Vandalia Healthcare & Senior Living

Inspectors wroteBased on interview and record review, the facility failed to provide dental services for 1 of 1 resident (R33) reviewed for dental services in the sample of 29. This failure resulted in R33's cavity and broken teeth going unaddressed and R33 acquiring an abscess requiring antibiotic treatment and ongoing pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's wound dressing was changed in accordance with physician's orders for 1 of 1 resident (R20) reviewed for wounds in the sample of 29.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the doctor and obtain treatment orders when the presence of a pressure area was detected for 1 of 3 residents (R4) reviewed for pressure areas in the sample of 29. R4's admission Record documents an admission date of 11/11/2024, with the following diagnoses in part: early-onset cerebellar ataxia, unspecified, sepsis, unspecified organism, and acute respiratory failure with hypoxia. R4's Minimum Data Set (MDS), dated [DATE], documents a Brief Interview for Mental Status (BIMS) of 2, indicating R4 is severely cognitively impaired. R4's care plan documents a focus area of has impairment to skin integrity. with interventions including, Monitor/document/report PRN (as needed) any changes in current wound and/or skin status: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to administrator intravenous medications safely for 1 of 1 (R25) resident reviewed for intravenous medication administration in a sample of 29.

Inspectors wroteBased on observation, interview, and record revied the facility failed to administration medication according to the standards of practice for 1 of 5 (R18) residents reviewed for medication administration in a sample of 29.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post enhanced barrier precaution signage and provide PPE (Personal Protective Equipment) for a resident and failed to follow proper infection control practices during resident care, for 2 of 2 residents (R4, R25) reviewed for infection control in a sample of 29.

Inspectors wroteBased in interview and record review, the facility failed to develop and implement new interventions to prevent falls for 1 of 3 (R6) residents reviewed for falls in a sample of 7.

Inspectors wroteBased on interview and record review, the facility failed to maintain sufficient staff to meet the needs of the residents timely. This has the potential to affect all 37 residents currently residing at the facility. Findings Include: The facility Resident Matrix provided to this surveyor on 4/7/25 document 37 residents currently reside at the facility. 1. R2's admission Record with a print date of 4/8/25 documents R2's admitted to the facility on [DATE] with diagnoses that include acute and chronic respiratory failure, heart failure, sleep apnea, diabetes, morbid obesity, and chronic obstructive pulmonary disease. R2's MDS (Minimum Data Set), dated 1/3/25, documents R2 has a BIMS (Brief Interview for Mental Status) score of 15, which indicates R2 is cognitively intact. This same MDS documents R2 requires substantial/maximal assistance for toileting. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were provided with a bedtime snack. This has the potential to affect all 37 residents who currently reside at the facility. Findings Include: The facility Resident Matrix provided to this surveyor on 4/7/25 documents 37 residents currently reside at the facility. On 4/7/25 at 1:00 PM, V4 (Ombudsman) stated she frequently attends the Resident Council Meetings at the facility. V4 stated R3 and R4 reported to her they were not getting snacks served at the facility unless the State Survey Agency was in the facility. On 4/7/25 at 11:30 AM, R3 and R4 stated they are served bedtime snacks. R3 and R4 stated they get them on the tray with their evening meal. On 4/7/25 at 1:29 PM, R2 stated he recently had an issue getting snacks, but after he complained he started getting them again. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure call lights were answered timely for 2 of 5 (R2 and R3) residents reviewed for call lights in the sample of 12. Findings Include: 1. R2's admission Record, with a print date of 4/8/25, documents R2's admitted to the facility on [DATE], with diagnoses that include acute and chronic respiratory failure, heart failure, sleep apnea, diabetes, morbid obesity, and chronic obstructive pulmonary disease. R2's MDS (Minimum Data Set), dated 1/3/25, documents R2 has a BIMS (Brief Interview for Mental Status) score of 15, which indicates R2 is cognitively intact. This same MDS documents R2 requires substantial/maximal assistance for toileting. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who require assistance receive a shower for 3 (R2, R3, and R5) of 5 dependent residents reviewed for Activities of Daily Living assistance in the sample of 21. 1. R2's admission Record documented an admission date of 12/17/24, and included diagnoses of unspecified intellectual disabilities and muscle weakness. R2's Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 00, indicating R2 has severe cognitive impairment. The MDS Section for Functional Abilities and Goals documented R2 as dependent for shower/bathing self. R2's Care Plan documented a Focus Area of: ADL's (Activities of Daily Living): Self care deficit-needs assist to complete quality care initiated on 12/28/24. Corresponding interventions include R2 will receive (showers) 2 times per week. [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure the resident rooms and resident equipment were maintained in a state of good repair for 5 of 5 residents (R1, R2, R3, R4 and R12) reviewed for environment in a sample of 14.

