Scenic Hills At The Monastery

Based on observation, interview, and record review, the facility failed to ensure residents with pressure ulcers received necessary treatment for 1 of 2 residents reviewed for pressure ulcers. Wound assessments were incomplete and treatment orders were not followed. (Resident 3)Findings include:On 5/20/26 at 8:17 A.M., Resident 3 was observed sitting in the common area by the nurse's station in her wheelchair wearing a specialized orthopedic shoe on her right foot. On 5/18/26 at 9:59 A.M., Resident 3's clinical record was reviewed. Diagnoses included, but were not limited to, dementia without behaviors and pressure ulcer on right heel.The most recent quarterly Minimum Data Set (MDS) assessment, dated 3/11/26, indicated Resident 3's cognition was severely impaired, had 1 or more unhealed, unstageable pressure ulcer that was facility acquired, used a wheelchair, and substantial to maximum assist of staff (staff performs half the effort) for sit to stand transfers.Physician's Orders included, but were not limited to, the following:Dietary Supplement: LiquaCel, 30 milliliters (mL), for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure a resident with weight loss was provided ordered nutritional supplements and monitored for weight loss for 1 of 1 residents reviewed for weight loss. Phyisican orders were not followed and meals and supplements were documented as given and were not. (Resident 48)Finding includes:On 5/19/26 at 2:29 P.M., Resident 48's clinical record was reviewed. Diagnoses included, but were not limited to, dementia without behaviors and malnutrition.The most recent quarterly Minimum Data Set (MDS) assessment, dated 4/30/26, indicated Resident 48's cognition was severely impaired, set up assistance from staff for eating, had weight loss and was not on a weight loss regimen. Physician's Orders included, but were not limited to, the following:Fortified Foods -Special Instructions: Offer double portions at breakfast. Magic cup with lunch and dinner. Sandwich at bedtime (HS), ordered 4/29/25Dietary Supplement: Sandwich HS & food of choice HS snack at Bedtime (7:00 P.M. - 11:30 P.M.), ordered 1/27/25Dietary Supplement:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure the clinical record included accurate documentation for 1 of 1 resident reviewed for nutrition and 2 of 2 resident reviewed for pressure ulcers. Documentation showed resident was getting supplements but was not and meal/snack consumption was documented before the resident had them. Resident's wound documentation lacked complete wound assessments. (Resident 48, Resident 2, Resident 3)Findings include:1. On 5/19/26 at 2:29 P.M., Resident 48's clinical record was reviewed. Diagnoses included, but were not limited to, dementia without behaviors.The most recent quarterly Minimum Data Set (MDS) assessment, dated 4/30/26, indicated Resident 48's cognition was severely impaired, set up assistance from staff for eating, had weight loss and was not on a weight loss regimen. Physician's Orders included, but were not limited to, the following:Fortified Foods -Special Instructions: Offer double portions at breakfast. Magic cup with lunch and dinner. Sandwich at bedtime (HS), ordered 4/29/25Dietary Supplement:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to provide sanitary care for 1 of 2 observations of incontinence care and 2 of 2 observations of wound care. The nursing staff failed to lather hands with soap for 20-30 seconds during handwashing, change gloves after touching multiple items in the bathroom during incontinence care, staff left an incontinence pad on after a resident urinated in it, and hands were not sanitized and gloves were not changed between dirty and clean tasks. (Resident 37, Resident 2, Resident 3)Findings include: 1. On 5/18/26 at 1:56 P.M., wound care on Resident 3's right heel pressure ulcer performed by Licensed Practical Nurse (LPN) 5 was observed. Resident 3 was laying on her back with her right foot elevated and a towel under it. The nurse removed the dressing. She removed her gloves and washed her hands with a ten second lather. LPN 5 put gloves back on and cleaned the wound with gauze and wound cleanser, applied skin prep to sorrounding tissue, and took the wound measurements. LPN 5 removed her gloves and washed her hands with an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to maintain resident dignity, and to protect and promote the rights of the residents. A dependent resident waited several minutes to be assisted to eat during 2 of 2 meals observed. (Resident 42) Findings include: During a continuous observation on 3/4/25 from 11:30 A.M. through 12:00 P.M., the following was observed on the locked unit: 11:33 A.M. A lunch cart was brought to the unit. 11:41 A.M. A lunch plate was placed in front of Resident 42, who was sitting in a high back chair at the table. 