Marymount Manor

Review of the resident's medical record, showed no Neurological Evaluation completed for the falls on 7/20/25 and 7/23/25. 3.

Review of Resident #3's admission MDS, dated [DATE], showed:-Severe cognitive impairment;-Occasionally incontinent of bowel and bladder;-No falls anytime in the last month;-Diagnoses included high blood pressure, end stage renal (kidney) disease (ESRD), stroke, dementia and depression.

Review of the resident's progress notes, dated 7/28/25 at 7:48 A.M., showed the resident was found on the floor next to his/her bed on his/her face as if he/she rolled out of bed. No apparent injury noted.

Physician, supervisor and family notified, neuro checks started.

Review of the resident's Neurological Evaluation, dated 7/28/25, showed:-7/28/25 at 7:03 A.M., not completed;-7/28/25 at 7:33 A.M., not completed;-7/28/25 at 8:03 A.M., not completed;-7/28/25 at 9:03 A.M., not completed;-7/28/25 at 10:03 A.M., not completed;-7/29/25, Day shift, not completed.

Review of the resident's progress notes, dated 7/29/25, Day shift: No IFU documentation.

Review of the resident's Neurological Evaluation, dated 7/28/25, showed:-7/30/25, Day shift, not completed;-7/30/25, Night shift, not completed. 4.

During an interview on 9/8/25 at 12:43 P.M., Licensed Practical Nurse (LPN) A said when a resident has a fall, the nurse assesses the resident for any injuries and vital signs are completed.

Neuro checks are also completed if the resident hit their head or if the fall was unwitnessed.

The nurse then would contact the physician, resident's family, the nursing supervisor and hospice if the resident is on hospice. A nurse's note would be completed on how the resident fell, if there were any injuries and the notifications that were made. An incident report would be filled out regarding the fall. A nurse's note would be completed each shift for three days for the IFU that would include if there was any new bruising or complaints of pain and vital signs each shift.

During an interview on 9/8/25 at 1:02 P.M., LPN B said when a resident has a fall, the nurse completes a full body assessment on the resident and vital signs.

Neuros are completed if the fall was unwitnessed or if the resident hit their head.

The nurse notifies the physician and the resident's family and documents the notifications and a description of the fall in a nurses note. An incident report is also completed on the fall.

IFU documentation is completed for three days on each shift in the nurse's notes.

The documentation includes vital signs, and the assessment of the resident for that shift.

During an interview on 9/8/25 at 2:23 P.M., the Administrator and Director of Nursing (DON) said when a resident has a fall, they expected the nurse to assess the resident to check for any injuries.

They expected the nurse to notify the physician, Administrator, DON and family and document the notifications in the nurses note and incident report.

They expect the nurses note and incident report to include what contributed to the fall and if there were any injuries, what happened, where it happened, how it happened and who was notified.

They expected the summary of the incident to show a picture of what happened.

They expected neuro checks to be completed for any resident who hits their head or if the fall is unwitnessed.

They expected IFU documentation to be completed for 72 hours and that documentation to include the full assessment of the resident and if there is any change of condition. If there is any change in condition, they expected the nurse to contact the physician, family, Administrator and DON.

They expected the change of condition and notifications to be documented in a nurses note.

They expected staff to be knowledgeable of and to follow the facility policies.

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