Vandalia Healthcare: Fall Prevention Failures Documented - IL
The resident, identified in inspection records only as R6, was admitted to the facility in May 2023. His diagnoses included dementia, moderate anxiety, and unsteadiness on his feet. By July 2025, a cognitive assessment gave him a score of 2 out of a possible 15, placing him in the category of severe cognitive impairment. He depended on staff for all transfers and toileting.
His fall history was not a surprise. A formal fall risk evaluation dated July 7, 2025, documented he was at risk for falling. His care plan already listed interventions from a fall on July 2, 2025, directing nursing staff to remain present with him in the dining room during meals, and from an unwitnessed fall on July 31, 2025, adding a pressure alarm to be used on all shifts.
Then came three more falls that nobody acted on.
On July 18, 2025, at 6:30 in the evening, R6 fell without a witness. He had two small bruises and two small skin tears. His care plan was not updated. No new interventions were added.
Two days later, on July 20 at 6:20 in the evening, he fell again, unwitnessed. No visible injuries that time. His care plan was not updated. No new interventions were added.
On August 16, at 10:39 in the morning, he slipped out of his chair. No visible injuries. His care plan was not updated. No new interventions were added.
The inspection record uses the phrase "unintentional change in plane" to describe the July falls, the clinical shorthand that appears in nursing notes when a resident goes down. Whatever language staff used to document what happened, the result was the same each time: a note in the electronic health record, and nothing else.
The facility's own falls policy, written in 2001, stated plainly that if falling recurs despite initial interventions, staff will implement additional or different interventions. The policy also required a resident-centered fall prevention plan for any resident at risk or with a history of falls.
R6 had both.
When inspectors interviewed a corporate nurse identified as V3 on August 27, she did not dispute the findings. She said all of R6's falls should have been addressed in his care plan. She said new fall interventions should have been developed and implemented. She confirmed they were not.
That acknowledgment, straightforward as it was, raised its own question: if the corporate nurse could state clearly what should have happened and what didn't, why did it take a federal inspection to surface it?
The inspection cited the deficiency at a level of minimal harm or potential for actual harm, the lower end of the scale used by the Centers for Medicare and Medicaid Services. The finding affected few residents. In the regulatory framework, this is not the most serious category of violation.
But R6 is a man who cannot ask for help in the way most people can. His BIMS score of 2 means he has almost no ability to communicate his needs, orient himself to his surroundings, or understand what is happening to him when he falls. He is dependent on staff for the most basic movements, getting up from a chair, walking to the bathroom, getting into the shower. When he goes down, he goes down alone. Three times between July 18 and August 16, he did exactly that, and the people responsible for his safety wrote it down and moved on.
His care plan, as of the inspection, still did not reflect what happened to him on those three days.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Vandalia Healthcare & Senior Living from 2025-09-03 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
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
VANDALIA HEALTHCARE & SENIOR LIVING in VANDALIA, IL was cited for violations during a health inspection on September 3, 2025.
The resident, identified in inspection records only as R6, was admitted to the facility in May 2023.
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.