Vineyards at Concord: Fall Safety Failures Cited - OH
Federal inspectors documented the failures after a complaint inspection completed November 19, 2025. The resident identified in the report as Resident 78 had fallen on September 16, 2025, and again on December 22, 2025. After both falls, the facility's own policy required the interdisciplinary team to investigate probable causes, review the care plan, and communicate any new interventions to staff. None of that happened.
The director of nursing confirmed it directly. In an interview with inspectors on November 10, 2025, at 2:00 p.m., the DON acknowledged that Resident 78 had no fall care plan in place and that no fall investigation or incident report had been completed for either event.
That confirmation matters. This wasn't a documentation gap that staff disputed or a record buried in an incomplete chart. The person responsible for nursing oversight at the facility sat down with inspectors and said, yes, the reports were never done, and yes, the care plan was never written.
The facility's own Falls Policy, reviewed by inspectors during the visit, spells out what is supposed to happen. Residents identified as being at risk for falls are to have a plan of care developed to address risk factors. After any fall, the interdisciplinary team is required to investigate for cause and probable cause, then review and revise the care plan as warranted. New and revised interventions are to be communicated to the full team.
The policy has no date on it. The inspectors noted that detail.
For Resident 78, none of those steps were taken after the first fall in September. When the resident fell again in December, the situation was the same: no investigation, no updated plan, no documented effort to understand what had gone wrong or to reduce the risk of it happening again.
Falls in nursing home residents are not minor events. A single fall can result in a fracture, a head injury, or a rapid decline in a resident's overall condition. The standard practice of investigating each fall exists precisely because the circumstances that lead to one fall often predict the next. A resident who fell because of a medication side effect, a wet floor, or inadequate footwear is at elevated risk until those factors are identified and addressed. Without an investigation, the facility has no basis for knowing what changed, if anything, needs to change.
The deficiency was cited under F0689, which covers the requirement to ensure residents receive adequate supervision and assistance to prevent accidents. Inspectors rated the level of harm as minimal harm or potential for actual harm, and noted that some residents were affected.
The inspection was triggered by a complaint, filed under Complaint Number 2661527. Complaint-driven inspections typically follow a specific allegation from a resident, family member, or staff. The report does not describe the nature of the original complaint, only what inspectors found when they arrived.
What they found was a resident who had fallen twice over three months with no formal response either time. The care plan that might have flagged this person as fall-risk, that might have outlined the interventions staff should be taking, that might have prompted someone to check whether the circumstances of the first fall had been resolved before the second one occurred, did not exist.
The director of nursing confirmed that too.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Vineyards At Concord, The from 2025-11-19 including all violations, facility responses, and corrective action plans.
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: August 29, 2026 · Our methodology
VINEYARDS AT CONCORD, THE in FRANKFORT, OH was cited for violations during a health inspection on November 19, 2025.
Federal inspectors documented the failures after a complaint inspection completed November 19, 2025.
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.