rationale, which was not followed in this case.
The facility failed to follow infection control standards for handling soiled linens, hand hygiene, and precautions for three residents. An LPN did not wear a gown during catheter care for a resident on Enhanced Barrier Precautions, improperly disposing of soiled linens. An RN did not don a gown for a resident on Contact Isolation, using regular trash for soiled dressings. Two CNAs did not change gloves or perform hand hygiene during incontinence care for a resident, handling clean items with contaminated gloves.
A resident with multiple diagnoses, including dementia and Alzheimer's, did not receive an influenza vaccine as per the facility's policy. The resident's medical record showed the last flu vaccination was over a year ago, and there was no documentation of consent or refusal for a more recent vaccine. The facility's policy requires annual flu vaccinations and proper documentation, which was not adhered to in this instance.
A resident reported that a nurse had forgotten to administer her noon dose of Ativan on several occasions. Facility records showed discrepancies in the administration and documentation of the medication, with missing entries on the Controlled Substance Proof of Use sheet and inconsistencies in the Medication Administration Record (MAR). The facility's Medication Administration policy was not consistently followed, leading to a deficiency in care.
A resident reported that an LPN had forgotten to administer her noon dose of Ativan on several occasions. The facility's records showed multiple instances where doses were not signed out at the correct times, and interviews revealed that the LPN had a history of not signing out narcotic medications. Despite previous education on the issue, the problem persisted, leading to a deficiency in maintaining accurate controlled substance records.
Failure to Arrange Timely Dental Care
Penalty
Summary
The facility failed to provide dental services for one resident, R33, who had an intact cognition score and was covered by Medicaid. R33 reported tooth pain and a cavity for about a year and said he had been asking to have it fixed since the beginning of the year. Physician notes documented complaints of a cavity in the right upper molar area and later in the right lower jaw area, with plans to get a dental appointment, but the record and staff interviews showed the appointment process was not completed in a timely manner. Later, R33 developed acute dental pain with gum swelling, and examination showed broken and carious teeth. He was diagnosed with a periapical abscess without sinus and was ordered clindamycin, acetaminophen as needed, and a dental referral. Staff interviews showed confusion and gaps in responsibility for arranging the appointment: Social Services said she did not make appointments and could not find evidence she had worked on one for R33, the Business Office Manager said she had only recently received a list of residents with appointment problems, and Activities staff described multiple failed attempts to secure and confirm dental appointments, including a canceled appointment because the facility did not confirm it.
Wound Dressing Not Changed Per Orders
Penalty
Summary
The facility failed to ensure that a resident's wound dressing was changed in accordance with physician's orders for R20, a resident admitted with diagnoses including cellulitis of the right lower limb, local infection of the skin and subcutaneous tissue, morbid obesity, prediabetes, and a personal history of MRSA infection. R20's MDS documented a BIMS score of 14, indicating intact cognition. The care plan identified antibiotic therapy for right leg cellulitis and actual impairment to skin integrity of the right posterior lower leg related to cellulitis. The order summary and wound assessment documents directed wound cleansing and dressing changes using specific products, including zinc barrier cream, calcium alginate, and elastic compression wrap, with later wound orders also directing cleansing with Dakins 1/4 strength solution and application of moisturizing cream or ointment to intact skin of the lower leg.
Failure to Obtain Orders for Newly Identified Open Wounds
Penalty
Summary
The facility failed to notify the physician and obtain treatment orders when pressure areas were identified for one resident. The resident had an admission date of 11/11/2024 and diagnoses including early-onset cerebellar ataxia, sepsis, and acute respiratory failure with hypoxia. The resident’s MDS documented a BIMS score of 2, indicating severe cognitive impairment, and the care plan included monitoring, documenting, and reporting changes in skin integrity, including wound appearance, drainage, odor, size, stage, and signs of infection. The physician order sheet documented an order for the right hip only, with an initiation date of 11/6/25, and there were no additional orders for wounds on the right buttock or back. The TAR documented treatment for the right hip on 11/18/25, but no treatment orders for the other open areas. On 11/19/25, surveyors observed a dressing on the right hip and another on the right upper buttocks/back; when removed, both areas were confirmed open, with scant drainage on the right hip bandage and a quarter-sized amount of drainage on the right upper buttocks/back bandage. The RN confirmed both wounds were open and later confirmed there was no new documentation or dressing change orders for the two open areas. The corporate nurse stated that when nursing staff find a new wound, they are expected to measure it and contact the physician for orders by the end of the shift.
