Scenic Wellness And Rehabilitation Center

Based on interview and record review, the facility failed to notify five residents (Residents #116, #123, #160, #170, and #186) out of 10 sampled residents when their resident trust fund account balances were within $200 of their Medicaid spend-down limit. This deficient practice had the potential to affect all residents receiving Medicaid benefits with a spend-down requirement. The facility census was 169. The facility did not provide a policy regarding spend-down notifications. Review of resident fund balance notification letters for Residents #116, #123, #160, #170, and #186 showed: - Letters were dated 05/13/26, and identified each resident by name; - The letters said, This letter is to notify you that your current resident fund balance is within $200 or exceeding what is allowable under Medicaid assistance. Please contact your Social Worker within the next seven days to discuss ways to assure continuance of Medicaid benefits; - Each letter contained a resident acknowledgment signature line; however, none of the letters were signed by the residents. Review of the facility's…

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 maintain the physical environment of the bathrooms and showers in a safe, clean, and sanitary manner. This deficient practice had the ability to affect all residents who use the bathrooms and showers. The facility census was 169. The facility did not provide a policy regarding cleaning the bathrooms and showers. Observation on 06/17/26 at 11:00 A.M., of the 500 Hall women's shower room showed: - The area around the floor drain located in the center of the room with multiple cracked, broken, and missing floor tiles, deteriorated grout surrounding the drain, and an uneven floor surface around the drain; - The shower floor drain located within the shower area with a wet tissue-like substance and black residue/debris on and around the drain cover with cracked, broken, and missing surrounding floor tiles, and deteriorated grout surrounding the drain; - The hanging shower curtain with black discoloration/staining on the lower portion of the curtain; - Black and green discoloration/residue along the floor-to-wall junction…

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 assess residents for the risk of entrapment, review possible risks and benefits of bed rails or trapeze (an overhead assistive device with a suspended triangular handle), and obtain informed consent prior to installation or use for five residents (Residents #8, #84, #162, #172, and #173) out of 33 sampled residents. The facility census was 169.Review of the facility's policy, Bed Rails, revised 06/20, showed: - The assessment of whether to use bed rails should include an evaluation of the alternatives to the use of bed rails that were attempted and how these alternatives failed to meet the resident's assessed needs; - Before installing a bed rail, the facility must assess the resident for the risk of entrapment from bed rails and ensure the bed's dimensions are appropriate for the resident's size and weight. The manufacturer's recommendations and specifications for installing and maintaining bed rails will be followed; - If the bed rail…

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 pharmaceutical services that assured accurate dispensing, storage, and labeling of medications. This had the potential to affect all residents. The facility's census was 169. Review of the facility's policy titled, Medication - Administration, undated, showed: - Medication will be administered by a Licensed Nurse per the order of an attending physician or licensed independent practitioner, or as consistent with state law; - Medications must be given to the resident by the Licensed Nurse preparing the medication, or as consistent with state law; - Medications may be administered one hour before or after the scheduled medication administration time; - Medications will not be left at the bedside. 1. Observation on 06/18/26 at 9:15 A.M. of the [NAME] Hall Medication Cart showed six medication cups in the top drawer of the cart with multiple unidentified medications popped out into each cup and not labeled with the residents' name, date, or time. During an interview on 06/18/26 at 9:22 A.M., Certified…

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 infection control practices to prevent the development and transmission of infection during perineal care (washing the genital and anal areas of the body) for three residents (Residents #69, #77, and #137) out of seven sampled residents. The facility failed to implement enhanced barrier precautions (EBP) and proper infection control practices when accessing the Peripherally Inserted Central Catheter (PICC - a thin, soft, flexible tube that is placed in a vein that leads to the heart) for one resident (Resident #1) out of three sampled residents. The facility failed to maintain infection control practices during saline flush administration via a gastrostomy tube (G-tube - a surgically placed tube that provides direct access to the stomach for feeding, fluids, or medications) for one resident (Resident #7) out of one sampled resident. The facility's census was 169. Review of the facility's policy titled, Enhanced Barrier Precautions, dated January 2026, showed:- Enhanced Barrier Precautions (EBP)…

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 conduct regular inspections of all bed frames, mattresses, side rails and trapeze (an overhead assistive device with a suspended triangular handle) as part of a regular maintenance program for seven residents (Residents #8, #16, #84, #155, #162, #172, and #173) out of 33 sampled residents. The facility's census was 169. Review of the facility's policy, Bed Rails, revised 06/20, showed: - Before installing a bed rail, the facility must assess the resident for the risk of entrapment from bed rails and ensure the bed's dimensions are appropriate for the resident's size and weight. The manufacturer's recommendations and specifications for installing and maintaining bed rails will be followed; - Maintenance/Designee will assess the bed dimensions no less than quarterly by utilizing Maintenance Inspection Checklist- Resident Rooms. Maintenance will also check bed rails regularly to ensure they are still installed correctly, as rails may shift or loosen over time. 1. Review of Resident #8's medical record showed: -…