Inspectors wroteBased on interview, observation, and record review, the facility failed to maintain safe water temperatures for 14 of 14 residents (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13 and R14) reviewed for water temperatures in a sample of 14.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide nutritional supplementation as recommended for three (R3, R15, and R4) of six residents reviewed for nutrition in a sample of 27. This failure resulted in significant weight loss for R3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have a full time Director of Nursing and to ensure Registered Nurse coverage 8 consecutive hours a day, seven days a week. This failure has the potential to affect all 33 residents who reside at the facility. Findings Include: The facility's Social Service Need Notice, dated 6/12/24, documents residents concern of the Administrator not being out on the floor more. V28 (Former Administrator) documented on this form, the Administrator does make daily rounds however is needing to do other things due to V2 (Director of Nursing/DON) being on the floor. On 7/29/24 at 12:09 PM and 7/30/24 at 12:13 PM, V2 (DON) was working the floor as a floor nurse and passing medications to residents. V2 was the only nurse on the unit both days at these times. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and serve food in a safe and sanitary manner in accordance with professional standards. This has the potential to affect all 33 residents residing at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an accessible call system for residents in the shower room or the community bathroom. This failure has the potential to affect all 33 residents residing at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide at least 80 square feet per resident bed in multible occupancy resident bedrooms. This failure affects four (R7, R10, R15, R21) of four residents reviewed for environment in the sample of 27.

Inspectors wroteBased on interview and record review, the facility failed to promote resident independence and dignity while providing care by neglecting to explain a task prior to beginning and allowing the resident time to perform the task independently for one (R31) of six residents reviewed for resident rights in the sample of 27. Findings Include: R31's MDS (Minimum Data Set), dated 6/28/24, documents R31 has moderate cognitive impairments. On 7/29/24 at 10:48 AM, R31 stated, Yesterday {7/28/24} around 2:00 PM, a bigger girl was very rough with me during cares. R31 explained R31 is normally able to turn over in bed by herself with just a little help but this bigger girl was in a hurry to get her job done and just pushed me over hard and fast. [...]

Inspectors wroteBased on interview and record review, the facility failed to honor resident choices regarding preferences for sleeping/waking schedules for one (R16) of one resident reviewed for Self-determination in a sample of 27.

Inspectors wroteBased on record review and interview, the facility failed to accurately code a Minimum Data Set (MDS) Assessment for one (R4) of 12 residents reviewed for accuracy of assessments in the sample of 27. Findings Include: R4's ongoing weight log documents the following weights: 12/21/23 - 132 pounds and 6/1/24 - 111.4 pounds. This change in weight calculates as a 15.61% weight loss in six months. R4's Minimum Data Set (MDS), dated [DATE], does not document a significant weight loss. On 7/31/24 at 12:52 PM, V13 (MDS/Care Plan Coordinator) stated significant weight losses should be coded on the MDS. The facility Comprehensive Assessment/MDS Policy, dated 11/1/17, documents the facility shall make every effort to ensure the MDS is accurate. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician orders for skin protection for one (R6) of two residents reviewed for standards of practice in the sample of 27. Findings Include: R6's July 2024 Physician Orders document an order for R6 to wear protective skin sleeves at all times related to being prone to skin tears. On 7/29/24 at 11:25 AM and 7/30/24 at 12:07 PM, R6 was sitting up in a reclining wheeled chair without the ordered protective skin sleeves in place. On 7/30/24 at 12:28 PM, V15 (Certified Nursing Assistants/CNA's) and V16 (CNA) both stated R6 is to wear protective skin sleeves at all times, and explained R6 isn't wearing them because they don't know know where they are. R6's Care Plan, last updated 7/24/24, documents R6 is supposed to have arm sleeve protectors in place at all times. [...]

