Inspection Reports for
Scenic Hills at the Monastery
710 SUNRISE DRIVE, FERDINAND, IN, 47532
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
10 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
138% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
69% occupied
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Life Safety
Census: 61
Capacity: 88
Deficiencies: 0
Date: Jun 24, 2025
Visit Reason
A Life Safety Code and Environmental Preoccupancy Survey was conducted for the relocation of two beds from room 704 to rooms 706 and 708, and to assess compliance with fire safety and environmental standards.
Findings
The facility was found in compliance with Medicare/Medicaid participation requirements, Life Safety Code from Fire, and Indiana's Health Facilities Rules. The facility is fully sprinklered with a fire alarm system and hard wired smoke detectors. The 600 Unit including 23 Assisted Living beds was surveyed due to lack of a two-hour fire barrier separation from the 700 Unit Memory Care for Comprehensive Care beds.
Report Facts
Beds relocated: 2
Assisted Living beds: 23
Inspection Report
Renewal
Deficiencies: 0
Date: Apr 14, 2025
Visit Reason
The visit was a paper compliance review for the Recertification, State Licensure Survey ending on March 10, 2025.
Findings
Scenic Hills at the Monastery was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review for the Recertification, State Licensure Survey.
Inspection Report
Life Safety
Census: 86
Capacity: 88
Deficiencies: 0
Date: Apr 2, 2025
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a).
Findings
The facility was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements. The facility is fully sprinklered with a fire alarm system and has a capacity of 88 certified beds with a census of 86 at the time of the survey. The 600 Unit Assisted Living beds were surveyed due to lack of a two-hour fire barrier separation from the 700 Unit Memory Care beds.
Report Facts
Certified beds capacity: 88
Resident census: 86
Assisted Living beds: 23
Inspection Report
Annual Inspection
Census: 122
Deficiencies: 6
Date: Mar 10, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey including a State Residential Licensure Survey conducted from March 4 to March 10, 2025.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity during meals, failure to meet professional standards in skin condition care, inadequate fall prevention interventions, improper infection control practices including PPE use and medication handling, and failure to complete and read required tuberculosis skin tests.
Deficiencies (6)
Failure to maintain resident dignity and provide timely assistance with meals for a dependent resident (Resident 42).
Failure to ensure services met professional standards for skin conditions; a blister was not assessed timely and wound care was improperly performed (Resident 40).
Failure to ensure adequate supervision and assistance devices to prevent falls; mattress not moved with resident during room change and fall interventions not consistently in place (Resident 40).
Failure to provide a safe and sanitary environment to prevent infections and properly prevent/contain COVID-19; improper PPE use, hand hygiene, and medication handling observed (Residents 40, 52, 81).
Failure to properly prevent and/or contain COVID-19 due to staff not using proper PPE when entering a COVID-19 room (Resident 106).
Failure to ensure tuberculin skin tests were completed and read for residents; missing second step tests and unread tests (Residents 103, 106, 107).
Report Facts
Survey dates: March 4-10, 2025
Census: 122
Resident 42 meal assistance delay: 19
Resident 42 meal assistance delay: 18
Blister measurement: 2.5
Blister measurement: 2.7
Fall incidents: 4
TB skin test dates: 2/8/25, 2/24/25, 1/25/25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bailey Sherman | Executive Director | Signed report and provided policies during survey |
| LPN 9 | Licensed Practical Nurse | Observed performing improper wound care and medication preparation |
| CNA 7 | Certified Nurse Aide | Interviewed regarding meal assistance protocol |
| QMA 13 | Qualified Medication Aide | Interviewed regarding fall interventions |
| Regional Consultant | Provided expert opinions and policy explanations during survey | |
| Infection Preventionist | Provided infection control guidance and policy explanations | |
| Administrator | Provided facility policies and job descriptions |
Inspection Report
Routine
Deficiencies: 4
Date: Mar 10, 2025
Visit Reason
Routine inspection to assess compliance with resident rights, quality of care, accident prevention, and infection control standards at Scenic Hills at the Monastery nursing home.
Findings
The facility failed to maintain resident dignity by delaying assistance with eating, did not meet professional standards in wound care, failed to ensure adequate supervision to prevent falls, and did not properly implement infection prevention and control protocols including PPE use and medication handling.
