Inspection·August 31, 2023

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Residents Affected - Some 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. R6's facility undated Immunization Record documents R6 was administered an unidentified pneumococcal immunization on 11/14/16. On 08/31/23 at 3:13 PM, V2 (Director of Nursing/DON) stated she didn't know what type of pneumonia vaccine R6 had on 11/14/2016, and wouldn't be able to find out, since they no longer used the pharmacy that provided the immunizations at that time. R6's Influenza and Pneumonia Vaccine Consent, dated 9/21/17, has handwritten next to the consent for pneumonia vaccine, Prevnar 13- contraindicated r/t (related to) immunosuppressive therapy. The facility was unable to provide this surveyor with reproducible evidence that R6 had been offered and/or had any pneumonia vaccine, including the Prevnar 20, administered after 11/14/2016. On 8/31/23 at 9:42 AM, R6 was observed sitting in her wheelchair in her room with V2 (DON) present. V2 asked R6 her if she wanted the pneumonia vaccine, and R6 stated she did. R6 stated she hadn't had it for a few years because no one had offered it to her. V2 asked R6 if she had refused it in the past, and R6 stated she wouldn't refuse it because she had a history of pneumonia. On 8/31/23 at 11:16 AM, V9 (Family Member) stated R6 had a history of pneumonia. V9 stated as far as she knows, R6 only gets immunizations at the facility, and the facility is keeping track of what immunizations had been administered to R6. V9 stated she didn't believe R6 would refuse the pneumonia vaccine, and when the facility calls V9 for consent, she always approves vaccines to be administered. 2. R3's admission Record, with a print date of 8/31/23, documents R3 is [AGE] years old and was admitted to the facility on [DATE], with diagnoses that include malignant neoplasm of left breast, diabetes, chronic obstructive pulmonary disease, and hypertension. R3's MDS, dated [DATE], documents a BIMS score of 15, which indicates R3 is cognitively intact. R3's ICARE immunization history report documents R3 received a pneumovax 23 on 12/03/2019, and a second unidentified pneumonia vaccine on 12/03/2020. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145903 If continuation sheet Page 2 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vandalia Healthcare & Senior Living 1500 West St Louis Avenue Vandalia, IL 62471 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 08/31/23 at 2:52 PM, V2 (DON) stated she did not know what pneumonia vaccine was administered to R3 on 12/03/2020. V2 stated she would have to contact R3's physician to find out what immunizations R3 needed. V2 stated she should have known what immunizations R3 had and what she needed, prior to being asked about it on this survey. On 8/31/23 at 2:32 PM, R3 stated she was offered immunizations when she moved into the facility. When asked about the pneumonia vaccines, R3 stated she gets one every five years, and it isn't time for one. When asked if she was familiar with Prevnar 20, she stated she was not. When asked if the facility had educated her regarding the Prevnar 20, R3 stated they had not. When asked if she would want the most current pneumonia vaccine if she were eligible, R3 stated she would. 3. R31's admission Record, with a print date of 8/31/23, documents R31 was admitted to the facility on [DATE], and is [AGE] years old. R31's admission Record documents R31's diagnoses include encephalopathy, aortic valve stenosis, and hypertension. R31's MDS, dated [DATE], documents R31 has a BIMS score of 12, which indicates R31 has a moderate cognitive deficit. This surveyor was provided with two separate undated facility Immunization Records for R31. One Immunization Record documents R31 was administered a Prevnar 13 on 11/2/2018, and one documents R31 was administered a Pneumovax 23 on 11/2/2018. On 08/31/23 at 2: 20 PM, V2 (DON) stated she wasn't sure which immunization record was accurate for R31, and would have to call the local health department to find out. On 8/31/23 at 2:10 PM, R31 stated he had not been offered a pneumonia vaccine since his admission to the facility on 6/13/23. When asked if he would have wanted the pneumonia vaccine, R31 stated, probably so. 4. R16's admission Record, with a print date of 8/31/23, documents R31 is [AGE] years old, and was admitted to the facility on [DATE], with diagnoses that include diabetes, hypertension, anemia, and personal history of nicotine dependence. R16's MDS, dated [DATE], documents R16 has a BIMS score of 15, which indicates R16 is cognitively intact. R16's Immunization Record documents R16 was administered the Prevnar 15 vaccine on 2/26/2020, with no other pneumonia vaccines documented. On 8/31/23 at 2:30 PM, R16 stated he has had pneumonia vaccines in the past, including the Prevnar a couple of years ago in 2020, and another one a few years prior to that. R16 stated he had not been offered