11:54 A.M. Legacy Leader 3 was observed serving cake to several residents. 11:58 P.M. The two other residents at the table with Resident 42 finished their meals. 12:00 P.M. Certified Nurse Aide (CNA) 5 sat with Resident 42 to begin assisting to eat the meal (19 minutes after it had been placed in front of the resident). On 3/5/25 at 12:24 P.M., Resident 42's clinical record was reviewed. Diagnoses included, but was not limited to, hemiplegia/hemiparesis following stroke. The most recent Annual Minimum Data Set (MDS)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure services provided met professional standards of quality for 1 of 1 residents reviewed for skin conditions. A blister on a resident was not assessed when initially identified, the nurse was unaware of the correct timing of the treatment, and the area was not cleaned appropriately. (Resident 40) Findings include: On 3/5/25 at 1:04 P.M., Resident 40's clinical record was reviewed. Diagnosis included, but were not limited to, Alzheimer's, malnutrition, and depression. The most recent Quarterly Minimum Data Set (MDS) assessment, dated 1/28/25, indicated a severe cognitive impairment. Resident 40 required substantial to maximum assistance (helper does more than half the effort) with toileting, showers, med mobility, and transfers. Current physician orders included the following: Inner left thigh: fluid filled blister. cover with border gauze, change daily and monitor until healed, dated 2/23/25. Blister on left upper thigh: cleanse wound with wound cleanser or normal saline, apply skin prep to peri-wound,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure adequate supervision and assistance devices were received to prevent accidents for 1 of 4 residents reviewed for falls. A resident's mattress was not moved with the resident during a room change resulting in a fall, and fall interventions were observed not in place. (Resident 40) Findings include: On 3/5/25 at 1:04 P.M., Resident 40's clinical record was reviewed. Diagnosis included, but were not limited to, Alzheimer's, malnutrition, and depression. The most recent Quarterly Minimum Data Set (MDS) assessment, dated 1/28/25, indicated a severe cognitive impairment, no behaviors, and no falls. Resident required substantial to maximum assistance (helper does more than half the effort) with toileting, showers, bed mobility, and transfers. Current physician orders included, but were not limited to: Dycem to wheelchair. Monitor placement every shift with foot pedals in place, dated 2/26/24. Pressure reducing parameter mattress with bed in lowest position, dated 8/21/23. A current falls care plan, last…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to provide a safe and sanitary environment to help prevent the development and transmission of diseases and infections for 1 of 1 residents reviewed for skin conditions, and the facility failed to properly prevent and/or contain COVID-19 for 2 random observation. Staff failed to use proper Personal Protective Equipment (PPE) when providing care of residents and entering a COVID-19 room, did not clean a wound or wash hands with appropriate infection control techniques, did not change gloves between tasks, and touched medication with bare hands prior to administering to a resident. (Resident 40, Resident 52, Resident 81) Findings include: 1. On 3/5/25 at 1:04 P.M., Resident 40's clinical record was reviewed. Diagnosis included, but were not limited to, Alzheimer's, malnutrition, and depression. The most recent Quarterly Minimum Data Set (MDS) assessment, dated 1/28/25, indicated a severe cognitive impairment. Resident 40 required substantial to maximum assistance (helper does more than half the effort) with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure appropriate labeling and storage of medications for 2 of 3 medication carts (500 Hall Cart and 300 Hall Cart) with 11 of 16 residents reviewed for Medication Storage. (Residents 9, 4, 77, 28, 20, 17, 46, 14, 43, 23, and 18) Findings include: 1. During an observation on 3/12/24 at 1:03 p.m. of the 500 Hall medication cart with RN 4, the following concerns were observed: a. Resident 9's had two Levemir FlexTouch insulin pens in the top drawer of the medication cart. The first pen was dated with an open date of 1/30/24, and had approximately 150 units left in it. The second pen had an open date of 2/7/24. The best use by date indicated