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 interview and record review, the facility failed to implement a baseline care plan (the minimum healthcare information necessary to properly care for the resident) upon admission with specific interventions needed to care for resident, and failed to assure the resident and/or guardian received a written summary of the baseline care plan for two residents (Resident #151 and #261) out of 32 sampled residents. The facility's census was 161. Review of the facility's policy, Care Plans, dated 01/15, showed: - Each resident will have a plan of care to identify problems, needs, and strengths that will identify how the team will provide care; - Responsibility of the nurse monitored by the Executive Director; - The Care Plan will be developed within two days; - The team along with the resident and/or family members will identify services needed, preferences, and ability and care level guidelines. 1. Review of Resident #151's medical record showed: - admitted on [DATE]; - Diagnoses of congenital malformation of…

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 appropriately assess the use of bed rails for three residents (Resident #107, #133, and #462) of 32 sampled residents. The facility's census was 161. Review of the facility's policy titled, Side Rail Use Evaluation, dated 02/25, showed: - The resident's risk for entrapment should be assessed prior to installation of bed rails; - Complete the Side Rail Evaluation form; - Documentation should contain alternatives prior to implementation of any type of rail(s), risk and benefits reviewed with the resident or resident representative, and informed consent obtained from the resident or resident representative. 1. Review of Resident #107's medical record showed: - admitted on [DATE]; - Diagnoses of displaced fracture (two or more portions of broken bone come out of proper alignment) of second cervical (neck) vertebra (series of small bones forming the backbone), burst fracture (a serious spinal injury where the vertebra shatters and breaks in…

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 infection control practices to prevent the development and transmission of infection during tracheostomy (surgical opening in the neck used to provide airway for breathing) care and g-tube (a medical device that delivers liquid nutrition directly to the stomach or small intestine through a flexible tube) medication administration for one resident (Resident #20) out of 32 sampled residents. The facility failed to maintain infection control practices when staff failed to wear proper personal protective equipment (PPE) for enhanced barrier precautions (EBP) for two residents (Resident #20 and #97) out of 32 sampled residents. The facility's census was 161. Review of the facility's policy, Enhanced Barrier Precautions, dated 04/24, showed: - EBP are indicated for residents with infections or colonization with a CDC-targeted MDRO when contact precautions do not apply or for resident with wounds and/or indwelling medical devices without secretions/excretions that are unable to be covered/contained and are…

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 interview, and record review, the facility failed to accurately code the Minimum Data Set (MDS, a federally mandated assessment instrument completed by the facility staff) for three residents (Resident #16, #30, and #56) out of 32 sampled residents. The facility census was 159. Review of the facility's policy, MDS Assessment, revised June 2023, showed: - The facility shall conduct interdisciplinary assessments using the MDS item sets as defined by Federal/State regulations; - These regulations provide information on the resident's condition to facilitate development of an individualized plan of care as a means by which the facility can track changes in a resident's status; - The interdisciplinary team as designated will complete specific portions of the MDS. The registered nurse (RN) designated by the facility will assure that all disciplines have completed their portion of the MDS; - The interdisciplinary team member's signatures in Z0400 will attest to completion/accuracy of the assessment. 1. Review…

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 interview and record review, the facility failed to attempt a gradual dose reduction (GDR) for three residents (Resident #30, #48, and #55) out of 32 sampled residents. This failure had the potential to keep any resident on a psychoactive medication from receiving the lowest possible dosage of medication due to not monitoring if a medication is treating the target symptom. The facility census was 159. Review of the facility's policy titled, Behavior Management and Psychopharmacological Medication Monitoring Protocol, revised March 2018, showed: - Residents who receive antipsychotic, anti-depressant, sedative/hypnotic, or anti-anxiety medications are to be maintained at the safest, lowest dosage necessary to manage the resident's condition; - Residents will be reviewed routinely for effectiveness and monitored for side effects of these medications and will receive gradual dose reductions, unless clinically contraindicated, in an effort to discontinue these drugs; - There will be an established Behavior Management Committee that will meet routinely to review all residents…

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 the dumpsters were closed at all times and maintained to keep pests out and/or to keep the garbage contained in the dumpster. The facility census was 159. The facility did not provide a policy regarding the dumpsters. Observations of two dumpsters, both with two lids, at the right side of the front entrance showed: - On 02/27/24 at 9:30 A.M., the dumpster on the left had both lids opened with visible trash bags, cardboard boxes, and other miscellaneous items; - On 02/28/24 at 4:00 P.M., the dumpster on the left had one lid opened with visible trash bags and other miscellaneous items; - On 02/29/24 at 8:10 A.M., the dumpster on the right had one lid opened. During an interview on 02/29/24 at 12:25 P.M., the Director of Nursing (DON) said housekeeping, dietary staff, and the night shift Certified Nursing Assistants (CNAs) are the people responsible for taking garbage out to the dumpsters and the dumpsters are emptied six days a week. During an interview on 02/29/24 at 2:45 P.M., the Dietary Manager said trash dumpster…

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.