Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Momentous Health At Vandalia during CMS and state inspections, most recent first.
Unsafe and Poorly Maintained Resident Rooms: Multiple residents were found in rooms with strong urine odors, and staff confirmed the odors were linked to roommates who were noncompliant with care. One resident with COPD, OCD, and DM II was observed forcing a sticking room door open with her shoulder and later had a clavicle fracture documented after using the door this way. Other residents had doors that were hard to open or broken, and one resident’s window was broken and covered with wood; staff and the Administrator confirmed these conditions.
A resident with pica and impaired cognition repeatedly swallowed batteries, a screw, and other foreign objects after accessing items from the nurse’s desk, a pulse oximetry machine, a thermometer, and a TV remote, and the DON confirmed the care plan was not updated with new interventions and the incidents were not recorded on the incident log. The secured unit was also observed with an unlocked and unalarmed exterior door, broken courtyard gate and keypad, broken concrete and scattered debris, cigarette butts throughout the smoking area, no fire blanket or extinguisher, and doors/windows that led directly to an unsecured courtyard without functioning alarms.
Failure to assess and monitor bed rails: A cognitively impaired resident with multiple diagnoses, including seizures and hospice care, had half bed rails on the bed despite records showing no side rails were in use and no orders to assess or monitor them. Staff observed the resident flailing in bed and hitting her head on the rails, with bruising noted to the forehead and scalp. The DON documented the bruising appeared consistent with the resident striking her forehead on the side rails, and staff reported the rails were wrapped with kerlix as a temporary measure.
A facility failed to ensure provider progress notes and orders were completed and signed at the time of required visits. One resident with COPD, OCD, type II DM, and severe cognitive impairment had a provider visit for a right shoulder hematoma, but the NP had not completed the note when interviewed, and the note was signed later.
Infection Control Lapse During Incontinence Care: A resident with severe cognitive impairment, COPD, OCD, and type II DM was frequently incontinent of bowel and bladder and required substantial assistance with toileting and bathing. During incontinence care, a CNA did not change gloves and touched the resident, clean depends, and sheets with soiled gloves, contrary to the facility's peri care policy requiring glove removal and hand hygiene during care.
Unsafe and Unsanitary Environment with Pest Issues: The facility failed to maintain a safe, clean, comfortable, and sanitary environment for residents, staff, and the public. An LPN observed alive and dead flies in the room of two residents, including one with severe cognitive impairment and one with intact cognition, and other areas on the East Unit had ceiling lights with copious amounts of dead bugs. An LPN confirmed the conditions, and one LPN stated the dead bugs had also been present during the recent annual survey.
The facility failed to ensure an RN was on duty for at least 8 consecutive hours per day, 7 days per week. Record review showed there was no RN coverage on one day, and the COO confirmed the RN was not on duty in the facility. The staffing policy stated the facility should maintain adequate staffing on each shift to meet residents' needs and services.
Surveyors found that a resident with pica and significant psychiatric diagnoses repeatedly ingested foreign objects, including a thumb tack and multiple batteries, requiring EMS transport and hospital care, while the facility delayed care planning and did not complete incident investigations to identify causes or preventive measures. Another cognitively impaired resident at risk for falls lacked care-planned and ordered fall-prevention measures, such as floor mats by the bed and Dycem on the wheelchair, during multiple observations confirmed by staff. In addition, an unlocked janitor’s closet on a resident hall contained concentrated sanitizing chemicals with corrosive warnings, and staff, including the Administrator, acknowledged the closet should have been locked, especially given cognitively impaired, independently mobile residents on that hall.
Surveyors found that the facility did not maintain two residents’ rooms in good repair, contrary to its homelike environment policy. One resident’s room had multiple small holes in the wall and a bathroom door with scratches and chipped paint, which the resident disliked and a maintenance assistant acknowledged should have been repaired. Another resident’s bedroom door was cracked, difficult to shut, and could not fully close because it caught on the frame; the resident expressed concern about the door’s condition, and a maintenance assistant confirmed the door needed hinge adjustment and had visible cracks.