Inspectors wroteDeficiencies at this level require more than 1 Deficient Practice Statement. A. Based on observation, interview, and record review, the facility failed to position a resident in an upright position and follow swallowing precautions per orders during meals to prevent choking episodes for one (R6) of 12 residents reviewed for dining on the sample list of 27. Findings Include: R6's Diagnosis Report, dated 7/31/24, documents a diagnosis of Dysphagia. R6's July 2024 Order Summary documents an order for swallow precautions and a Carbohydrate Controlled/No added Salt diet of pureed texture with pudding/extremely thick consistency liquids. R6's Care Plan, updated 7/24/24, documents R6 requires a pureed diet with pudding thick liquids and is dependent on staff assistance for feeding. R6 is to stay awake/alert during meals; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary services consistent with professional standards of practice to prevent the worsening of pressure ulcers for one (R4) resident reviewed for pressure ulcer care in the sample of 27. Findings Include: The facility's Quality Assurance (QA) Weekly Skin Eval Documentation List, dated 7/26/24, documents R4 has a Stage III Pressure Ulcer to the lower right buttock. R4's Minimum Data Set (MDS), dated [DATE], documents R4 is at risk for pressure ulcers and has one Stage III Pressure Ulcer. R4's Care Plan, dated 4/25/24, documents R4 is at high risk for pressure ulcers according to R4's Skin Risk Assessment. This Care Plan was updated on 6/27/24, and documents R4 has a stage III pressure ulcer to the right lower buttock with an intervention to complete pressure ulcer treatments per physician orders. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess a resident after a fall and failed to implement interventions for one (R28) of eight residents reviewed for falls in a sample of 27.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a urinary catheter was secured in accordance with the plan of care, and failed to complete incontinence care and catheter care in accordance with standards of practice to prevent irritation and cross contamination for two (R6 and R32) of two residents reviewed for incontinence/catheter care in the sample of 27. Findings Include: 1. R6's Care Plan, dated 4/27/24, documents R6 has an alteration in bladder elimination which resulted in R6 having a Suprapubic Catheter being placed by an unidentified Urologist on 6/19/23 for Obstructive Uropathy. This care plan documents to complete catheter care and maintenance per orders and secure catheter to avoid tension. R6's July 2024 Physician Orders document an order for Suprapubic Catheter Care every shift. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow current standards and practices for infection control regarding handling of soiled linens, hand hygiene, Enhanced Barrier Precautions, and Contact Isolation Precautions to prevent the spread of infection. This failure affects 3 (R6, R13 and R32) of 3 residents reviewed for infection control on the sample list of 27. Findings Include: 1. R6's July 2024 Physician Orders document an order for a Suprapubic Catheter size 16 French and for Suprapubic Catheter Care to be completed every shift. R6's Care Plan, dated 7/24/24, documents R6 has a Suprapubic Catheter due to a diagnosis of Obstructive Uropathy and is on Enhanced Barrier Precautions (EBP). On 7/29/24 at 11:01 AM, R6 was sitting up in a reclining wheelchair in the room. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow the Influenza Immunization Policy to ensure an influenza vaccine was offerred/provided for one (R21) of five residents reviewed for Influenza Immunizations in the sample of 27.

Inspectors wroteBased on interview and record review, the facility failed to follow physician's orders to administer anti-anxiety medication as ordered for 1of 5 (R4) residents reviewed for physician orders in a sample of 12.

Inspectors wroteBased on interview and record review, the facility failed to determine that drug records were in order, and an account of all controlled drugs were maintained and periodically reconciled for 1of 5 (R4) residents reviewed for controlled substances in a sample of 12.

Inspectors wroteBased on interview and record review, the facility failed to ensure coverage was provided by a Registered Nurse (RN) 8 hours a day, 7 days a week. This has the potential to affect all 36 residents living in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure they had a Registered Nurse (RN)working 8 hours a day, 7 days a week. This failure has the potential to effect all 36 residents residing at the facility. Findings Include: The Resident Census and Conditions of Residents form, dated 8/28/23, documents 36 residents reside at the facility. On 08/29/23 at 11:20 AM, V1 (Administrator) stated they do not have RN coverage 8 hours a day, 7 days a week. V1 stated, V2 (Director of Nurses) is a Registered Nurse, and is at the facility for any skilled nursing that requires an RN. V1 stated they run continuous ads and are attempting to recruit RN's, but they are in a small rural area, and have to compete with larger areas that are just 30 minutes from the facility. V1 stated they have had interviews, but the RN's do not accept the position once it is offered. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received the education addressing the benefits and risks and/or had the opportunity to receive the 20-valent pneumococcal conjugate vaccine (PCV20 or Prevnar 20) for 4 of 5 (R3, R6, R16, and R31) residents reviewed for immunizations in the sample of 33. Findings Include: 1. R6's admission Record, with a print date of 8/31/23, documents R6 is [AGE] years old and was admitted to the facility on [DATE], with diagnoses that include heart failure, chronic obstructive pulmonary disease, diabetes, pancreas and kidney transplants, anemia, and pneumocystis. R6's MDS (Minimum Data Set), dated 7/28/23, documents a BIMS (Brief Interview for Mental Status) score of 12, which indicates R6 has a moderate cognitive impairment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the required 80 square feet of floor space per resident for 9 of 9 (R5, R8, R14, R17, R18, R20, R21, R24, R32, and R137) residents reviewed for room size in the sample of 33. Findings Include: On 8/29/23 beginning at 3:03 PM, V7 (Maintenance Director) and V8 (Maintenance Assistant) measured all the resident rooms located on A and B hall that didn't meet the required 80 square feet (sq. ft.) of floor space per resident. The measurements were as follows: rooms [ROOM NUMBER] measured 140 (inches) x 151 which equals 146.81 sq. ft. which indicates 73.40 sq. ft. per resident. rooms [ROOM NUMBERS] measured 141 x 152 which equals 148.83 sq. ft. which indicates 74.42 sq. ft. per resident. rooms [ROOM NUMBERS] measured 142 x 152 which equals 149.88 sq. ft. which indicates 74.94 sq. ft. per resident. [...]