Deficiencies (4)
F 0550: The facility failed to maintain resident dignity and protect resident rights by delaying assistance with eating for Resident 42 during observed meals.
F 0658: The facility failed to meet professional standards for wound care for Resident 40, including lack of assessment, improper dressing changes, and failure to address skin irritation.
F 0689: The facility failed to ensure adequate supervision and use of assistive devices to prevent falls for Resident 40, including failure to move mattress during room change and missing fall interventions.
F 0880: The facility failed to provide proper infection prevention and control, including improper PPE use, inadequate hand hygiene, and unsafe medication handling for Residents 40, 52, and 81.
Report Facts
Falls: 4
Wound measurement: 2.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 9 | Licensed Practical Nurse | Named in wound care and infection control deficiencies involving Resident 40 and medication administration. |
| CNA 5 | Certified Nurse Aide | Observed delaying assistance with Resident 42 during meals. |
| CNA 7 | Certified Nurse Aide | Interviewed about meal assistance protocols. |
| QMA 7 | Qualified Nurse Aide | Observed improper infection control during toileting of Resident 40. |
| CNA 22 | Certified Nurse Aide | Observed improper PPE use entering Resident 81's COVID-19 isolation room. |
Inspection Report
Complaint Investigation
Census: 120
Deficiencies: 0
Date: Aug 2, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00438378.
Complaint Details
Complaint IN00438378 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00438378 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type Total: 120
Census Payor Type Total: 86
Medicare Census: 11
Medicaid Census: 45
Other Payor Census: 30
Inspection Report
Life Safety
Census: 81
Capacity: 88
Deficiencies: 0
Date: Apr 2, 2024
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a).
Findings
The facility was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements. The facility is fully sprinklered with a fire alarm system and has a capacity of 88 certified beds with a census of 81 at the time of the survey. The 600 Unit Assisted Living beds were surveyed due to lack of a two-hour fire barrier separation from the 700 Unit Memory Care beds.
Report Facts
Certified beds capacity: 88
Census: 81
Assisted Living beds: 23
Inspection Report
Routine
Census: 81
Deficiencies: 3
Date: Mar 13, 2024
Visit Reason
The inspection was conducted to evaluate the sanitary conditions of food storage, preparation, and service in the facility's kitchen.
Findings
The facility failed to maintain sanitary conditions in the kitchen during three observations, with multiple areas showing food debris, grease buildup, and improper cleaning practices that could potentially affect 81 residents receiving meals.
Deficiencies (3)
F 0812: The facility failed to procure food from approved sources and did not store, prepare, distribute, and serve food under sanitary conditions during three kitchen observations. Multiple areas including fryers, storage rooms, grills, sandwich stations, and carts had accumulations of food particles, grease, and debris.
A dietary aide was observed holding dishes removed from the clean side of the dishwasher against her soiled uniform, indicating improper handling of clean dishes.
Cleaning schedules indicated limited completion of cleaning tasks, and a facility policy related to kitchen cleanliness was not provided.
Report Facts
Residents affected: 81
Date survey completed: Mar 13, 2024
Inspection Report
Recertification
Census: 119
Deficiencies: 2
Date: Mar 13, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey and the Investigation of Complaint IN00429678. This visit included a State Residential Licensure Survey.
Complaint Details
Complaint IN00429678 - No deficiencies related to the allegations are cited.
Findings
The facility was found to have deficiencies related to medication labeling and storage, and food safety and sanitation in the kitchen. No deficiencies were cited related to the complaint investigation. The medication carts had multiple issues with improper labeling, storage, and expired or discontinued medications. The kitchen had multiple sanitation issues including food particles, grease buildup, and improper cleaning practices.
Deficiencies (2)
Failed to ensure appropriate labeling and storage of medications for 2 of 3 medication carts with 11 of 16 residents reviewed for Medication Storage.
Failed to ensure food was served and stored under sanitary conditions during 3 of 3 kitchen observations.
Report Facts
Census Bed Type: 119
Residential Census: 36
Residents affected by medication deficiency: 11
Residents affected by food safety deficiency: 81
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennie Deyne | Admin | Laboratory Director's or Provider/Supplier Representative's signature on report |
| RN 4 | Nurse involved in medication cart observations and interviews | |
| LPN 7 | Nurse involved in medication cart observations and interviews | |
| Clinical Support Nurse | Interviewed regarding medication orders and storage | |
| Dietary Manager | Interviewed and observed during kitchen sanitation inspections | |
| Dietary Cook 1 | Observed during kitchen sanitation inspections | |
| Assistant Dietary Manager | Provided cleaning schedules for kitchen |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 13, 2024
Visit Reason
Paper compliance review for the Recertification, State Licensure, and Investigation of Complaint IN00429678 survey.
