Inspection Reports for Scenic Manor

1409 N. Fremont, IA, 501261319

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Deficiencies per Year

8 6 4 2 0
2020
2021
2022
2023
2024
2025
Severe High Moderate Low Unclassified

Census Over Time

40 50 60 70 80 90 Jun '20 Oct '21 Oct '23 May '24 May '25
Inspection Report Annual Inspection Census: 65 Deficiencies: 0 May 1, 2025
Visit Reason
The inspection was conducted as an annual recertification survey for Scenic Manor Nursing Home from April 28, 2025 to May 1, 2025.
Findings
The facility was found to be in compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities following the annual recertification survey.
Inspection Report Complaint Investigation Deficiencies: 0 Dec 17, 2024
Visit Reason
Investigation of facility reported incident #124662 conducted from December 11, 2024 to December 17, 2024.
Findings
The facility was found to be in compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities. The reported incident #124662-I was not substantiated.
Complaint Details
Facility reported incident #124662-I was investigated and found not substantiated.
Inspection Report Plan of Correction Deficiencies: 0 Nov 4, 2024
Visit Reason
The document is a Plan of Correction following a credible allegation of substantial compliance for Scenic Manor Nursing Home.
Findings
The facility is in compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities based on acceptance of the credible allegation of substantial compliance and Plan of Correction. The facility will be certified in compliance effective October 23, 2024.
Inspection Report Complaint Investigation Census: 65 Deficiencies: 1 Oct 11, 2024
Visit Reason
The inspection was conducted due to a complaint investigation (#122716-C) regarding the facility's failure to comply with 42 CFR Part 483 requirements, specifically related to physician supervision and monitoring of a resident on anticoagulant therapy.
Findings
The facility failed to ensure proper physician orders were obtained for monitoring therapeutic levels of Coumadin for Resident #3 after hospital discharge. The resident's INR was not checked for three weeks, resulting in dangerously high INR levels (up to 8.85). Interviews confirmed the facility did not follow up with the primary care provider to obtain necessary lab orders.
Complaint Details
Complaint #122716-C was investigated from 10/10/24 through 10/11/24. The complaint involved failure to monitor therapeutic levels of Coumadin for Resident #3, resulting in elevated INR levels and hospital readmission.
Severity Breakdown
Level D: 1
Deficiencies (1)
DescriptionSeverity
Failure to properly obtain a physician order for monitoring therapeutic levels of Coumadin for a resident admitted from the hospital, resulting in delayed INR testing and elevated INR levels.Level D
Report Facts
Census: 65 INR levels: 8.85 INR levels: 5.86 INR levels: 2.54 Medication administration dates: 20
Employees Mentioned
NameTitleContext
Lisa HoofyExecutive DirectorSigned the Statement of Deficiencies and Plan of Correction
Inspection Report Plan of Correction Deficiencies: 0 Jun 24, 2024
Visit Reason
The document is a Plan of Correction following a survey to address deficiencies and certify the facility's compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.
Findings
The Scenic Manor Nursing Home is in substantial compliance based on acceptance of a credible allegation of substantial compliance and the submitted Plan of Correction. The facility will be certified in compliance effective June 14, 2024.
Inspection Report Annual Inspection Census: 60 Deficiencies: 5 May 16, 2024
Visit Reason
The inspection was conducted as the facility's annual recertification survey from May 13 to May 16, 2024.
Findings
The facility was found deficient in notifying a resident representative of a change in condition, medication administration practices regarding insulin pen priming, medication error rates exceeding 5%, medication cart security, and infection prevention and control practices during urinary catheter care.
Severity Breakdown
SS=D: 5
Deficiencies (5)
DescriptionSeverity
Failed to notify a resident representative of a change in condition for Resident #50.SS=D