Unsafe IV Medication Administration and Central Line Access
Penalty
Summary
The facility failed to administer IV medications safely for a resident with an admission date of 11/7/25 and diagnoses including infection following a procedure, surgical aftercare following genitourinary surgery, peritoneal abscess, and long-term use of antibiotics. The resident’s care plan documented enhanced barrier precautions because of surgical wounds with wound vacuum and/or dressing, secretions or excretions that could not be covered or contained, and IV medications with a PICC line related to wound infection. The order summary documented micafungin sodium 100 mg IV daily for candidiasis and saline flushes for PICC maintenance, along with documentation of a single-lumen PICC in the upper extremity that was later discontinued and a double-lumen line to the right chest. During observation, the resident’s door did not have an enhanced barrier sign and there was no PPE available at the door or in the room. The RN administered micafungin through the double-lumen line in the right chest after cleaning hands and donning gloves, but did not don a gown, did not change gloves while moving between line access steps, and did not pull blood back before administering the medication on either lumen to check patency. The DON later stated the resident should have been on enhanced barrier precautions with gown and gloves for IV medication administration, and that blood return should be obtained before each infusion. The facility policy titled Central Venous Catheter Flushing and Locking also required flushing and aspirating for blood return prior to each infusion.
Medication Left at Bedside Instead of Being Administered Directly
Penalty
Summary
The facility failed to administer medication according to the standards of practice for 1 of 5 residents reviewed for medication administration. The resident involved had an admission record dated 7/28/25 with diagnoses including type 2 diabetes, hypertension, hypothyroidism, atrial fibrillation, weakness, chronic kidney disease, and depression. The resident’s MDS documented a BIMS score of 14, indicating cognition was intact. The MAR for 11/1/25-11/30/25 showed the resident received multiple morning medications, including absorbic acid, levothyroxine, metoprolol succinate, modafinil, multivitamin, omeprazole, potassium chloride, sertraline, colace, eliquis, tylenol, and meclizine on 11/17/25. On 11/17/25 at 10:39 AM, a cup of pills was observed sitting on the bedside table beside the resident’s bed, and the resident stated the nurse did not wake him to tell him the medication was there, so he did not know how long it had been sitting there. The LPN stated she does not usually wake the resident if he is sleeping when she brings medication and will leave the cup of pills on the bedside table. She also stated she usually tries to return to check whether the resident took the pills, but on this occasion she documented giving the morning medication at 9:09 AM and did not return to the room until 11:21 AM, when the pills were gone. The DON stated that if a resident is sleeping when the nurse goes to give medication, the resident should be woken up and the medication given directly rather than left on the bedside table. The facility policy stated medications are to be administered in a safe and timely manner and, for residents not in their rooms or otherwise unavailable, the MAR may be flagged and the nurse will return after the medication pass to administer the missed medication.
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to post enhanced barrier precaution signage and provide PPE for a resident on enhanced barrier precautions, and failed to follow proper infection control practices during resident care for two residents. One resident had diagnoses including early-onset cerebellar ataxia, sepsis, and acute respiratory failure with hypoxia, and was severely cognitively impaired with a BIMS of 2. The resident’s care plan and physician orders documented enhanced barrier precautions, and PPE was stored just inside the room door, but during observed wound care neither the RN nor the LPN donned a gown. During an observed feeding tube flush, neither nurse wore a gown, one nurse performed hand hygiene and applied gloves while the other did not, and later the RN stated a gown should be worn when providing care for a resident on enhanced barrier precautions. A second resident had diagnoses including chronic kidney disease, hypertension, and pseudomonas, and was cognitively intact with a BIMS of 15. The care plan documented enhanced barrier precautions, but there was no physician order for them. On observation, the resident’s door had no enhanced barrier sign and no PPE was available at the door or in the room. During IV micafungin administration through a double lumen midline, the RN cleaned hands, donned gloves, mixed and hung the medication, programmed the pump, and then handled the catheter lumens and flushed them without changing gloves or donning a gown; blood was not pulled back before flushing either lumen. The DON stated the RN should be on enhanced barrier precautions due to the central line and that a gown and gloves should be worn when administering IV medication.
Failure to Update Care Plan and Implement New Fall Prevention Interventions
Penalty
Summary
The facility failed to develop and implement new interventions to prevent falls for a resident with severe cognitive impairment and a history of falls. The resident, who was dependent on staff for all transfers and toileting and required assistance with showers, experienced multiple falls, including unwitnessed incidents resulting in bruises and skin tears. Despite these occurrences, the resident's care plan was not updated to include new or revised interventions following each fall event. Progress notes documented several fall incidents, but the care plan did not reflect any newly implemented strategies to address these repeated events. The facility's own policy required staff to identify and implement additional or different interventions if falls recurred, but this was not done. Interviews confirmed that falls should have been addressed in the care plan and that new interventions should have been developed, but these actions were not taken.
