The most recent inspection on May 1, 2025 found the facility in compliance with all applicable long-term care requirements and no deficiencies were noted. Earlier inspections showed a mixed record, with some deficiencies related to medication management, infection control, and physician order monitoring, including a substantiated complaint in October 2024 involving delayed INR testing for a resident on anticoagulant therapy. Prior reports also cited issues with medication administration practices, notification of resident condition changes, and securing medication carts, as well as a substantiated complaint in April 2024 for failure to ensure prescription medication availability after discharge. Complaint investigations were mostly unsubstantiated except for the noted cases involving medication monitoring and discharge medication availability. The trend suggests improvement over time, with the most recent inspection showing no deficiencies following previous corrective actions.
Deficiencies (last 6 years)
Deficiencies (over 6 years)2.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
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.
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 CorrectionDeficiencies: 0Nov 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.
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)
Description
Severity
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.
Signed the Statement of Deficiencies and Plan of Correction
Inspection Report Plan of CorrectionDeficiencies: 0Jun 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.
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)
Description
Severity
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: 7.69Resident census: 60Insulin dose: 5Insulin dose: 9Insulin dose: 54Size of back mass: 10
Employees Mentioned
Name
Title
Context
Lisa Hoedjen
Executive Director
Signed the initial comments and plan of correction.
Staff A
Registered Nurse (RN)
Administered insulin without priming the pen.
Staff B
Licensed Practical Nurse (LPN)
Administered insulin without priming the pen.
Staff C
Licensed Practical Nurse (LPN)
Responsible for medication cart found unlocked.
Staff D
Certified Nursing Assistant (CNA)
Failed to follow proper infection control practices during catheter care.
Inspection Report Plan of CorrectionDeficiencies: 0May 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.
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: 61Deficiencies cited: 1
Employees Mentioned
Name
Title
Context
Lisa Atwood
Executive Director
Signed the statement of deficiencies and plan of correction.
Director of Nursing
Interviewed regarding discharge medication issues and pharmacy communication.
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 CorrectionDeficiencies: 0Mar 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.
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)
Description
Severity
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: 10Residents reviewed for unsecured oxygen tanks: 10Residents reviewed for oxygen therapy orders: 10Medication carts reviewed: 2Expired medication pills counted: 11
Employees Mentioned
Name
Title
Context
Licensed Practical Nurse 2
Licensed Practical Nurse
Confirmed oxygen concentrator and BIPAP use for Resident 16
Registered Nurse 1
Registered Nurse
Verified oxygen use by Resident 19 and oxygen administration details
Registered Nurse 3
Registered Nurse
Confirmed expired medication for Resident 21
Director of Nursing
Director of Nursing
Observed unsecured oxygen tanks and confirmed policy expectations
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)
Description
Severity
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.
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.
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.
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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