Vandalia Healthcare & Senior Living
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Based in interview and record review, the facility failed to develop and implement new interventions to prevent falls for 1 of 3 (Resident R6) residents reviewed for falls in a sample of 7.Findings included:Per admission Record, Resident R6 was admitted to this facility on 5/18/2023, with diagnoses of dementia with moderate anxiety, unsteadiness on feet, and history of prostate cancer.Resident R6's MDS (Minimum Data Set), dated 7/10/25, documented Resident R6 has a BIMS (Brief Interview for Mental Status) score of 2 out of 15 total, which indicates Resident R6 has severe cognitive impairment. This same MDS documented Resident R6 is dependent on staff for all transferring and toileting, and needs partial to moderate assistance with showers.Resident R6's Fall Risk Evaluation, dated 7/7/2025, documented Resident R6 is at risk for fall.Resident R6's Care Plan included a focus area of:1. Resident had
an unwitnessed fall 7/31/25 with intervention of pressure alarm (to be used) all shifts (for Resident R6). 2. Fall: (Resident R6) has had an actual fall 7/2/2025 with intervention of nursing staff to remain present in dining room during meals. 3. Risk for falls r/t (related to) dementia, anxiety and history of falls (initiation date 8/28/2024) with interventions of assist resident with ambulation and transfers and keep environment tidy among others.Resident R6's progress notes in his EHR (electronic health record) documented on 8/16/2025 at 10:39am, Resident R6 had slipped out of his chair and had no visible injuries. Resident R6's care plan does not include a plan of care or newly implemented interventions for this fall occurrence.Resident R6's progress notes documented on 7/20/2025 at 6:20pm, Resident R6 had an un-witnessed unintentional change in plane, which indicated Resident R6 had fell. This same progress note documents Resident R6 had no visible injuries. Resident R6's care plan does not include a plan of care or newly implemented interventions for this fall occurrence.Resident R6's progress notes document in part on 7/18/2025 at 6:30pm, Resident R6 had an un-witnessed unintentional change in plane, which indicated Resident R6 had fallen. This same progress note documents Resident R6 had two small bruises and two small skin tears. Resident R6's care plan does not include a plan of care or newly implemented interventions for this fall occurrence.On 8/27/2025 at 9:30am, V3 (Corporate Nurse) said all of Resident R6's falls should have been addressed in his care plan, but they were not.
V3 said new fall interventions should have been developed and implemented for Resident R6, but they were not.The facility's Falls and Falls Risk Management policy, dated 2001, documented the following: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Staff will implement a resident-centered fall prevention plan to reduce falls for each resident at risk or with a history of falls. If falling recurs despite initial interventions, staff will implement additional or different interventions.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
VANDALIA HEALTHCARE & SENIOR LIVING in VANDALIA, IL inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in VANDALIA, IL, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from VANDALIA HEALTHCARE & SENIOR LIVING or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.