to use within 42 days. In the same bag, was a bottle of flonase nasal spray. The pharmacy labeling had been partially ripped off and had no identifying information. The medication was not in the original packaging. It was lying on its side. There was no open date on the medication and it was approximately three-quarters of the way used. The record for Resident 9 was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to ensure food was served and stored under sanitary conditions during 3 of 3 kitchen observations. This deficiency had the potential to affect 81 current residents who received meals from the kitchen. Findings include: 1. During the initial tour of the kitchen with the Dietary Manager on 3/7/24 at 9:10 a.m., the following concerns were observed: - The fryer had a moderate amount of brown crumbs in the oil. The Dietary Manager indicated it was last used at yesterday's dinner. - In the dry storage room under the vinegar and soy sauce shelf, there was a brown dried spill with food particles in it which measured 3 inches in length and 8 inches in width. A white piece of paper was under the bean shelf in the corner. - There were 2 jelly packets, 1 pink and 1 yellow sweetener packets under the cereal shelf. - The egg storage drawers had multiple yellow spots on the bottoms. - The grill had a heavy coating of charred black debris on the grates; the ledge in front and back of the grates had a heavy build up of black debris. - The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a clean, homelike environment in resident resident rooms and resident areas for 2 of 2 days during the survey. Resident rooms were not cleaned daily and resident areas contained dust, debris, and trash. (Resident B, Resident C, Resident D, Resident F) Finding includes: 1. During a review of facility grievances on 12/7/23 at 12:50 P.M., a Resident Concerns Log included a concern, dated 11/13/23, by Resident B's family member regarding the cleanliness of Resident B's room (room [ROOM NUMBER]). The concern included, .[Family] is concerned that room is not being cleaned daily as she continues to find food ground in the carpet and the bathroom floor is in need (of) deep cleaning . 2. During an observation on 12/7/23 at 9:45 A.M., Resident C's carpet in room (room [ROOM NUMBER]) had a noticeable stain next to the resident's bed. A balled up tissue was on the floor at the base of the bed. 3. During an observation on 12/7/23 at 3:05 P.M.,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to provide qualilty care and services timely following resident falls that resulted in fractures for 2 of 3 residents reviewed for falls with fractures. A resident was not sent out for further assessment and treatment following a fall with multiple fractures that occurred before lunch, until after 8:00 P.M. that evening, and a resident's X-ray results confirming fractures were not communicated to the physician prior to receiving an order to transfer the resident to the hospital until more than 6 hours after the X-ray results were made available to the facility. (Resident F, Resident G) Findings include: 1. During a review of facility reported incidents on 12/7/23 at 12:55 P.M., an incident, dated 9/8/23, included that Resident F had fallen on 9/7/23 at 10:26 A.M. The following morning, Resident F had facial grimacing with movement of right leg and complained of pain. X-ray results included a right femoral neck fracture. During record review on 12/8/23 at 9:16 A.M., Resident F's diagnoses included, but were not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to provide assistance with bathing for 1 of 3 residents reviewed for activities of daily living (ADLs). A resident did not receive bathing according to the plan of care or resident preferences. (Resident F) Finding includes: During a review of facility grievances on 8/16/23 at 10:30 A.M., Resident F had submitted a grievance on 6/28/23 that he had not received a shower. During record review on 8/16/23 at 1:00 P.M., Resident F's diagnoses included, but were not limited to chronic kidney disease, heart disease, obesity, chronic pain, muscle weakness, and need for assistance with personal care. Resident F's most recent Quarterly MDS (Minimum Data Set) assessment, dated 5/17/23, included that the resident was cognitively intact, required extensive assistance with transfers, and required total dependence with bathing. Resident F's care plan included, but was not limited to; resident requires staff assistance to complete ADL tasks completely and safely with a goal of; Resident will have ADL needs met safely by staff…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.