Complaint Details
Investigation of Complaint IN00429678 was part of the survey.
Findings
Scenic Hills at the Monastery was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review for the Recertification, State Licensure, and Investigation of Complaint IN00429678 Survey.
Inspection Report
Routine
Deficiencies: 2
Date: Mar 13, 2024
Visit Reason
The inspection was conducted to evaluate compliance with medication storage and labeling regulations, as well as food safety and sanitation standards in the facility's kitchen.
Findings
The facility failed to ensure proper labeling and storage of medications on two medication carts affecting multiple residents, and failed to maintain sanitary conditions in the kitchen during three observations, potentially affecting 81 residents.
Deficiencies (2)
F 0761: The facility failed to ensure drugs and biologicals were labeled and stored according to accepted professional principles, with issues found on two medication carts involving improperly labeled, stored, and discontinued medications for multiple residents.
F 0812: The facility failed to procure food from approved sources and maintain sanitary conditions in the kitchen, with multiple observations of food particles, grease buildup, and unsanitary storage areas during three kitchen inspections.
Report Facts
Residents affected: 11
Residents affected: 81
Medication doses remaining: 186
Medication open date days: 42
Medication order dates: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 4 | Registered Nurse | Interviewed regarding medication storage and labeling issues on 500 Hall medication cart |
| LPN 7 | Licensed Practical Nurse | Interviewed regarding medication storage on 300 Hall medication cart |
| Clinical Support Nurse | Interviewed regarding medication orders and storage practices | |
| Dietary Manager | Interviewed during kitchen observations about sanitation issues | |
| Consultant Pharmacist | Interviewed regarding inhaler storage instructions |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Dec 8, 2023
Visit Reason
The inspection was conducted in response to complaints regarding the facility's failure to provide timely and appropriate care following resident falls resulting in fractures, and concerns about cleanliness and the homelike environment in resident rooms and areas.
Complaint Details
The citation relates to complaints IN00422495 and IN00416683. Complaints involved delayed care after resident falls with fractures and inadequate cleanliness in resident rooms and areas.
Findings
The facility failed to provide timely assessment and treatment following resident falls with fractures for two residents, resulting in delayed hospital transfers. Additionally, the facility failed to maintain a clean and homelike environment in resident rooms and common areas over multiple days.
Deficiencies (2)
F 0684: The facility failed to provide timely treatment and care following resident falls that resulted in fractures for 2 of 3 residents reviewed. Delays included waiting several hours for X-ray results and physician orders before hospital transfer.
F 0921: The facility failed to maintain a clean, homelike environment in resident rooms and areas for 2 of 2 days during the survey. Rooms were not cleaned daily and resident areas contained dust, debris, and trash.
Report Facts
Pain assessment scores: 5
Dates of missing housekeeping forms: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| PT 8 | Physical Therapist | Witnessed Resident G fall during physical therapy on 11/17/23. |
| Director of Nursing | Director of Nursing (DON) | Provided information on nursing expectations for X-ray follow-up and was notified of delayed care. |
| Housekeeper 4 | Housekeeper | Reported being the only housekeeper scheduled on a day and unable to clean all rooms. |
| Housekeeper 6 | Housekeeper | Reported housekeeping staffing shortages affecting daily cleaning. |
| Housekeeper 2 | Housekeeper | Reported housekeeping staff fill out daily cleaning schedules. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 8, 2023
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of complaints IN00416683 and IN00422495 ending on December 8, 2023.
Complaint Details
Investigation of Complaint IN00416683 and IN00422495; facility found in compliance.
Findings
Scenic Hills at the Monastery was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review for the investigation of the specified complaints.
Inspection Report
Complaint Investigation
Census: 80
Capacity: 115
Deficiencies: 2
Date: Dec 7, 2023
Visit Reason
This visit was for the investigation of complaints IN00422495 and IN00416683 concerning quality of care and environmental conditions at the facility.