A cognitively intact resident with osteoarthritis and other comorbidities had a physician’s order for PRN Voltaren gel to the right shoulder for pain, but the MAR showed no administrations over multiple days. The resident reported requesting the PRN medication on several occasions and being told by nurses that it was not available. An LPN confirmed the resident had an active order, had requested the medication, and that the Voltaren gel was out of stock, resulting in the resident not receiving the ordered pain management.
Inaccurate advance directive documentation was found for four residents. Records showed mismatches between physician code status orders, care plans, face sheets, and hard-chart documents, including DNRCC orders that were not reflected consistently and full-code listings that conflicted with DNRCC documentation. Staff confirmed several of these discrepancies during interview, and facility policy required advance directives to be reviewed and documented on designated forms and assessments.
Failure to develop comprehensive care plans for identified resident needs. A resident with pain needs had a care plan that did not include pain management interventions despite frequent PRN use for shoulder pain. Another resident with cognitive impairment had no activities care plan, and a third resident with pica had repeated foreign-object ingestions before a behavioral care plan was developed. The COO confirmed the missing care plans.
The facility failed to update a resident’s care plan after the resident no longer had a Foley catheter. The resident’s MDS showed no indwelling catheter and occasional urinary incontinence, but the care plan still listed Foley catheter care. An RN confirmed the catheter had been removed and the care plan had not been revised to match the resident’s current status.
A resident with CHF, COPD, and respiratory failure was observed on continuous O2 via nasal cannula at 3 LPM even though the MAR had no O2 order. An LPN confirmed the resident used continuous O2, did not know the ordered flow rate, and said staff typically set all residents’ O2 at 3 LPM unless otherwise ordered.
The facility failed to maintain an adequate food supply for scheduled meals and emergencies, affecting all 99 residents. Observations showed limited food stocks and no emergency supply. Staff confirmed meals were served as scheduled but with no leftovers. The facility's emergency plan requires a seven-day food supply, which was not met. The administrator was unaware of the issue, and the dietary supervisor noted that weekly orders barely sufficed.
The facility failed to securely store medications, affecting residents, especially those cognitively impaired. Medications were left unsupervised on carts, and refrigerated medications were improperly stored due to lack of temperature monitoring.
The facility failed to maintain a safe and homelike environment in the Northeast Unit, affecting 21 residents. Observations revealed structural issues with the roof, including missing wood and sagging shingles, and temporary measures like a blue tarp. The dining area had exposed electrical outlets and a ceiling light without covers. The corridor had a wall section covered with plastic and exposed plaster. The Maintenance Director confirmed these issues, citing a previous water heater leak and difficulties in securing repair services.
A facility failed to maintain an adequate supply of paper towels and toilet paper in a resident's bathroom, affecting a resident with multiple diagnoses who required assistance with toileting. Housekeeping staff and the resident confirmed frequent shortages due to insufficient ordering, and management acknowledged the absence of a related policy.
The facility failed to maintain a licensed nursing home administrator (LNHA) with a valid license, affecting all residents. Administrator #1's license expired, and Administrator #2 temporarily took over until the license was renewed. This deficiency was identified through a review of the BELTSS system and staff interviews.
The facility failed to ensure that shower rooms were clean and ceilings were maintained, affecting 60 residents. Observations revealed mold and mildew in the [NAME] and Northeast shower rooms, confirmed by various staff members. The deficiency was investigated under Complaint Number OH00153585.
A cognitively impaired resident with a history of wandering eloped from the facility due to inadequate supervision and interventions. The resident was found by police approximately 0.3 miles away and returned without injuries. The facility's elopement policy was not effectively implemented, leading to the incident.
