Marymount Manor
Inspection Findings
F-Tag F0684
F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
7/24/25, Day shift: No IFU documentation;-On 7/24/25, Night shift: No IFU documentation;-On 7/25/25, Day shift: No IFU documentation;-On 7/25/25, Night shift: No IFU documentation. 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 REDACTED], 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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MARYMOUNT MANOR in EUREKA, MO 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 EUREKA, MO, (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 MARYMOUNT MANOR or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.