Complaint Details
Complaints IN00422495 and IN00416683 were investigated. Deficiencies related to allegations in IN00422495 were cited at F684. Deficiencies related to allegations in IN00416683 were cited at F921 and F684. The investigation found substantiated issues with quality of care and environmental cleanliness.
Findings
The facility failed to provide timely quality care following resident falls resulting in fractures for 2 residents, and failed to maintain a clean, homelike environment in resident rooms and areas during the survey.
Deficiencies (2)
Failure to provide timely quality care and services following resident falls resulting in fractures for 2 of 3 residents reviewed.
Failure to provide a clean, homelike environment in resident rooms and resident areas; rooms were not cleaned daily and contained dust, debris, and trash.
Report Facts
Census Bed Type Total: 115
Census Payor Type Total: 80
Deficiencies cited: 2
Audit frequency: 5
Audit frequency: 5
Audit frequency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennie Deyne | Admin | Signed the report |
| Director of Nursing | Director of Nursing | Interviewed regarding expectations for x-ray follow-up and notification |
| PT 8 | Physical Therapist | Witnessed Resident G fall during physical therapy |
| Housekeeper 4 | Housekeeper | Interviewed about housekeeping staffing and cleaning schedules |
| Housekeeper 6 | Housekeeper | Interviewed about housekeeping staffing and cleaning schedules |
| Housekeeper 2 | Housekeeper | Interviewed about housekeeping daily cleaning schedule |
| Facility Administrator | Facility Administrator | Provided policy documents and information about diagnostic testing agreements |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 16, 2023
Visit Reason
Paper compliance review related to the Investigation of Complaint IN00412493 survey ending on August 17, 2023.
Complaint Details
Investigation of Complaint IN00412493; paper compliance review found the facility in compliance.
Findings
Scenic Hills at the Monastery was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review for the Investigation of Complaint IN00412493 survey.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 17, 2023
Visit Reason
The inspection was conducted in response to a complaint (IN00412493) regarding failure to provide bathing assistance to a resident as per the care plan and resident preferences.
Complaint Details
Complaint IN00412493 was substantiated. The facility failed to provide bathing assistance as required, confirmed by resident grievance, record review, and staff interviews.
Findings
The facility failed to provide bathing assistance to 1 of 3 residents reviewed for activities of daily living. Resident F did not receive scheduled showers or complete bed baths according to the care plan and preferences, with documented missed bathing days and resident grievances.
Deficiencies (1)
F 0677: The facility failed to provide assistance with bathing for 1 of 3 residents reviewed. Resident F did not receive bathing according to the plan of care or resident preferences, with missed showers documented.
Report Facts
Residents reviewed for ADLs: 3
Residents affected: 1
Dates of documented complete bed baths/showers for Resident F: 9
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 0
Date: Aug 16, 2023
Visit Reason
This visit was conducted for the investigation of Residential Complaint IN00412493, which included the investigation of Nursing Home Complaint IN00412493.
Complaint Details
Complaint IN00412493 was investigated and no deficiencies were cited related to the allegations.
Findings
No deficiencies were cited related to the allegations. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the investigation of the residential complaint.
Report Facts
Residential Census: 34
Inspection Report
Complaint Investigation
Census: 120
Capacity: 75
Deficiencies: 2
Date: Jun 29, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00409650 regarding federal/state deficiencies related to allegations cited at F689 and F880.
Complaint Details
Complaint IN00409650 was substantiated with federal/state deficiencies cited at F689 and F880 related to fall prevention and infection control.
Findings
The facility failed to provide adequate supervision to prevent falls for 2 residents, failed to complete neurological assessments after unwitnessed falls, and left a medication cart unlocked on a locked dementia unit. Additionally, infection control practices were deficient with staff failing to sanitize hands and change gloves properly during perineal/incontinence care.
Deficiencies (2)
Failed to provide adequate supervision and fall prevention interventions for residents with multiple falls; neurological assessments not completed for unwitnessed falls; medication cart left unlocked on locked dementia unit.
Failed to establish and maintain an infection prevention and control program; staff failed to sanitize hands and change gloves properly during perineal/incontinence care.