Unsafe and Poorly Maintained Resident Rooms
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for seven reviewed residents. Multiple resident rooms had strong pervasive urine odors, and staff confirmed that the odors were related to roommates who were noncompliant with care and refused to be changed after being soiled. Resident #36, who had diagnoses including bipolar disorder, anxiety disorder, and schizoaffective disorder and was cognitively intact with a BIMS score of 15, reported that the constant smell of urine in the room was caused by the roommate. CNA #67 also verified the strong urine odor in the room. Resident #60, who had diagnoses including OCD, schizoaffective disorder, bipolar type, and dementia and was also assessed as cognitively intact with a BIMS score of 15, complained that the room smelled of urine because of the roommate. LPN #23 verified the strong odor and reported that the roommate was noncompliant with care. The report also documented that Resident #45, who had COPD, OCD, and type II DM and was severely cognitively impaired, had a room door that was sticking and difficult to open. Staff observed the resident using her right shoulder to push the door open, and witness statements confirmed she was hitting the door with her shoulder to get it open. X-ray results showed a comminuted fracture of the distal third of the right clavicle, and later documentation stated the injury occurred when she used her shoulder to force the door open. Additional observations showed Resident #59's room door was very difficult to open, dragging on the floor with loose hinges, and Resident #59 had to use her right shoulder to enter the room. Resident #95, who had diagnoses including angina pectoris, diabetes mellitus, anemia, encephalopathy, major depressive disorder, and adult failure to thrive and was cognitively intact and independently ambulatory in a wheelchair, had a broken door handle with a large notch missing from the wooden door and a bathroom door that was sticking and hard to open. Resident #90 and Resident #91 shared a room door that was not functioning properly and hard to open. Resident #46's window was broken and covered with a large piece of wood, and the Administrator confirmed the condition. The facility policy stated residents are to be provided with a safe, clean, comfortable, and sanitary environment.
Failure to Prevent Repeated Foreign Object Ingestion and Unsafe Secured Unit Conditions
Penalty
Summary
The facility failed to implement interventions and provide sufficient supervision to prevent a resident with a history of pica and swallowing foreign objects from ingesting batteries, a screw, and other foreign items. Resident #33 was admitted with diagnoses including suicidal ideation, bipolar disorder, borderline personality disorder, asthma, pica, depression, intellectual disabilities, conversion disorder, and morbid obesity. The care plan dated 02/03/26 identified a behavior problem that included swallowing batteries and other foreign objects, but the DON confirmed the care plan was not updated with new interventions after the repeated incidents. The resident’s record showed multiple episodes in which she reported swallowing foreign objects and was sent to the hospital. On 04/05/26, she told police and staff that she ate a battery, was observed holding a thermometer, and stated she ate the battery from the thermometer left on the table; she was transferred to the hospital and later had surgery with two batteries removed. On 05/14/26, she reported swallowing two small batteries from a pulse oximetry machine and was sent to the hospital. On 05/23/26, she approached the nurse’s station and stated she swallowed a screw, pointed toward the shower room area when asked where she got it, and was sent to the emergency room; hospital paperwork confirmed a foreign body and endoscopic removal of a screw. On 05/26/26, she reported swallowing a battery from a television remote and was again sent to the hospital, where invasive procedures were performed to remove foreign objects. The facility’s incident/accident log did not record the incidents on 04/05/26, 05/14/26, 05/23/26, and 05/26/26. During interview, the DON stated the resident was quick to grab items from the nurse’s desk and that she had considered placing dividers around the nurse’s station but did not do so. The DON also confirmed the guardian had asked the facility to sweep the resident’s room to ensure she was safe to return, and the hospital discharge instructions included removing all small objects from the resident’s room for safety. The facility policy stated the environment should be made as free from accident hazards as possible and that targeted interventions and adequate supervision should be used to reduce individual risks.