Failure to Maintain Sufficient Nursing Staff for Timely Resident Care
Penalty
Summary
The facility failed to maintain sufficient nursing staff to meet the needs of all residents in a timely manner, as evidenced by multiple interviews and record reviews. The census at the time was 37 residents, with several requiring substantial or maximal assistance for activities of daily living (ADLs), including toileting and incontinence care. One resident with significant medical conditions, including respiratory failure, heart failure, and morbid obesity, reported waiting up to 45 minutes for assistance after activating the call light, particularly during evening and overnight shifts. This resident also stated that CNA hours had been reduced on his unit, leading to frequent delays in receiving help, especially when left on the toilet. Staff interviews corroborated these delays, with CNAs and LPNs reporting that call lights often went unanswered for extended periods due to insufficient staffing. Staff described situations where only one CNA was available per unit or for the entire building, making it difficult to provide timely care, especially for residents requiring two-person assistance. Staff also reported that when short-staffed, essential care such as toileting, incontinence care, showers, and vital signs were delayed. The ombudsman and other residents confirmed ongoing concerns about untimely responses to call lights, particularly during evening and night shifts. Administrative staff acknowledged awareness of staffing shortages but indicated that efforts to fill shifts were sometimes unsuccessful, and administrative personnel did not always come in to assist when notified of shortages. The facility's own policy requires sufficient licensed and unlicensed nursing staff on each shift to meet residents' needs, but interviews and documentation revealed that this standard was not consistently met. The deficiency affected the ability to provide timely and adequate care to all residents, as reported by both staff and residents.
Failure to Provide Bedtime Snacks in Accordance with Resident Needs and Facility Policy
Penalty
Summary
The facility failed to ensure that residents were provided with a bedtime snack in accordance with their needs, preferences, and requests. Interviews with residents and staff revealed that snacks, which were supposed to be served at bedtime, were instead being distributed with the evening meal at 4:30 PM. Many residents consumed these snacks with their supper, leaving them without food options until breakfast the next morning. Staff reported that the kitchen was locked after supper, and they did not have access to additional snacks to offer residents later in the evening or at night. Multiple staff members, including CNAs and LPNs, stated that the reduction in snack availability was due to budget cuts following a change in facility ownership. Staff also indicated that they sometimes purchased snacks with their own money to provide for residents, as the facility no longer stocked the kitchenette or linen closet with adequate snack options. Observations by the surveyor confirmed that the areas designated for snacks were inadequately stocked, with only minimal items such as a can of peanut butter, a box of oatmeal, and a few pudding cups available, and no bread or other items to make sandwiches. Residents affected by this deficiency included individuals with significant medical histories, such as diabetes, heart failure, and chronic respiratory conditions, who may have specific dietary needs. Despite the facility's policy requiring an evening snack to be offered and documented for each resident, the practice of serving snacks with supper and the lack of accessible snacks throughout the night did not meet the stated policy or regulatory requirements. Staff interviews and direct observation confirmed that the deficiency was facility-wide and had the potential to affect all 37 residents.
Delayed Call Light Response Due to Insufficient Staffing
Penalty
Summary
The facility failed to ensure that call lights were answered in a timely manner for two residents who required assistance with activities of daily living, specifically toileting. One resident, who was cognitively intact and required substantial to maximal assistance for toileting due to multiple medical conditions including respiratory failure, heart failure, and morbid obesity, reported waiting up to 45 minutes for assistance after activating the call light in the early morning hours. This resident stated that delays were most pronounced during evening and overnight shifts and that he was frequently left on the toilet for extended periods. Staff interviews confirmed that call lights were not always answered promptly, particularly during shift changes or when staffing levels were low, with one CNA noting that the average response time could be fifteen minutes or longer depending on circumstances. Another resident, also cognitively intact and requiring supervision or assistance for toilet hygiene, reported rarely using the call light and instead seeking staff directly for help. However, when the call light was used, the resident stated it was generally answered in a timely manner. Despite this, the facility's ombudsman and multiple CNAs corroborated ongoing concerns about delayed call light responses, especially during times of reduced staffing. Resident Council meeting minutes further documented repeated complaints about untimely call light responses over several months. Staff interviews consistently indicated that insufficient staffing contributed to delays in responding to residents' needs, particularly for toileting and other personal care tasks. Several CNAs and nurses acknowledged that they were unable to meet residents' needs promptly, especially when only one CNA was available per unit or during busy periods. The facility's policy required immediate response to call lights, but this standard was not consistently met, as evidenced by both resident and staff reports as well as facility documentation.
