Vandalia Healthcare & Senior Living

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 (R6) residents reviewed for falls in a sample of 7.

Findings included:Per admission Record, 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.R6's MDS (Minimum Data Set), dated 7/10/25, documented R6 has a BIMS (Brief Interview for Mental Status) score of 2 out of 15 total, which indicates R6 has severe cognitive impairment.

This same MDS documented R6 is dependent on staff for all transferring and toileting, and needs partial to moderate assistance with showers.R6's Fall Risk Evaluation, dated 7/7/2025, documented R6 is at risk for fall.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 R6). 2.

Fall: (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.R6's progress notes in his EHR (electronic health record) documented on 8/16/2025 at 10:39am, R6 had slipped out of his chair and had no visible injuries. R6's care plan does not include a plan of care or newly implemented interventions for this fall occurrence.R6's progress notes documented on 7/20/2025 at 6:20pm, R6 had an un-witnessed unintentional change in plane, which indicated R6 had fell.

This same progress note documents R6 had no visible injuries. R6's care plan does not include a plan of care or newly implemented interventions for this fall occurrence.R6's progress notes document in part on 7/18/2025 at 6:30pm, R6 had an un-witnessed unintentional change in plane, which indicated R6 had fallen.

This same progress note documents R6 had two small bruises and two small skin tears. 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 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 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.

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