Failure to Assess and Monitor Bed Rails
Penalty
Summary
The facility failed to ensure residents with bed rails affixed to their beds were properly assessed and monitored for safety. The deficiency involved Resident #42, who was admitted with diagnoses including conversion disorder with seizures, bipolar disorder, adult failure to thrive, major depressive disorder, hyperlipidemia, hypoglycemia, autistic disorder, cerebral aneurysm, aphasia, and joint derangement, and who required hospice services. The resident was cognitively impaired, dependent on staff for all ADLs, and had care plan interventions for bilateral assist bars to help with bed mobility, as well as wound care interventions that included padding and protecting the foot board of the bed. Record review showed the most recent side rail assessment marked the resident as not having side rails, and the enabler evaluation listed the secured unit as the device assessed without other information indicating side rails. The MDS also indicated no bed rails were utilized. However, progress notes and incident documentation showed the resident had bruising to the forehead and scalp, and staff stated the resident flailed around in bed and hit her head on the side rails. The DON documented that the interdisciplinary team investigated the bruising and determined it appeared consistent with the resident hitting her forehead on the side rails. Observation of the resident showed half bed rails on both sides of the bed with kerlix wound dressing wrapped around them, and the resident was positioned with her head toward the footboard. An LPN confirmed the resident was in bed with half bed rails wrapped with kerlix and stated the resident moved around in bed, which resulted in bruising to her forehead. The LPN also stated the kerlix was a temporary fix until hospice provided a new bed. The PCC stated the resident had half bed rails and that seizure pads were supposed to be applied to protect the resident, while the physician order summary showed no orders for half side rails affixed to the bed and no orders to assess or monitor the resident for side rails.
Delayed Completion and Signature of Provider Progress Note
Penalty
Summary
The facility failed to ensure medical providers completed and signed progress notes and orders at the time of required visits. This affected one resident out of three reviewed for provider visits. Resident #45 was admitted on 11/01/22 and had diagnoses including COPD, OCD, and type II DM. The resident’s quarterly MDS assessment showed severe cognitive impairment with a BIMS score of zero. Review of a physician progress note for a provider visit on 04/07/26 showed the note was not completed and signed until 06/03/26 at 11:42 A.M. During an interview on 06/03/26 at 10:29 A.M., the NP confirmed she had seen Resident #45 on 04/07/26 for a hematoma to the right shoulder but had not yet completed the progress note.
Infection Control Lapse During Incontinence Care
Penalty
Summary
The facility failed to ensure appropriate infection control measures were followed during incontinence care for one resident. Resident #45 was admitted on 11/01/22 and had diagnoses including COPD, OCD, and type II DM. The Quarterly MDS assessment showed the resident had severe cognitive impairment with a BIMS score of zero, required partial assistance with eating, substantial assistance with toileting, bathing, and dressing, and was frequently incontinent of bowel and bladder. During observation on 06/03/26 at 1:17 P.M., CNA #67 and CNA #81 provided incontinence care to Resident #45. CNA #67 did not change gloves during care and touched the resident, clean depends, and sheets with soiled gloves. During interview on 06/03/26 at 1:32 P.M., CNA #67 confirmed she did not change her gloves during incontinence care and touched Resident #45, clean depends, and sheets with soiled gloves. The facility policy titled Peri Care, dated 05/01/22, directed staff to remove gloves and perform hand hygiene, then apply clean gloves and a clean brief, and again remove gloves and perform hand hygiene.
Unsafe and Unsanitary Environment with Pest Issues
Penalty
Summary
The facility failed to ensure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, affecting all 45 residents housed on the East Unit. Observation of the room shared by Resident #59 and Resident #60 revealed several alive and dead flies throughout the room. Resident #59 had diagnoses including major depressive disorder, bipolar disorder, and anxiety disorder, and a Quarterly MDS assessment showed severely impaired cognition with a BIMS score of 0. Resident #60 had diagnoses including OCD, schizoaffective disorder, bipolar type, and dementia, and a Quarterly MDS assessment showed intact cognition with a BIMS score of 15. An LPN verified the flies were present in the room during the observation. Additional observations showed widespread accumulation of dead bugs in ceiling light fixtures. In the secured unit, nearly all ceiling lights had copious amounts of visible dead bugs, and an LPN verified the condition. In the 200-unit hallway, multiple ceiling lights also had numerous dead bugs visible in the lights, and an LPN confirmed this was present and stated the dead bugs had also been present during the recent annual survey in March 2026. Facility policy titled Homelike Environment stated residents are to be provided with a safe, clean, comfortable, and sanitary environment, and the Pest Control policy stated the facility shall maintain a pest control program.
