Stonespring of Vandalia

In the surveyor’s words

From the most serious findings on record at Stonespring of Vandalia, in the surveyor’s own words.

• Actual harm, isolatedF689Jul 8, 2026

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on record review, staff interview, review of hospital documentation, review of a death certificate, and policy review, the facility failed to ensure adequate care was provided to prevent an avoidable fall with injury. This resulted in Actual Harm when on [DATE] Certified Nursing Assistant (CNA) #315 rolled Resident #135 away from her in the bed during personal care. Resident #135 shifted and rolled out of the bed onto the floor and had immediate complaints of severe back pain. Resident #135 was sent to the hospital and had five rib fractures, admitted to the Surgical Intensive Care Unit (SICU) and died at the hospital. […]

• No harm, potential for more than minimal, patternF711Aug 13, 2026

  Based on staff interview and record review, the facility failed to ensure provider visit notes were written, signed and dated at each visit. This affected four Residents (#3, #10, # 40, and #42) of the four residents reviewed for provider visit notes. The facility census was 140.Findings include: 1) Review of the medical record revealed Resident #3 was admitted to the facility on [DATE]. Diagnoses included chronic kidney disease, hemiplegia and hemiparesis, aphasia, dysphagia, and vascular dementia.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #3 had moderately impaired cognition and psychotic disorder.Review of the provider progress note for Resident #3 revealed a date of service of 07/27/26 and the note was signed and dated 08/13/26.2)… […]

• No harm, potential for more than minimal, patternF712Aug 13, 2026

  Based on staff interview and record review, the facility failed to ensure the Medical Director (MD) visited the residents once every 60 days. This affected four (#3, #11, #12, and #54) of four reviewed for physician visits. This had the potential to affect all the residents who resided in the facility. The census was 140.Findings include1) Review of the medical record revealed Resident #3 was admitted to the facility on [DATE]. Diagnoses included chronic kidney disease, hemiplegia and hemiparesis, aphasia, dysphagia, and vascular dementia.Review of the medical record for Resident #3 revealed MD visits on 01/20/25, 08/11/25 and 07/27/26.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #3 had moderately impaired cognition and psychotic… […]

• No harm, potential for more than minimal, patternF813Aug 13, 2026

  Based on observation, staff interview, and facility policy, the facility failed to ensure food brought in by family or visitors were stored or handled safely and in a sanitary manner. This affected 43 Residents (#3, #6, #8, #10, #11, #14, #15, #20, #21, #23, #28, #31, #36, #39, #40, #45, #46, #54, #56, #59, #62, #68, #71, #72, #75, #77, #80, #82, #83, #87, #88, #91, #93, #98, #99, #103, #105, #111, #119, #121, #123, #134, and #144) out of 140 residents reviewed for refrigerators in room.Findings include: Observation on 08/12/26 at 11:06 A.M. […]

• No harm, potential for more than minimal, isolatedF641Aug 13, 2026

  Based on staff interview, record review, and policy review, the facility failed to ensure a comprehensive assessment was accurate. This affected one (#16) of the seven residents reviewed for assessments. The facility census was 140.Findings include:Review of the medical record revealed Resident #16 was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, dysphagia, and cognitive communication deficit. Review of Resident #16's dental visits on 12/12/25, 01/08/26, 02/13/26 and 07/16/26 with a plan for denture replacement.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #16 cognitively intact, no broken or loosely fitting full or partial denture, and no dental issues.Review of the active care plan for Resident #16 revealed… […]