Inspection Report Summary
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.
48% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
65 residents
Based on a May 2025 inspection.
Census over time
Inspection Report
Annual Inspection
Census: 65
Deficiencies: 0
Date: 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
Date: Dec 17, 2024
Visit Reason
Investigation of facility reported incident #124662 conducted from December 11, 2024 to December 17, 2024.
Complaint Details
Facility reported incident #124662-I was investigated and found not substantiated.
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.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: 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
Date: 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.
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.
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.
Deficiencies (1)
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.
Report Facts
Census: 65
INR levels: 8.85
INR levels: 5.86
INR levels: 2.54
Medication administration dates: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Hoofy | Executive Director | Signed the Statement of Deficiencies and Plan of Correction |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: 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
Date: 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.
Deficiencies (5)
Failed to notify a resident representative of a change in condition for Resident #50.
Failed to provide services that met professional standards regarding medication administration for Residents #22 and #30 by not priming insulin pens prior to administration.
Medication error rate was 7.69%, exceeding the 5% threshold, due to insulin pen administration errors.
Medication carts were found unlocked and unattended on two occasions.
Failed to use appropriate infection control practices during urinary catheter care for Resident #46, including improper glove use and handling of urine spillage.
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
| 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. |
| Staff E | Certified Nursing Assistant/Certified Medication Aide (CNA/CMA) | Reported the lump on Resident #50's back. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: 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
Date: 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.
Complaint Details
Complaint #118777-C was substantiated. Incident #118240-I was not substantiated.
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.
Deficiencies (1)
Failure to ensure a resident had prescription medication readily available following discharge.
Report Facts
Total Census: 61
Deficiencies 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. | |
| Administrator | Interviewed regarding discharge protocol policy. |
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 0
Date: 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.
Complaint Details
Investigation of a facility self-reported incident #116214-I and a facility complaint #116293-C; no deficiencies found.
Findings
No deficiencies resulted from the investigation of the self-reported incident and complaint.
Report Facts
Total Residents: 68
Inspection Report
Plan of Correction
Deficiencies: 0
Date: 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
Date: 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.
Complaint Details
Complaint #110106 was not substantiated. Incidents #106497, #108206, and #111043 were substantiated.
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.
Deficiencies (4)
Failure to ensure 3 of 10 residents had accurate Minimum Data Set (MDS) assessments reflecting oxygen administration.
Oxygen tanks were not secured in resident rooms, posing potential injury hazards.
Failure to ensure residents had active physician orders for oxygen therapy, risking inaccurate care.
Failure to remove expired medications from medication carts, risking resident safety.
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
| 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 |
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 3
Date: 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.
Complaint Details
Facility Reported Incident #99246 was substantiated. Facility Reported Incident #101660 was not substantiated.
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.
Deficiencies (3)
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.
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
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Confirmed medication counts and storage issues |
| Staff B | Licensed Practical Nurse (LPN) | Confirmed medication counts and storage issues |
| Staff C | Licensed Practical Nurse (LPN) | Confirmed storage of liquid lorazepam outside locked container |
| Staff D | Licensed Practical Nurse (LPN) | Confirmed storage of liquid lorazepam outside locked container |
| Staff E | Licensed Practical Nurse (LPN) | Reported narcotic shift count complacency prior to education |
| Assistant Director of Nursing | ADON | Confirmed medication storage practices and medication measurements |
| Director of Nursing | DON | Prepared medication review document provided to Administrator |
| Administrator | Provided document prepared by DON |
Inspection Report
Annual Inspection
Census: 51
Deficiencies: 0
Date: 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.
Complaint Details
Complaint #93230 was not substantiated. Complaint #97971 was not substantiated. Incident #100131 was not substantiated.
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.
Report Facts
Total residents: 51
Inspection Report
Abbreviated Survey
Census: 57
Deficiencies: 0
Date: 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
Date: 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
Report
May 1, 2025
Report
Oct 11, 2024
Report
May 16, 2024
Report
Apr 30, 2024
Report
Feb 23, 2023
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