No RN Coverage for Required Daily Hours
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was scheduled for at least eight consecutive hours per day, seven days per week. Record review and staff interview showed that the facility did not have an RN on duty on 02/28/26. Review of the facility's Staffing policy dated 05/01/22 stated that the facility should maintain adequate staffing on each shift to ensure residents' needs and services are met. During an interview on 03/13/26 at 1:52 P.M., the Chief Operating Officer confirmed that the facility did not have an RN on duty in the facility on 02/28/26. Review of the Minimum Direct Care Daily Average of 2.50 survey tool for 02/27/26 through 03/05/26 also showed there was no RN coverage on 02/28/26.
Failure to Prevent Ingestion Incidents, Maintain Fall Interventions, and Secure Hazardous Chemicals
Penalty
Summary
Surveyors identified a deficiency related to accident hazards and inadequate supervision when a resident with a known history of pica and ingesting foreign objects repeatedly swallowed hazardous items without timely, targeted interventions in place. The resident was admitted with diagnoses including pica, borderline personality disorder, bipolar disorder, morbid obesity, and conversion disorder, and the facility was aware upon admission that she had a behavior of swallowing foreign objects at a sister facility. Despite this, the care plan addressing her behavior of swallowing batteries and other foreign objects was not initiated until early February, after three separate incidents in which she swallowed a thumb tack and multiple batteries, each requiring EMS transport and hospital evaluation or treatment. Facility leadership, including the COO, Administrator, and DON, confirmed that no follow-up investigations were completed to determine root causes or to develop interventions to prevent recurrence of these ingestion incidents, contrary to facility policies on safety, supervision, and incident investigations. A second deficiency involved failure to implement and maintain fall-prevention interventions for another resident with impaired cognition and a documented risk for falls. This resident had physician orders for Dycem to the wheelchair every shift and a fall care plan that included interventions such as placing the bed against the wall, keeping the bed in the lowest position, using floor mats beside the bed when the resident was in bed, and applying Dycem above and below the wheelchair cushion. During multiple observations, the resident was seen in bed without fall mats and with a wheelchair lacking Dycem above or below the cushion. A CNA, an RN, and the DON each confirmed that the resident did not have the ordered Dycem in place and that the care-planned fall interventions, including the floor mat, were not being implemented as specified. A third deficiency concerned unsecured hazardous chemicals accessible in an unlocked janitor’s closet on a resident hall. On two separate observations, the janitor’s closet on the 100 hall was found unlocked and containing three containers of concentrated sanitizing fabric refresher with warning labels indicating the product was corrosive, could cause irreversible eye damage, and could be harmful if absorbed through the skin. Staff, including a CNA, an LPN, an RN, and the Administrator, confirmed that the closet was unlocked and that it should have been locked when unattended. The Administrator further acknowledged concern because several facility-identified residents on that hall were cognitively impaired and independently mobile, making the unsecured chemicals a particular hazard under the facility’s own safety expectations.
Failure to Maintain Resident Rooms in Good Repair
Penalty
Summary
The deficiency involves the facility’s failure to maintain resident rooms in good repair, resulting in an environment that was not fully safe, clean, comfortable, or homelike for two residents. One resident, admitted with diagnoses including paranoid schizophrenia, presbyopia, and type 2 diabetes mellitus and assessed as having moderate cognitive impairment, was observed to have multiple small holes in the bedroom wall and a bathroom door with scratches and chipped paint. The resident stated she did not like the holes in the wall and felt the damaged bathroom door should be repaired. The maintenance assistant confirmed that the holes were from screws that should have been filled with plaster and that the bathroom door was scratched and needed repainting. Another resident, admitted with diagnoses including cerebral infarction, major depressive disorder, and diabetes mellitus and assessed as cognitively intact, had a bedroom door that was cracked and difficult to shut because it caught on the door frame. Observation confirmed that the door could not be fully closed. This resident expressed concern about the poor condition of the bedroom door and its inability to fully close. The maintenance assistant confirmed that the door hinges needed adjustment so the door would not catch on the frame and acknowledged the presence of cracks on the side of the door. These conditions were inconsistent with the facility’s “Homelike Environment” policy, which states the facility will provide a homelike and orderly environment for residents.