Inconsistent Shower Provision for Residents Requiring Assistance
Penalty
Summary
The facility failed to ensure that residents requiring assistance received showers as scheduled, affecting three residents (R2, R3, and R5) out of a sample of 21. R2, who has severe cognitive impairment and is dependent on assistance for bathing, did not receive showers consistently according to the facility's schedule. The documentation showed gaps in shower provision, with no records of refusals or additional showers beyond those documented. Similarly, R3, also with severe cognitive impairment and dependent on assistance, experienced inconsistencies in receiving scheduled showers, with records indicating bed baths instead of showers on some occasions. R5, who is cognitively intact but requires partial assistance for bathing, reported receiving fewer showers than previously scheduled. The resident expressed a preference for two showers per week, which was not consistently provided. The care plan for R5 lacked specific details on the level of assistance required and the frequency of showers, contributing to the inconsistency in care. Interviews with CNAs revealed challenges in adhering to the shower schedule due to staffing issues, resulting in missed showers that were not always rescheduled. The facility's policy mandates at least weekly showers for all residents, but the lack of complete documentation and adherence to the schedule suggests a failure to meet this standard. The administrator and regional nurse acknowledged the absence of shower sheets for the affected residents, indicating that showers may not have been completed as required. This deficiency highlights a gap in the facility's ability to provide consistent and adequate hygiene care for its residents.
Facility Maintenance and Housekeeping Deficiencies
Penalty
Summary
The facility failed to maintain resident rooms and equipment in a state of good repair, affecting five residents. Observations revealed issues such as leaking toilets, missing tiles, and unsecured fixtures. For instance, one resident's bathroom had a leaking and crooked toilet with tiles fallen from the wall, while another resident's toilet was not secure to the floor and could be easily moved. Additionally, some rooms had window sills with dust, dirt, debris, and cobwebs. Residents reported being aware of these issues, with some expressing frustration over the inconvenience caused by non-functional bathrooms. Two residents had been unable to use their bathroom for several months, requiring them to use a shared bathroom down the hall, which sometimes resulted in waiting times. Staff interviews indicated that the maintenance man responsible for repairs had quit, leaving some repairs incomplete, and that he had been using his own money for parts due to a lack of budget. The Director of Nursing and other staff members were not fully aware of the extent of the issues, with some only learning about them during the survey. The facility's policy emphasizes the importance of maintaining a safe and clean environment, but the lack of routine maintenance and housekeeping staff shortages contributed to the deficiencies. The maintenance assistant was unaware of work orders for some repairs, and the housekeeping staff was understaffed, further exacerbating the situation.
Unsafe Water Temperatures in Facility
Penalty
Summary
The facility failed to maintain safe water temperatures for 14 residents, as observed during a survey. The water temperatures in various locations within the facility were recorded using a calibrated digital metal stemmed thermometer. The temperatures ranged from 116 to 122.5 degrees Fahrenheit, exceeding the facility's policy of maintaining water temperatures between 100 and 110 degrees Fahrenheit. The Director of Nursing (DON) and the Maintenance Assistance/Therapy Assistant were involved in monitoring the water temperatures, but discrepancies were noted between their recorded temperatures and those observed during the survey. Several residents, including those who were cognitively impaired and ambulatory, were affected by the high water temperatures. One resident reported that the water was too hot but had not been burned. Another resident mentioned that a bathroom had been closed for several months, causing inconvenience. The DON acknowledged that a wandering cognitively impaired resident could have accessed the shower rooms or bathrooms, potentially leading to safety concerns. The facility had experienced maintenance issues, including a hole in the pipe leading to the hot water heater, which was believed to cause the water heater to overheat. The facility's maintenance staff had been reduced, with the Maintenance Assistance/Therapy Assistant temporarily filling in. The DON and the Maintenance Assistance/Therapy Assistant were aware of the water temperature policy but failed to ensure compliance, resulting in unsafe conditions for the residents.
Failure to Provide Nutritional Supplementation
Penalty
Summary
The facility failed to provide nutritional supplementation as recommended for three residents, leading to significant weight loss for one of them. Resident R3, who had multiple medical conditions including acute kidney failure and diabetes, experienced a 21.8% weight loss over four months. Despite recommendations from the Registered Dietician (RD) for additional protein due to weight loss and skin breakdown, R3 did not receive the extra protein with meals. The dietary manager and staff were unaware of the need for extra protein, and R3's dietary card did not reflect this requirement. Additionally, R3 expressed dissatisfaction with the food quality and reported that some meals were not suitable for his dietary needs. Resident R15, who has severe cognitive impairment and is on hospice care, did not receive the prescribed nutritional supplement at lunch on two consecutive days. The dietary aide admitted to forgetting to serve the supplements due to being nervous and overwhelmed. The dietary manager acknowledged the oversight and stated that R15 often does not consume the supplement, but no corrective action was documented to ensure future compliance with dietary orders. Resident R4, who is on a regular diet with pureed texture and pudding thick liquids, did not receive the high calorie/high protein supplement as ordered during lunch. The CNA and cook were unaware that R4 was supposed to receive the supplement twice a day. The RD confirmed the order for BID supplementation due to R4's history of weight loss, but the facility failed to consistently provide the necessary nutritional support.
