Inspection Reports for
Scenic Manor

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.

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.

The complaint investigation focused on Resident #3's anticoagulation management. The facility did not have PT/INR lab orders from admission on 5/8/24 until 5/29/24 when the INR was critically high at 8.85. Interviews confirmed the facility failed to follow up with the primary care provider to obtain lab orders, despite the resident's high risk.

The facility failed to ensure Resident #3 had a physician order to monitor PT/INR levels upon admission, resulting in no PT/INR tests for nearly three weeks. Resident #3's INR levels were critically high, reaching 8.85, which posed a risk of hemorrhage or blood clots.

The facility failed to notify a resident's representative of a significant change in condition, improperly administered insulin without priming the pens, left medication carts unlocked unattended, and failed to follow proper infection control practices during urinary catheter care.

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.

Complaint #118777-C was substantiated. Incident #118240-I was not substantiated.

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.

The complaint was substantiated. Resident #3 did not have medication available for 2 days post-discharge due to communication failures between the facility, pharmacy, and physician's office.

The facility failed to ensure that Resident #3 had prescription medication available immediately after discharge. Communication issues between the nursing home, pharmacy, and physician's office contributed to the delay in medication availability.

The facility failed to ensure accurate Minimum Data Set (MDS) assessments for residents receiving oxygen therapy, secure oxygen tanks properly, maintain active physician orders for oxygen administration, and remove outdated medications from medication carts. These deficiencies posed potential risks for resident safety and care accuracy.

Complaint #110106 was not substantiated. Incidents #106497, #108206, and #111043 were substantiated.

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.

Facility Reported Incident #99246 was substantiated. Facility Reported Incident #101660 was not substantiated.

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.