Failure to Provide Ordered PRN Pain Medication Due to Out-of-Stock Voltaren Gel
Penalty
Summary
Facility staff failed to provide ordered and requested pain management for a cognitively intact resident with osteoarthritis, obstructive sleep apnea, and congestive heart failure. The physician had ordered Voltaren gel to be applied topically to the resident’s right shoulder every six hours as needed for pain. Review of the March 2026 MAR showed no documentation of Voltaren gel administration on 03/07/26, 03/08/26, 03/09/26, and 03/10/26. The resident reported that on each of those dates he requested his PRN Voltaren gel, but nurses told him it was not available. An interview with an LPN confirmed the resident had a physician’s order for Voltaren gel, had asked for it to be applied to his right shoulder, and that the medication was out of stock. This resulted in the resident not receiving the ordered PRN pain medication despite multiple requests. This deficiency represents noncompliance investigated under Complaint Number 1360651.
Inaccurate Advance Directive Documentation
Penalty
Summary
The facility failed to ensure current and accurate documentation of residents’ advance directives was included in the medical record for four residents reviewed. Resident #24 had diagnoses including chronic pain syndrome, major depressive disorder, and bipolar disorder, was cognitively intact, and had a physician order for DNRCC and a care plan reflecting DNRCC, but the hard chart had an undated sticker indicating full code status. Resident #65 had diagnoses including cerebral infarction, fracture of the left femur, and vascular dementia; the physician order in the EHR listed full code, while the care plan listed DNRCC and the hard chart contained a signed Ohio DNRCC form, and RN #223 confirmed the orders in the hard chart did not match the EHR. Resident #6 had diagnoses including generalized muscle weakness, COPD, and chronic pain syndrome, was cognitively intact, and had a physician order for DNRCC, but the care plan and face sheet listed full code. Resident #27 had diagnoses including traumatic brain injury, dementia, and bipolar disorder, had severe cognitive impairment, and had a physician order for DNRCC, but the face sheet listed full code. Facility policy stated advance directives were to be reviewed upon admission, readmission from the hospital, quarterly, and annually, with documentation noted on the advance directive care plan, quarterly social work assessment, and/or admission/annual advance directive information form.
Failure to Develop Comprehensive Care Plans for Identified Resident Needs
Penalty
Summary
The facility failed to develop comprehensive care plans to address identified resident needs for three of four residents reviewed. Resident #42, admitted with osteoarthritis, obstructive sleep apnea, and congestive heart failure, had a care plan that identified a risk for potential pain or discomfort but did not include pain management interventions. The resident’s MDS showed he was cognitively intact, and the physician later ordered Voltaren gel for right shoulder pain as needed every six hours. The resident confirmed he frequently requested the medication for his shoulder pain, and an LPN verified the pain care plan did not include pain management interventions. Resident #9, admitted with anxiety disorder, hypertension, Alzheimer’s disease, and schizoaffective disorder, had an MDS showing mild cognitive impairment, but the care plan did not include an activities care plan. The resident stated she did not like to go to facility activities because they were infantile, and the COO confirmed no activities care plan had been developed. Resident #8, admitted with pica, borderline personality disorder, bipolar disorder, morbid obesity, and conversion disorder, had nurse progress notes documenting ingestion of a thumb tack and batteries on three occasions before a behavioral care plan was developed. The care plan dated later identified pica and the behavior of ingesting foreign objects, and the COO confirmed the behavioral care plan was not developed and implemented until after the resident had already ingested foreign objects three times.
Care Plan Not Updated for Change in Toileting Status
Penalty
Summary
The facility failed to revise Resident #4’s care plan to reflect a change in toileting status. The resident was admitted with diagnoses including COPD, type 2 diabetes mellitus, and bilateral below-knee amputations. A MDS assessment dated 12/16/25 showed the resident did not have an indwelling catheter and was occasionally incontinent of urine, but the care plan dated 1/09/26 still identified the resident as having an indwelling Foley catheter and needing catheter care per facility policy. During observation on 03/09/26, Resident #4 was in bed and did not have a Foley catheter. An RN later confirmed on 3/16/26 that the resident no longer had a Foley catheter and that the care plan had not been updated. Facility policy stated care plans should be revised and updated with changes in resident condition and status.
