Cycle 1
Health 2024-10-24 · Fire 2024-10-24
3 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Vandalia, IL
Fayette County Hospital
4-star overall rating with 5-star inspections with $18,233 in total fines with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
650 W Taylor St, Vandalia, IL
(618) 283-1231
Overall
4 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
63
Certified beds
Average residents
29
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1984-10-17
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
1.03
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
1.05
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
3.08
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
5.16
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
2.08
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
4.74
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.62
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
1.08
CMS adjusted RN staffing hours
Adjusted total hours
5.43
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
39%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
311
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
73.55
Composite VBP score used to determine payment impact.
Payment multiplier
1.0239
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
5.61
Baseline 38.78% · Performance 40.74% · Measure score 5.61 · Achievement 5.61 · Improvement 0
Adjusted total nurse staffing
9.10
Baseline 4.92 hours · Performance 5.67 hours · Measure score 9.10 · Achievement 9.10 · Improvement 8.16
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Medicare spending per beneficiary | Not Available |
1.02
|
No data were submitted for this measure. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator Not Available · Adjusted rate Not Available · No data were submitted for this measure. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 64 |
| Staff flu vaccination coverage | 91.49% |
42%
49.5 pts better
|
Numerator 43 · Denominator 47 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.6% |
89.6%
6 pts better
|
93.4%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 86.2% · Q2 100.0% · Q3 100.0% · Q4 96.4% · 4Q avg 95.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
91.6%
8.4 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 9.7% |
3.3%
6.4 pts worse
|
3.3%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 10.3% · Q3 14.8% · Q4 7.1% · 4Q avg 9.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 17.8% |
50.3%
32.5 pts better
|
11.4%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.8% · Q2 16.0% · Q3 19.2% · Q4 21.7% · 4Q avg 17.8% |
| Percentage of long-stay residents who lose too much weight | 5.6% |
6.5%
0.9 pts better
|
5.4%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 7.4% · Q3 12.0% · Q4 3.6% · 4Q avg 5.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 45.8% |
18.5%
27.3 pts worse
|
19.6%
26.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.7% · Q2 55.6% · Q3 44.0% · Q4 42.9% · 4Q avg 45.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 32.6% |
22.8%
9.8 pts worse
|
16.7%
15.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.6% · Q2 27.3% · Q3 36.0% · Q4 31.8% · 4Q avg 32.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 27.3% |
17.2%
10.1 pts worse
|
16.3%
11 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 27.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 27.2% |
15.0%
12.2 pts worse
|
14.9%
12.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.6% · Q2 23.8% · Q4 35.0% · 4Q avg 27.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 11.8% |
1.1%
10.7 pts worse
|
1.0%
10.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.6% · Q2 15.1% · Q3 9.7% · Q4 9.5% · 4Q avg 11.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 8.8% |
1.7%
7.1 pts worse
|
1.7%
7.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 6.9% · Q3 3.7% · Q4 21.4% · 4Q avg 8.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.3% |
21.3%
10 pts worse
|
19.8%
11.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.3% · Q2 36.7% · Q3 43.3% · Q4 24.5% · 4Q avg 31.3% |
| Percentage of long-stay residents with pressure ulcers | 6.9% |
5.2%
1.7 pts worse
|
5.1%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 5.5% · Q3 10.0% · Q4 9.3% · 4Q avg 6.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-14 · Fire 2023-09-14
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-08-25 · Fire 2022-08-25
2 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-24
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-11-15
F · Potential for more than minimal harm
2024-10-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-11-15
E · Potential for more than minimal harm
2024-10-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-15
F · Potential for more than minimal harm
2023-09-14
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2023-10-15
F · Potential for more than minimal harm
2023-09-14
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-10-15
E · Potential for more than minimal harm
2023-09-14
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-10-15
F · Potential for more than minimal harm
2022-08-25
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2022-09-13
E · Potential for more than minimal harm
2022-08-25
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-09-14
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-10-24
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-11-13
E · Potential for more than minimal harm
2024-10-24
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-11-13
D · Potential for more than minimal harm
2024-10-24
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-11-13
G · Actual harm
2023-09-14
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-10-04
D · Potential for more than minimal harm
2023-09-14
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2023-10-04
D · Potential for more than minimal harm
2023-07-12
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-08-04
G · Actual harm
2022-08-25
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-09-18
Penalties and ownership
What sits behind the stars
$18,233
2023-09-14
Fine
Fine · fine $18,233
Fine
$0
2023-09-14
Payment Denial
Payment Denial · denial start 2023-10-07 · 8 days
8 day denial
Ownership
Nearby options
Other facilities in reach
#1
Vandalia Healthcare & Senior Living
Vandalia, IL
1-star overall rating with 2-star inspections with 20 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
The Haven Of St. Elmo
St Elmo, IL
1-star overall rating with 3-star inspections with 9 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Greenville Nursing & Rehab
Greenville, IL
2-star overall rating with 4-star inspections with $10,874 in total fines with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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