Deficiency in Nursing Leadership and Coverage
Penalty
Summary
The facility failed to maintain a full-time Director of Nursing (DON) and ensure Registered Nurse (RN) coverage for 8 consecutive hours a day, seven days a week, potentially affecting all 33 residents. Observations and interviews revealed that the DON was working as a floor nurse, passing medications, and not performing DON duties for the past two months due to staffing shortages. The DON reported working 12-hour shifts, three days a week on the floor, and had recently resigned from the position due to the inability to fulfill DON responsibilities. The facility's assessment indicated the need for a full-time DON and additional RNs if the DON had other responsibilities, which was not adhered to. Further investigation showed that on multiple occasions, the DON and the Assistant Director of Nursing (ADON) were working as floor nurses instead of fulfilling their administrative roles. The facility's schedule for June 2024 documented several days without any RN hours worked, confirming the lack of adequate RN coverage. The administrator acknowledged the staffing issues and the DON's floor duties, which contributed to the deficiency in meeting regulatory requirements for nursing coverage and leadership.
Food Storage and Handling Deficiencies
Penalty
Summary
The facility failed to store and serve food in a safe and sanitary manner, which has the potential to affect all 33 residents residing at the facility. During an initial tour of the kitchen, surveyors observed several opened food items, including containers of thickened juice, bags of cereal, dried milk, liquid eggs, and lunchmeat ham, all without dates on them. Additionally, scoops were found inside the sugar bin and coffee container, laying directly on top of the contents. During lunch service, a dietary staff member was observed touching various surfaces and then transferring residents' drinks by the rim, which is against professional standards. The Dietary Manager acknowledged that opened items in the kitchen should be dated, and scoops should not be left in bins or containers. The manager also confirmed that staff should not transfer glasses by the rims but rather by the middle or bottom of the glass.
Inaccessible Call System in Bathrooms and Shower Rooms
Penalty
Summary
The facility failed to provide an accessible call system for residents in the shower room and community bathroom, affecting all 33 residents. Observations on multiple occasions revealed that the hall bathrooms and shower rooms on E-Hall, D-Hall, and A-Hall had call light boxes on the wall, but no pull cords were attached to the toggle switches. This made the call lights near the toilets inaccessible from the toilet or the floor. Additionally, the shower stalls in these areas did not contain any call system. Interviews with staff members indicated a lack of awareness and policy regarding the call light systems. The maintenance staff acknowledged the absence of pull cords and expressed uncertainty about the duration of this issue. The administrator also confirmed the lack of accessible call lights and stated that there was no existing policy on call light systems. The deficiency was identified through observations, interviews, and record reviews, highlighting a significant oversight in ensuring resident safety and accessibility.
Deficiency in Room Size Requirements
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet per resident bed in multiple occupancy rooms, affecting four residents in the sample of 27. Observations and measurements conducted on August 1, 2024, revealed that the rooms occupied by these residents were certified for double occupancy but did not meet the required space per resident. Specifically, the rooms measured between 71.31 and 74.48 square feet per resident bed, which is below the mandated 80 square feet. The rooms contained various furniture and equipment, such as beds, bedside tables, dressers, and medical supplies, which further limited the available space for residents to move around. During the survey, the Administrator acknowledged that several rooms in the facility did not meet the required space per resident bed and confirmed that residents were not informed of this during admission. Although the facility's Daily Midnight Census sheet indicated that none of the rooms currently had more than one resident, the Administrator noted that this could change at any time. Despite the space limitations, observations and measurements during the survey determined that adequate space exists to meet the medical and personal needs of the residents living in these waivered rooms. Additionally, Resident Council Minutes from the past six months showed no concerns related to the size of the rooms included in the waiver.
Failure to Promote Resident Dignity and Independence
Penalty
Summary
The facility failed to promote resident independence and dignity by not explaining a task prior to beginning care and not allowing the resident time to perform the task independently. This incident involved a resident with moderate cognitive impairments who reported that a CNA was rough during care, pushing the resident over hard and fast without explanation. The resident expressed distress, yelling out during the incident, which was overheard by another resident across the hall. The resident felt rushed and manhandled, indicating a lack of communication and respect for the resident's ability to assist in their own care. Further investigation revealed that the CNA involved did not pause to allow the resident to voice concerns and continued with the task despite the resident's request for more time to assist. The facility's administrator confirmed that the CNA admitted to being rough and not explaining the care process to the resident. Although the facility did not classify the incident as abuse, it was acknowledged as poor customer service, highlighting a deficiency in promoting resident rights to dignity and self-determination.