Oxygen Therapy Not Administered Per Physician Order
Penalty
Summary
The facility failed to ensure oxygen therapy was administered as ordered by the physician for one resident with diagnoses including congestive heart failure, COPD, and respiratory failure. The resident’s care plan identified a risk for altered respiratory status and included an intervention to provide oxygen per physician’s order, but the physician’s orders for March 2026 contained no oxygen order. Despite this, the resident was observed receiving continuous oxygen via nasal cannula from a concentrator set at 3 LPM. During interview, an LPN confirmed the resident used continuous oxygen therapy and stated she did not know what level of oxygen had been ordered by the physician; she also stated the facility typically set all residents’ oxygen at 3 LPM unless otherwise ordered.
Inadequate Food Supply and Lack of Emergency Stock
Penalty
Summary
The facility failed to maintain an adequate supply of food for both scheduled meals and emergency situations, potentially affecting all 99 residents who rely on the kitchen for their meals. Observations of the kitchen revealed a limited stock of dry, refrigerated, and frozen food items, with no emergency food supply available. Interviews with staff confirmed the lack of an emergency food supply and indicated that while meals were served as scheduled, there were rarely any leftovers for residents who might want additional servings. The facility's comprehensive emergency management plan (CEMP) mandates maintaining a seven-day supply of food and meal service products, which was not adhered to. The administrator, who has been in position since October, was unaware of the lack of an emergency food supply until recently. The dietary supervisor, employed for approximately 90 days, reported that weekly food orders barely sufficed for regular meal service. The facility's food vendor had not been fulfilling all orders, contributing to the deficiency.
Medication Storage Deficiencies
Penalty
Summary
The facility failed to ensure that prescription medications were stored securely, which had the potential to affect multiple residents, particularly those who were cognitively impaired and independently mobile. During an observation, medications for a resident were found unsupervised and unsecured on a medication cart. The resident had a history of various medical conditions, including respiratory failure, diabetes, and schizoaffective disorder, and was assessed to be capable of self-administering medications. However, the medications were left unattended, and the staff involved were not aware of the proper procedures for securing medications. Additionally, the facility's treatment carts were found unlocked and unsupervised on multiple occasions. These carts contained various creams and solutions with warning labels indicating the need for medical assistance if ingested. The unsecured carts were accessible to residents who were cognitively impaired and independently mobile, increasing the risk of unsupervised access to potentially harmful substances. Furthermore, the facility failed to maintain proper storage conditions for refrigerated medications. The refrigerator used for storing medications did not have a temperature log, and the temperature was recorded at 48 degrees Fahrenheit, which is above the recommended range. This oversight affected the storage of several medications, including insulin and Ativan, which require specific temperature conditions to remain effective. The lack of temperature monitoring and the presence of ice buildup in the refrigerator compromised the safety and efficacy of the stored medications.
Facility Maintenance Deficiencies in Northeast Unit
Penalty
Summary
The facility failed to maintain the building in a safe and homelike manner, which had the potential to affect 21 residents residing in the Northeast Unit. Observations revealed significant structural issues with the facility's roof, including areas of splintered and missing wood, unattached rain gutters, and sagging shingles. A large blue tarp was also noted over the shingles, indicating temporary measures to address the damage. Additionally, the dining area in the Northeast Unit had two outlets without covers and a ceiling light without a cover, exposing electrical components. The corridor outside the nursing station had a section of the wall covered with heavy black plastic and stapled in place, with a cut section of plaster exposing the inside of the wall space and an electrical outlet covered with beige tape. The Maintenance Director confirmed these observations and stated that the facility had experienced a water heater leak before his employment, which caused water damage in several areas, including the dining area, hot water storage area, corridor, and a resident room. Despite efforts to contact repair companies, the facility had not received any responses, leading the Maintenance Director to attempt repairs himself as time allowed. This deficiency was investigated under Complaint Numbers OH00158425 and OH00158273.