Failed to provide services that met professional standards regarding medication administration for Residents #22 and #30 by not priming insulin pens prior to administration.SS=D
Medication error rate was 7.69%, exceeding the 5% threshold, due to insulin pen administration errors.SS=D
Medication carts were found unlocked and unattended on two occasions.SS=D
Failed to use appropriate infection control practices during urinary catheter care for Resident #46, including improper glove use and handling of urine spillage.SS=D
Report Facts
Medication error rate: 7.69 Resident census: 60 Insulin dose: 5 Insulin dose: 9 Insulin dose: 54 Size of back mass: 10
Employees Mentioned
NameTitleContext
Lisa HoedjenExecutive DirectorSigned the initial comments and plan of correction.
Staff ARegistered Nurse (RN)Administered insulin without priming the pen.
Staff BLicensed Practical Nurse (LPN)Administered insulin without priming the pen.
Staff CLicensed Practical Nurse (LPN)Responsible for medication cart found unlocked.
Staff DCertified Nursing Assistant (CNA)Failed to follow proper infection control practices during catheter care.
Staff ECertified Nursing Assistant/Certified Medication Aide (CNA/CMA)Reported the lump on Resident #50's back.
Inspection Report Plan of Correction Deficiencies: 0 May 13, 2024
Visit Reason
The document is a Plan of Correction related to the facility's substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, following a survey.
Findings
The Scenic Manor Nursing Home is in substantial compliance based on acceptance of their credible allegation of substantial compliance and Plan of Correction. The facility will be certified in compliance effective May 10, 2024.
Inspection Report Complaint Investigation Census: 61 Deficiencies: 1 Apr 30, 2024
Visit Reason
The inspection was conducted due to substantiated complaint #118777-C and an unsubstantiated incident #118240-I, focusing on compliance with 42 CFR Part 483 requirements for Long Term Care Facilities.
Findings
The facility failed to ensure a resident had prescription medication readily available following discharge, as evidenced by review of clinical records, staff interviews, and pharmacy correspondence. The facility lacked a discharge protocol policy other than care planning.
Complaint Details
Complaint #118777-C was substantiated. Incident #118240-I was not substantiated.
Deficiencies (1)
Description
Failure to ensure a resident had prescription medication readily available following discharge.
Report Facts
Total Census: 61 Deficiencies cited: 1
Employees Mentioned
NameTitleContext
Lisa AtwoodExecutive DirectorSigned the statement of deficiencies and plan of correction.
Director of NursingInterviewed regarding discharge medication issues and pharmacy communication.
AdministratorInterviewed regarding discharge protocol policy.
Inspection Report Complaint Investigation Census: 68 Deficiencies: 0 Oct 24, 2023
Visit Reason
Investigation of a facility self-reported incident #116214-I and a facility complaint #116293-C conducted from October 18, 2023 through October 24, 2023.
Findings
No deficiencies resulted from the investigation of the self-reported incident and complaint.
Complaint Details
Investigation of a facility self-reported incident #116214-I and a facility complaint #116293-C; no deficiencies found.
Report Facts
Total Residents: 68
Inspection Report Plan of Correction Deficiencies: 0 Mar 22, 2023
Visit Reason
The document reflects acceptance of a credible allegation of compliance and plan of correction for the facility.
Findings
The facility will be certified in compliance effective March 22, 2023, based on acceptance of the credible allegation of compliance and plan of correction.
Inspection Report Complaint Investigation Deficiencies: 4 Feb 23, 2023
Visit Reason
A recertification survey and investigation of complaint #110106-C, and incidents #106497-I, #108206-I, #111043-I were conducted from February 20 to 23, 2023 by Healthcare Management Solutions on behalf of Iowa Department of Inspections and Appeals.
Findings
The facility was found not in substantial compliance with 42 CFR 483 subpart B. Deficiencies included inaccurate resident assessments related to oxygen administration, unsecured oxygen tanks posing accident hazards, failure to ensure active physician orders for oxygen therapy, and failure to remove expired medications from medication carts.