Report Facts
Residents reviewed for accidents: 6
Residents observed for infection control: 5
Fall events audited: 5
Medication carts audited: 5
Census Bed Type Total: 120
Total Capacity: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bailey Sherman | Executive Director | Signed the report |
| LPN 14 | Licensed Practical Nurse | Provided information on fall interventions and supervision |
| CNA 6 | Certified Nurse Aide | Observed during medication cart unlocked and fall interventions |
| CNA 4 | Certified Nurse Aide | Observed during infection control deficiencies in perineal care |
| QMA 20 | Qualified Medication Aide | Observed during infection control deficiencies in incontinence care |
| DON | Director of Nursing | Provided interviews regarding falls, neurological assessments, and infection control |
| Administrator | Provided policies and interviews regarding falls and infection control |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 29, 2023
Visit Reason
The inspection was conducted as a paper compliance review for the Investigation of Complaint IN00409650 survey ending on June 29, 2023.
Complaint Details
Investigation of Complaint IN00409650; facility found in compliance.
Findings
Scenic Hills Care Center was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review for the Investigation of Complaint IN00409650 Survey.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jun 29, 2023
Visit Reason
The inspection was conducted in response to a complaint (IN00409650) regarding falls, accident hazards, and infection control practices at the nursing home.
Complaint Details
This Federal tag relates to Complaint IN00409650.
Findings
The facility failed to provide adequate supervision and fall prevention interventions for residents with multiple falls, including incomplete neurological assessments after unwitnessed falls. Additionally, infection control practices were deficient, with staff failing to properly sanitize hands and change gloves during perineal/incontinence care. A medication cart was also found unlocked on the locked dementia unit.
Deficiencies (2)
F 0689: The facility failed to ensure a nursing home area was free from accident hazards and provided inadequate supervision to prevent falls for 2 residents. Fall interventions were not updated after ineffective outcomes and neuro assessments were incomplete after an unwitnessed fall.
F 0880: The facility failed to implement proper infection prevention and control practices for 4 of 5 residents during perineal/incontinence care. Staff did not sanitize hands or change gloves appropriately and failed to wash hands for at least 20 seconds.
Report Facts
Number of falls for Resident G: 7
Number of residents observed for infection control: 5
Inspection Report
Complaint Investigation
Census: 112
Deficiencies: 0
Date: Mar 13, 2023
Visit Reason
This visit was for an investigation of Complaints IN00399725 and IN00401192.
Complaint Details
Complaint IN00399725: No deficiencies were cited related to the allegations. Complaint IN00401192: No deficiencies were cited related to the allegations.
Findings
No deficiencies were cited related to the allegations in both complaints. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the investigation of the complaints.
Report Facts
Census Bed Type Total: 112
Census Payor Type Total: 78
Census Bed Type SNF: 11
Census Bed Type SNF/NF: 67
Census Bed Type Residential: 34
Census Payor Type Medicare: 13
Census Payor Type Medicaid: 47
Census Payor Type Other: 18
Inspection Report
Life Safety
Census: 75
Capacity: 88
Deficiencies: 1
Date: Dec 7, 2022
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a) respectively.
Findings
The facility was found in compliance with Emergency Preparedness Requirements and in substantial compliance with Life Safety Code requirements. However, a deficiency was cited for incomplete quarterly fire drill documentation for one shift during the first quarter of 2022.
Deficiencies (1)
Failed to provide complete quarterly fire drill documentation for the second shift (evening) of the first quarter (January, February, and March) of 2022.
Report Facts
Certified beds capacity: 88
Census: 75
Assisted Living beds: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bailey Sherman | Executive Director | Present during exit conference and referenced in plan of correction |
| Director of Plant Operations | Interviewed regarding fire drill documentation deficiency |
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 7
Date: Oct 28, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey and Investigation of Complaint IN00391007.
Complaint Details
Complaint IN00391007 was investigated and found to be unsubstantiated due to lack of evidence.
Findings
The facility was found to have multiple deficiencies including failure to maintain resident privacy during medication administration, failure to implement comprehensive care plans, inadequate supervision and assistance to prevent accidents, improper medication cart security and medication handling, unsanitary food storage and preparation areas, and lapses in infection prevention and control practices. The complaint was unsubstantiated due to lack of evidence.
Deficiencies (7)
Failed to maintain privacy for 6 of 8 residents during medication administration and staff did not knock before entering rooms.
Failed to implement comprehensive person-centered care plans for 5 of 7 residents reviewed, including failure to follow physician orders and care plan interventions.