Inadequate Supply of Bathroom Essentials
Penalty
Summary
The facility failed to ensure an adequate supply of paper towels and toilet paper in a resident's bathroom, affecting one resident out of three reviewed for the physical environment. The resident, who was admitted with diagnoses including synovitis, hypertension, diabetes mellitus, depression, and schizophrenia, required moderate assistance with toileting. Interviews with housekeeping staff revealed that the facility was out of toilet paper and paper towels, a situation that occurred often due to insufficient ordering. The resident confirmed experiencing shortages of these supplies before. The Housekeeping and Laundry Director verified the lack of supplies, and management confirmed the absence of a policy related to stock supplies. This deficiency was investigated under specific complaint numbers.
Deficiency in LNHA Licensing
Penalty
Summary
The facility failed to ensure that a licensed nursing home administrator (LNHA) with a valid license was providing supervision and leadership. This deficiency was identified through a review of the online license verification system of the Bureau of Executives of Long-Term Services and Supports (BELTSS), the Administrator job description, and staff interviews. The facility's census was 106 residents, and the lack of a valid LNHA license had the potential to affect all residents. Administrator #1, who had been serving as the LNHA of record, was notified by BELTSS that her license had expired. Consequently, Administrator #2, from a sister facility, temporarily served as the LNHA until Administrator #1 could renew her license. During the period when Administrator #1's license was expired, the facility did not have a validly licensed LNHA from the time her license expired until it was renewed. Administrator #2 confirmed that she served as the LNHA of record during this time and had a valid Ohio license to practice as an LNHA. The deficiency was identified as an incident of past non-compliance that was subsequently corrected prior to the survey.
Facility Failed to Maintain Clean Shower Rooms
Penalty
Summary
The facility failed to ensure that shower rooms were clean and ceilings were maintained, which had the potential to affect 60 residents who receive showers in the [NAME] and Northeast shower rooms. Observations revealed a black substance on the floor and caulk where the floor of the shower met the wall of the shower in the [NAME] shower room, and a large round black spot on the ceiling of the shower in the Northeast shower room. Resident #96 reported that the [NAME] shower room smelled like mold. These observations were verified by LPN Unit Manager #800. Interviews with various staff members, including an RN, LPN, STNA, and a housekeeper, confirmed the presence of mold and mildew in the Northeast shower room. The RN mentioned that STNAs had informed her about the mold, but she did not inspect the shower room herself. The facility census was 101, and the deficiency was investigated under Complaint Number OH00153585.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to provide adequate interventions and supervision to prevent a cognitively impaired resident with a history of wandering from eloping. The resident, who had diagnoses including cardiac arrest, major depressive disorder, chronic obstructive pulmonary disease, anxiety disorder, hypertension, encephalopathy, and malignant neoplasm of the prostate, was moderately cognitively impaired and required assistance with various activities of daily living. Despite having a care plan that included measures to prevent elopement, the resident was moved off a secured unit due to a perceived reduction in exit-seeking behaviors. However, the resident subsequently eloped from the facility and was found by the police approximately 0.3 miles away, knocking on a neighbor's door. The resident was returned to the facility without injuries but had been able to leave the premises unassisted, indicating a lapse in supervision and adherence to the care plan. Interviews with staff revealed that the resident had been seen in the hallway shortly before the elopement, and the facility received a call from the police about the resident's whereabouts. The facility's elopement policy was not effectively implemented, leading to the resident's unsupervised departure from the facility. The deficiency was identified during a survey and was subsequently corrected by the facility before the survey was completed.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 429 citations issued within 25 miles in the last 12 months — including the 2 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
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) |
|---|---|---|---|---|
| Laurels Of Huber Heights The | 2 mi | ★★★★★ | 2 | 0 |
| Stonespring Of Vandalia | 5 mi | ★★★★★ | 0 | 0 |
| Springmeade Healthcenter | 5.7 mi | ★★★★★ | 0 | 0 |
| Siena Woods Care Center | 6.2 mi | ★★★★★ | 14 | 0 |
| Riverside Nursing And Rehabilitation Center | 6.4 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 August 2026) and official state health department websites.