Scenic Manor

In the surveyor’s words

From the most serious findings on record at Scenic Manor, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF761Feb 3, 2022

  Based on observation, clinical records review, facility policies review, and staff interviews; the facility failed to ensure a level 4 controlled drug that required refrigeration was secured in a separately locked compartment within the medication refrigerator for 2 of 4 residents reviewed (Residents #2 and #3). Schedule II (2) - (through) V (5) controlled medications have a potential for abuse and may lead to a physical or psychological dependence. Additionally, the facility failed to destroy the ordered PRN (as needed) liquid [MEDICATION(S)] (anti-anxiety medication), that was discontinued after 14 days as it had not been reordered per the facility policy. The facility failed to complete the control shift count as directed by facility policy. […]

• No harm, potential for more than minimal, isolatedF710Oct 11, 2024

  Based on clinical record review, staff, and provider interviews, the facility failed to properly obtain a physician order for a resident admitted to the facility on Coumadin/warfarin (an anticoagulant or blood thinner medication) after discharge from the hospital (Resident #3). Resident #3 admitted to the facility from the hospital following an admission related to acute strokes and atrial fibrillation (AF - rapid heart rate caused by poor blood flow). Resident #3 required the use of Coumadin to help prevent blood clots to prevent future strokes. When he admitted to the facility, the facility failed to ensure he had an order on admission to monitor the therapeutic levels of Coumadin. […]

• No harm, potential for more than minimal, isolatedF580May 16, 2024

  Based on clinical record review, family interview, staff interviews and facility document review, the facility failed to notify a resident representative of a change in condition for 1 of 1 resident reviewed (Resident #50). Resident #50 was found to have a large raised area on her lower back on 2/2/24. The facility did not notify Resident #50's resident representative of the area until after the primary care provider (PCP) had seen the area on 2/7/24. The facility reported a census of 60 residents. Findings include: The Minimum Data Set for Resident #50 documented a Brief Interview of Mental Status score of 9 indicating moderately impaired cognition. The Clinical Resident Profile for Resident #50 listed her son as the emergency contact #1. […]

• No harm, potential for more than minimal, isolatedF658May 16, 2024

  Based on observations, record review, staff interviews and manufacturer's insert, the facility failed to provide services that met professional standards regarding medication administration for 2 of 8 residents (Resident #30 twice) observed who did not have their insulin flex pen primed prior to administering insulin (to ensure the proper amount of insulin administered). The facility reported a census of 60 residents. Findings include: During an observation on 5/15/24 at 8:28 AM, Staff A, Registered Nurse (RN) administered Novolog 5 units to Resident #22. Staff A gave the shot in the upper right arm. She did not prime the insulin pen prior to administration. […]

• No harm, potential for more than minimal, isolatedF759May 16, 2024

  Based on observations, clinical record review, staff interview, and manufacturer's package insert review, the facility failed to keep their medication error rate less than 5 percent. An observation of 39 medications being passed was completed with 3 medication errors noted giving the facility a 7.69% medication error rate. Resident #30 had 2 observations of insulin administration via FlexPen and both observations revealed no priming of the FlexPen. There was no way of knowing if the resident received the appropriate scheduled dose. The facility reported a census of 60 residents. Finding Include: 1. During an observation on 5/15/24 at 8:28 AM, Staff A, Registered Nurse (RN) administered Novolog 5 units to Resident #22. Staff A gave the shot in the upper right arm. […]