Complaint Details
Complaint #110106 was not substantiated. Incidents #106497, #108206, and #111043 were substantiated.
Severity Breakdown
SS=D: 4
Deficiencies (4)
DescriptionSeverity
Failure to ensure 3 of 10 residents had accurate Minimum Data Set (MDS) assessments reflecting oxygen administration.SS=D
Oxygen tanks were not secured in resident rooms, posing potential injury hazards.SS=D
Failure to ensure residents had active physician orders for oxygen therapy, risking inaccurate care.SS=D
Failure to remove expired medications from medication carts, risking resident safety.SS=D
Report Facts
Residents reviewed for oxygen administration accuracy: 10 Residents reviewed for unsecured oxygen tanks: 10 Residents reviewed for oxygen therapy orders: 10 Medication carts reviewed: 2 Expired medication pills counted: 11
Employees Mentioned
NameTitleContext
Licensed Practical Nurse 2Licensed Practical NurseConfirmed oxygen concentrator and BIPAP use for Resident 16
Registered Nurse 1Registered NurseVerified oxygen use by Resident 19 and oxygen administration details
Registered Nurse 3Registered NurseConfirmed expired medication for Resident 21
Director of NursingDirector of NursingObserved unsecured oxygen tanks and confirmed policy expectations
Inspection Report Complaint Investigation Census: 80 Deficiencies: 3 Feb 3, 2022
Visit Reason
The inspection was conducted as an investigation of incidents #99246 and #101660 between 1/19/22 and 2/3/22 to determine compliance with drug labeling and storage regulations.
Findings
The facility failed to ensure proper storage of controlled drugs requiring refrigeration in locked compartments, failed to destroy discontinued medications timely, and failed to complete required control shift counts. The facility reported a census of 80 residents during the inspection.
Complaint Details
Facility Reported Incident #99246 was substantiated. Facility Reported Incident #101660 was not substantiated.
Severity Breakdown
Level 4: 1
Deficiencies (3)
DescriptionSeverity
Failure to ensure a level 4 controlled drug requiring refrigeration was secured in a separately locked compartment within the medication refrigerator for 2 of 4 residents reviewed.Level 4
Failure to destroy ordered PRN liquid lorazepam discontinued after 14 days as per facility policy.
Failure to complete the control shift count as directed by facility policy.
Report Facts
Census: 80 Medication bottles: 7 Medication measurement: 22 Medication measurement: 28.5
Employees Mentioned
NameTitleContext
Staff ALicensed Practical Nurse (LPN)Confirmed medication counts and storage issues
Staff BLicensed Practical Nurse (LPN)Confirmed medication counts and storage issues
Staff CLicensed Practical Nurse (LPN)Confirmed storage of liquid lorazepam outside locked container
Staff DLicensed Practical Nurse (LPN)Confirmed storage of liquid lorazepam outside locked container
Staff ELicensed Practical Nurse (LPN)Reported narcotic shift count complacency prior to education
Assistant Director of NursingADONConfirmed medication storage practices and medication measurements
Director of NursingDONPrepared medication review document provided to Administrator
AdministratorProvided document prepared by DON
Inspection Report Annual Inspection Census: 51 Deficiencies: 0 Oct 7, 2021
Visit Reason
The annual health recertification survey and investigation of complaints #93230-C, #97971-C, and incident #100131-I was conducted from 10/4/2021 to 10/7/2021.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, Requirement for Long Term Care Facilities. Complaints #93230 and #97971, and incident #100131 were not substantiated.
Complaint Details
Complaint #93230 was not substantiated. Complaint #97971 was not substantiated. Incident #100131 was not substantiated.
Report Facts
Total residents: 51
Inspection Report Abbreviated Survey Census: 57 Deficiencies: 0 Dec 15, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report Abbreviated Survey Census: 58 Deficiencies: 0 Jun 18, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total residents: 58

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