Failure to Honor Resident's Sleeping Preferences
Penalty
Summary
The facility failed to honor a resident's preferences regarding their sleeping and waking schedule, which is a violation of the resident's right to self-determination. The resident, identified as R16, expressed dissatisfaction with being woken up too early, sometimes as early as 4:30 AM, and being taken to the dining room where they would sit with nothing to do until breakfast was served around 8:00 AM. This routine was not in alignment with R16's preference to sleep longer, as stated by the resident during interviews. Multiple staff members, including a Licensed Practical Nurse (LPN), dietary staff, and Certified Nurse Aides (CNAs), confirmed that R16 was typically in the dining room by the time they arrived for their shifts at 6:00 AM. The facility administrator acknowledged that residents should be able to get up at their preferred times, but was unsure if there was a specific policy in place to support this. The report highlights a lack of adherence to resident choice, as R16's expressed preferences were not being respected, leading to the identified deficiency.
Failure to Accurately Code MDS for Significant Weight Loss
Penalty
Summary
The facility failed to accurately code a Minimum Data Set (MDS) Assessment for one resident, identified as R4, out of 12 residents reviewed for assessment accuracy in a sample of 27. R4's weight log documented a significant weight loss from 132 pounds on December 21, 2023, to 111.4 pounds on June 1, 2024, which calculates to a 15.61% weight loss over six months. However, this significant weight loss was not documented on R4's MDS dated [DATE]. On July 31, 2024, the MDS/Care Plan Coordinator, identified as V13, confirmed that significant weight losses should be coded on the MDS. The facility's Comprehensive Assessment/MDS Policy, dated November 1, 2017, states that the facility should ensure MDS accuracy and follow the RAI Manual instructions for amending assessments if inaccuracies are found.
Failure to Follow Physician Orders for Skin Protection
Penalty
Summary
The facility failed to adhere to physician orders for a resident identified as R6, who was prone to skin tears and required protective skin sleeves at all times. Observations on two consecutive days revealed that R6 was seated in a reclining wheeled chair without the prescribed protective skin sleeves. Interviews with Certified Nursing Assistants (CNAs) V15 and V16 confirmed that R6 was supposed to wear the sleeves at all times, but they were not in place because the CNAs did not know their location. The resident's care plan, last updated a few days prior, also documented the necessity for arm sleeve protectors to be worn at all times. This was further corroborated by V13, the Minimum Data Set/Care Plan Coordinator, who confirmed the requirement for R6 to wear the arm sleeve protectors consistently.
Failure to Follow Care Plans and Professional Standards
Penalty
Summary
The facility failed to position a resident with dysphagia in an upright position during meals, as per the physician's orders and care plan, which led to choking episodes. The resident, who requires a pureed diet with pudding thick liquids and staff assistance for feeding, was observed being fed while reclined in a wheelchair at angles of approximately 60 and 45 degrees on two separate occasions. During these meals, the resident experienced coughing and choking, with one instance resulting in the resident's face turning red. Staff members confirmed that the resident was not positioned correctly, and the care plan's instructions for feeding were not followed. Additionally, the facility did not adhere to professional standards to prevent the development of an open wound for another resident. This resident, who is at moderate risk for pressure ulcers and has a history of skin impairments, was found with an open and bleeding area on the right buttock during incontinence care. The Certified Nursing Assistants providing care did not dry the resident after cleaning, failed to apply barrier cream, and did not change gloves before placing a new incontinent brief. The Registered Nurse was not informed of the open wound, and the treatment plan was not adjusted despite the wound being open and bleeding. These deficiencies highlight a lack of adherence to prescribed care plans and professional standards, resulting in potential harm to residents. The failure to follow swallowing precautions and proper skin care protocols demonstrates a need for improved staff training and communication to ensure resident safety and well-being.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary services consistent with professional standards of practice to prevent the worsening of pressure ulcers for a resident identified as R4. R4 had a Stage III pressure ulcer on the lower right buttock, as documented in the facility's Quality Assurance Weekly Skin Eval Documentation List. Despite being at high risk for pressure ulcers, R4's medical record did not contain any pressure ulcer assessments, and the care plan was not adequately followed. The Director of Nursing stated that the resident's treatment consisted only of a barrier cream applied by CNAs, and the wound was not being assessed or measured weekly because the resident was on hospice care. Observations revealed that the pressure ulcer was still open, and the facility's records, including the Treatment Administration Record and Physician Order Sheets for June and July 2024, did not document any pressure ulcer treatment orders. The MDS/CP Coordinator confirmed that the hospice order was not transcribed or signed out as completed, and emphasized that nurses should be responsible for completing treatments and assessing the wound. The facility's policy required proper treatment and documentation of pressure areas, which was not adhered to in this case.