Failed to ensure adequate supervision and assistance to prevent accidents; medication carts left unlocked; medications left unattended in resident rooms; loose pills found in medication carts.
Failed to ensure sanitary preparation and storage of food; expired food items found; dirty refrigerator, microwave, and coffee mugs.
Failed to ensure infection control practices during wound care, medication administration, and catheter care; hands not washed or gloves changed appropriately; catheter bag hung on trash can.
Failed to designate a dementia care unit director with a required earned degree.
Failed to post completed nurse staffing sheets daily for 5 of 5 days during the survey.
Report Facts
Survey dates: October 24, 25, 26, 27, 28, 2022
Census Bed Type: 112
Census Payor Type: 76
Resident count affected by privacy deficiency: 6
Resident count affected by care plan deficiency: 5
Weight gain for Resident 68: 6
Medication administration observation count: 3
Medication cart loose pills count: 9
Expired food items count: 2
Blue coffee mugs with brown debris: 5
Nurse staffing sheets missing: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bailey Sherman | Executive Director | Signed report and involved in leadership |
| LPN 17 | Licensed Practical Nurse, Dementia Care Unit Director | Named as dementia care unit director without required degree |
| RN 3 | Registered Nurse | Observed medication administration with infection control lapses |
| PTD | Physical Therapy Director | Observed performing wound care with infection control lapses |
| LPN 14 | Licensed Practical Nurse | Interviewed regarding medication administration and medication cart cleaning |
| ADON | Assistant Director of Nursing | Interviewed regarding medication administration and catheter care |
| Regional Support Nurse | Interviewed regarding medication administration policies | |
| Housekeeping Director | Interviewed regarding cleaning responsibilities |
Inspection Report
Renewal
Deficiencies: 0
Date: Oct 28, 2022
Visit Reason
The inspection was conducted as a paper compliance review for the Recertification and State Licensure Survey ending on October 28, 2022.
Findings
Scenic Hills Care Center was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review for the Recertification and State Licensure Survey.
Inspection Report
Routine
Deficiencies: 6
Date: Oct 28, 2022
Visit Reason
The inspection was a routine survey to assess compliance with federal regulations regarding resident care, medication administration, infection control, staffing, food safety, and safety hazards.
Findings
The facility was found deficient in maintaining resident privacy during medication administration, implementing comprehensive care plans, ensuring safety during resident transfers and dining, securing medication carts, posting nurse staffing information, maintaining sanitary food preparation areas, and following infection prevention and control protocols.
Deficiencies (6)
F 0583: The facility failed to maintain privacy for 6 of 8 residents during medication administration and 1 of 1 random interview. Doors were left open during insulin injection, staff did not knock before entering rooms, and resident doors were not always closed.
F 0656: The facility failed to implement comprehensive person-centered care plans for 5 of 7 residents, including failure to keep call lights within reach, use gait belts during transfers, and administer ordered medications such as Lasix.
F 0689: The facility failed to ensure adequate supervision and safety during dining and medication administration. Medication carts were left unlocked, medications were left unattended in resident rooms, and loose pills were found in medication carts.
F 0732: The facility failed to post completed nurse staffing sheets daily for 5 of 5 days during the survey, with incomplete information on posted forms.
F 0812: The facility failed to ensure sanitary food preparation and storage. A refrigerator and microwave were dirty, coffee mugs had brown debris inside, and dry storage items were past their use-by dates.
F 0880: The facility failed to implement infection prevention and control practices. A disposable syringe was left on a bathroom sink, medications were handled with bare hands, catheter bags were hung improperly, and wound care was performed without proper hand hygiene.
Report Facts
Residents affected: 6
Residents affected: 5
Residents affected: 1
Residents affected: 6
Residents affected: 1
Days: 5
Loose pills: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 3 | Registered Nurse | Observed administering medications improperly and not sanitizing hands between rooms |
| LPN 14 | Licensed Practical Nurse | Interviewed about Lasix medication administration and medication cart cleaning |
| LPN 17 | Licensed Practical Nurse | Observed and interviewed regarding call light use and gait belt use |
| PTD | Physical Therapy Director | Observed performing wound care without proper hand hygiene and privacy practices |
| ADON | Assistant Director of Nursing | Interviewed about medication handling and catheter bag hanging practices |
| RN 22 | Registered Nurse | Observed locking medication cart |
| Regional Support Nurse | Interviewed about medication administration policies |
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