one since 2020, and would want it if he was eligible. On 8/31/23 at 9:59 AM, V2 stated the facility had not started offering the Prevnar 20 immunizations to the residents. V2 stated they were planning to offer the Prevnar 20 at the same time they offered the flu vaccine this year. The website for the Center for Disease Control (CDC) found at, https://www.cdc.gov/vaccines/vpd/pneumo/hcp/who-when-to-vaccinate.html documents, CDC recommends pneumococcal vaccination for adults 19 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145903 If continuation sheet Page 3 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vandalia Healthcare & Senior Living 1500 West St Louis Avenue Vandalia, IL 62471 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete through [AGE] years old who have certain chronic medical conditions or other risk factors. The factors listed include cigarette smoking, diabetes, chronic lung disease and solid organ transplant. The recommendations for adults 19-[AGE] years old are documented as, for those who have not previously received any pneumococcal vaccine give 1 dose of PCV15 or PCV20. For those who have only received PPSV23, give 1 dose of PCV15 or PCV20. For those who have received PCV13, give 1 dose of PCV20 at least 1 year after PCV13. For adults 65 and older the CDC recommends giving 1 dose of PCV15 or PCV20 for those who have not received any pneumococcal vaccine and for those who have received the PPSV23 vaccine. For those who have received PCV13, give one dose of PCV20 at least 1 year after PCV13. For those who have received PCV13 at any age and PPSV23 before 65 years, give 1 dose of PCV20 at least 5 years after the last pneumococcal vaccine. Event ID: Facility ID: 145903 If continuation sheet Page 4 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vandalia Healthcare & Senior Living 1500 West St Louis Avenue Vandalia, IL 62471 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0912 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. room [ROOM NUMBER] measured 148 x 152 which equals 156.22 sq. ft. which indicates 78.11 sq. ft. per resident. room [ROOM NUMBER] measured 149 x 152 which equals 157.28 sq. ft. which indicates 78.64 sq. ft. per resident. room [ROOM NUMBER] measured 143 x 152 which equals 150.95 sq. ft. which indicates 75.47 sq. ft. per resident. rooms [ROOM NUMBERS] measured 136 x 151 which equals 142.61 sq. ft. which indicates 71.31 sq. ft. per resident. room [ROOM NUMBER] measured 139 x 151 which equals 145.76 sq. ft. which indicates 72.88 sq. ft. per resident. room [ROOM NUMBER] measured 143 x 150 which equals 148.96 sq. ft. which indicates 74.48 sq. ft. per resident. room [ROOM NUMBER] measured 145 x 150 which equals 151.04 sq. ft. which indicates 75.52 sq. ft. per resident. room [ROOM NUMBER] measured 142 x 151 which equals 148.90 sq. ft. which indicates 74.45 sq. ft. per resident. room [ROOM NUMBER], 9, and 12 measured 143 x 151 which equals 149.95 sq. ft. which indicates 74.98 sq. ft. per resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145903 If continuation sheet Page 5 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vandalia Healthcare & Senior Living 1500 West St Louis Avenue Vandalia, IL 62471 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0912 Level of Harm - Minimal harm or potential for actual harm room [ROOM NUMBER] measured 139 x 152 which equals 146.72 sq. ft. which indicates 73.36 sq. ft. per person. Rooms 8, 10, 11, and 13 measured 141 x 151 which equals 147.85 sq. ft. which indicates 73.93 sq. ft. per resident. Residents Affected - Some This surveyor observed all of the rooms measured. In the rooms occupied by residents, all had two beds, two night stands; one room had a recliner, and some had wheelchairs. The residents residing in these rooms were all non-interviewable. There were no negative resident or family observations regarding room size. At the time of the survey, the space provided in these rooms was adequate to meet the needs of the residents. On 8/29/23 at 3:12 PM, V7 (Maintenance Director) stated he had not had any residents and/or families voice concerns to him they didn't have enough space in the rooms they resided in. On 8/29/23 at 3:27 PM, V1 (Administrator) stated all of the rooms located on A and B hall were licensed as double occupancy and Medicaid certified rooms. V1 stated they had not had any incident and/or accidents in those rooms related to the size of the room, and she had not had any complaints/concerns brought to her related to the size of the rooms. V1 stated they are careful to not put two residents who require transfer with a mechanical lift in the rooms with less than 80 sq. ft. per person. The untitled, undated facility resident roster documents R5, R8, R14, R17, R18, R20, R21, R24, R32, and R137 reside in rooms 3, 5-8, and 10-15. Rooms 4, 9, 16-23, and 28-31 were unoccupied. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145903 If continuation sheet Page 6 of 6