Failure to Assess and Implement Fall Interventions for High-Risk Resident
Penalty
Summary
The facility failed to adequately assess and implement interventions for a resident, identified as R28, who was at high risk for falls. R28, who has multiple diagnoses including unspecified dementia, vascular dementia, and muscle weakness, was observed crawling on the floor and sliding out of his wheelchair on multiple occasions. Despite these incidents, nursing staff did not assess R28 after these events, nor did they implement the interventions outlined in his care plan, such as offering ambulation with a walker and staff assistance. On one occasion, R28 was found crawling on the floor with a pillow, and a CNA attempted to assist him back into his wheelchair without notifying a nurse or conducting an assessment. The personal alarm intended to alert staff was not functioning properly, as it was found disconnected and lying in R28's bed. Staff members were aware of R28's behavior of crawling on the floor but did not consistently follow the protocol of notifying a nurse or treating the situation as a fall if it was unwitnessed. Additionally, R28 was observed in the dining room attempting to slide out of his wheelchair without any staff present to assist him. When alerted, staff members helped R28 back into his wheelchair but again failed to assess him or offer ambulation assistance as per his care plan. The facility's policy on fall prevention was not adhered to, as staff did not conduct fall huddles or assess the resident immediately after these incidents, which are critical steps in minimizing injuries related to falls.
Deficiencies in Catheter and Incontinence Care
Penalty
Summary
The facility failed to provide appropriate catheter care for a resident with a suprapubic catheter, as observed during a survey. The resident's care plan required the catheter to be secured to prevent tension, but it was not secured during the observation. The LPN providing care used an unclean over bed table, did not follow proper hand hygiene, and used personal scissors from their pocket to cut tape for the dressing. The LPN also failed to clean the catheter insertion site correctly, using the same washcloth area multiple times, which could lead to cross-contamination. Another deficiency was noted in the care of a resident requiring incontinence care. Two CNAs failed to change gloves or perform hand hygiene after cleaning the resident, who had a history of ESBL in urine and was on Enhanced Barrier Precautions. The CNAs did not dry the resident's skin after washing, and they handled clean items with contaminated gloves. This improper practice was against the facility's policy, which requires changing gloves and washing hands when moving from contaminated to clean tasks. The facility's policies on perineal cleansing and infection control were not followed, as evidenced by the actions of the staff. The policies require thorough drying of the skin, changing gloves, and performing hand hygiene after resident contact. The failure to adhere to these procedures was confirmed by the staff involved, who acknowledged the need for proper glove changing and hand hygiene during incontinence care.
Failure to Limit As-Needed Psychotropic Medication to 14 Days
Penalty
Summary
The facility failed to ensure that as-needed psychotropic medications were limited to 14 days for a resident reviewed for unnecessary medications. The resident, identified as R4, was receiving Lorazepam, a benzodiazepine, at a dosage of 0.5 mg twice a day and 1 mg every four hours as needed for anxiety. A pharmacy consultation report dated January 10, 2024, recommended assessing the resident's medication dosage and considering a gradual dose reduction if clinically appropriate. However, on February 14, 2024, the physician declined this recommendation without documenting a resident-specific rationale for not attempting a gradual dose reduction. The facility's policy states that as-needed psychotropic medications should not be given for an excessive duration and are limited to 14 days unless a physician documents a rationale for extending the use. Despite this policy, the resident's July 2024 Physician Order Sheet documented an order for Lorazepam as needed for anxiety, which should have been discontinued after 14 days. The Minimum Data Set/Care Plan Coordinator confirmed that the as-needed Lorazepam should have been discontinued after 14 days, indicating a failure to adhere to the facility's policy on the duration of psychotropic medication use.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to adhere to infection control standards and practices, particularly in the handling of soiled linens, hand hygiene, Enhanced Barrier Precautions (EBP), and Contact Isolation Precautions. This deficiency was observed in the care of three residents. For Resident 6, who had a suprapubic catheter and was on EBP, a Licensed Practical Nurse (LPN) failed to wear a gown while providing catheter care, despite signage indicating the need for gloves and a gown. The LPN also improperly disposed of soiled washcloths by throwing them on the floor, and later picked them up with bare hands, indicating a lack of adherence to proper infection control protocols. Resident 13, who was on Contact Isolation Precautions due to a positive ESBL of a left foot wound, received wound care from a Registered Nurse (RN) who did not don a gown before entering the room, despite the presence of EBP signage and available PPE. The RN placed soiled dressings in a regular trash can instead of a designated red barrel for isolation waste, demonstrating a failure to follow proper disposal procedures for infectious materials. For Resident 32, who was on EBP due to a gastrostomy tube and risk of pressure ulcers, two Certified Nurse Assistants (CNAs) failed to change gloves or perform hand hygiene during incontinence care. They continued to handle clean items and the resident's gown with contaminated gloves, which is against the facility's infection control policy. These actions reflect a significant lapse in maintaining hygiene standards and preventing cross-contamination during resident care.
