AHC Vanayer: Fatal Fall After Aide Turns Away - TN
MARTIN, TN - A 94-year-old resident at Vanayer Senior Living and Rehabilitation died four days after sustaining multiple leg fractures when she fell from her bed during routine care, according to a federal inspection report that cited the facility for failing to prevent the incident.
Fatal Fall During Personal Care
The incident occurred on January 14, 2025, when a certified nursing assistant was providing incontinence care to the resident, who had been weakened by a recent bout of influenza A. According to facility records, the aide turned the resident onto her side, then completely turned away to retrieve supplies from an overbed table. While the aide's back was turned, the resident slid off the edge of the bed and fell to the floor.
The fall resulted in devastating injuries: fractures to both femurs (thighbones) and a fracture to the left tibia (shinbone). X-rays confirmed the severity of the trauma, showing "acute appearing femoral and tibial fracture" in the left leg and "acute appearing femoral fracture" in the right leg. The resident died four days later on January 18, 2025.
According to the aide's written statement, "As I was turned I heard her start to slide off of the side [of the bed]. I tried to get to her in time to keep her on the bed but I wasn't quick enough. She fell on her bottom hitting her knee on the ground."
Multiple Safety Protocols Ignored
The inspection revealed a cascade of safety failures that contributed to the preventable incident. The resident had been classified as high-risk for falls with a score of 11 on the facility's fall risk evaluation, indicating she required enhanced safety measures. Her care plan specifically called for mechanical lift assistance with two staff members for transfers.
However, the aide who provided care that morning had not reviewed the resident's care plan or received a proper shift report. The aide later acknowledged she was unaware of the resident's weakened condition from recent illness. "When I went in there, she wasn't looking too good because she was sick, so I definitely should've gotten help," the aide stated during interviews.
The resident's family member emphasized the preventable nature of the accident, telling investigators: "I'm just so unhappy about the accident because it was avoidable... the only objection, with a patient who is 94, immobile from the waist down, [had] just gone through the flu, [was given] antibiotics for chest congestion, that instead of two CNAs to change her they had one and that's how the accident happened."
Medical Vulnerabilities Compounded Risk
The resident presented multiple medical factors that significantly increased her fall risk and vulnerability to injury. She had been diagnosed with Parkinson's disease, vascular dementia, hemiplegia (paralysis on one side of the body) following a stroke, and severe osteoporosis - a bone-weakening condition that makes fractures more likely and more severe.
Hand contractures - permanent tightening of muscles and tendons - limited her ability to grip the bed rails that were meant to provide stability during positioning. Most critically, she had been battling influenza A for several days before the fall, receiving antiviral medication and antibiotics for chest congestion. This illness had noticeably weakened her already limited physical capabilities.
Medical research demonstrates that acute illness significantly compromises an elderly person's physical stability and cognitive awareness. Influenza can cause muscle weakness, fatigue, and decreased alertness - all factors that increase fall risk. For residents with existing mobility limitations and cognitive impairment, even minor illness can dramatically reduce their ability to maintain safe positioning.
The facility's own staff recognized these heightened risks. The Licensed Practical Nurse who responded to the incident noted: "You could just tell she didn't feel good" and acknowledged being "shocked" when the fall occurred, as the resident had no previous history of falls during her two-year tenure at the facility.
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
VANAYER SENIOR LIVING AND REHABILITATION in MARTIN, TN was cited for violations during a health inspection on February 11, 2025.
According to facility records, the aide turned the resident onto her side, then completely turned away to retrieve supplies from an overbed table.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.