Failure to Administer Influenza Vaccine
Penalty
Summary
The facility failed to adhere to its Influenza Immunization Policy by not offering or providing an influenza vaccine to one of the residents reviewed for immunizations. The resident, identified as R21, had a care plan documenting an admission date and diagnoses including frontotemporal neurocognitive disorder, dementia, Alzheimer's disease, major depressive disorder, anxiety disorder, and muscle weakness. The resident's physician order sheet included an active order dated 11/27/23 for an annual flu vaccine with consent unless contraindicated. However, the resident's current medical record only documented an influenza vaccination date of 10/20/22, with no further information on subsequent vaccinations or refusals. During the survey, the facility's administrator, V1, provided a list of current immunizations for all residents, which confirmed that R21's most recent influenza vaccination was on 10/20/22. A registered nurse, V22, was unable to find additional information regarding R21's influenza vaccination or any documentation of refusal or consent. The facility's policy requires obtaining permission or consent for the vaccine and offering the influenza immunization annually from September 1st through March 31st. The policy also mandates documentation of the immunization on the resident's medication administration record and immunization record, which was not followed in this case.
Failure to Administer and Document Anti-Anxiety Medication
Penalty
Summary
The facility failed to follow physician's orders to administer anti-anxiety medication as prescribed for one resident (R4). R4, who has a history of cerebral infarction, Alzheimer's disease, and other significant health conditions, reported that a male nurse (V7) had forgotten to give her the noon dose of Ativan on several occasions. R4 mentioned this issue to an outside provider, which led to a call to the facility's administration. The facility's records showed discrepancies in the administration and documentation of the medication, with missing entries on the Controlled Substance Proof of Use sheet and inconsistencies in the Medication Administration Record (MAR). On one occasion, the Director of Nursing (V2) admitted to possibly forgetting to administer the morning dose of Ativan to R4 before she left for an outside appointment. Another nurse (V8) reported that when she took over the shift from V7, the documentation was in disarray, and she mistakenly signed off on the MAR for the 8:00 PM dose of Ativan, believing it had already been administered by V7. V8 did not verify this against the controlled substance proof of use sheet, leading to further discrepancies. The facility's Medication Administration policy requires that any medication not administered be documented with the reason for omission, but this was not consistently followed. The failure to properly administer and document the anti-anxiety medication as ordered resulted in a deficiency in the care provided to R4, as evidenced by the inconsistencies and omissions in the medication records and the resident's own reports of missed doses.
Failure to Maintain Accurate Controlled Substance Records
Penalty
Summary
The facility failed to ensure that drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled for one resident. The resident, who was admitted with multiple diagnoses including Alzheimer's disease, anxiety, and depression, reported that a male nurse, V7, had forgotten to give her noon medication, Ativan, on several occasions. The resident expressed concerns that the medication was not in her medication cup as claimed by V7, leading to doubts about whether she received her prescribed doses. This issue was brought to the attention of the facility's administration by an outside provider after the resident reported the missed doses during a visit. The Medication Administration Record and Controlled Substance Proof of Use sheets for the resident documented several instances where doses of Ativan were not signed out at the correct times. Specifically, doses on 02/20/24, 02/21/24, 03/19/24, and 03/23/24 were not signed out until later dates, indicating a failure to maintain accurate records. Despite the facility's policy requiring narcotic counts at the beginning and end of each shift, the records showed that these counts were not consistently performed or documented correctly. Interviews with the Director of Nursing and several LPNs revealed that V7 had a history of not signing out narcotic medications and that this issue had been previously addressed with him. However, the problem persisted, with other nurses often correcting the records later. The facility's Controlled Substance Policy mandates immediate reporting of discrepancies to the Director of Nursing, but the ongoing issues with V7's record-keeping were not adequately resolved, leading to the deficiency noted in the report.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 74 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Vandalia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fayette County Hospital | 1.1 mi | ★★★★★ | 6 | 0 |
| The Haven Of St. Elmo | 15 mi | ★★★★★ | 8 | 0 |
| Greenville Nursing & Rehab | 17 mi | ★★★★★ | 2 | 0 |
| Lutheran Care Center | 20.3 mi | ★★★★★ | 7 | 1 |
| Montgomery Nursing & Rehab Ctr | 22.2 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.