Above average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Scenic Manor during CMS and state inspections, most recent first.
A resident admitted to a facility on Coumadin after hospital discharge did not have their INR levels monitored, leading to a critically high INR of 8.85 upon readmission to the hospital. The facility failed to obtain necessary physician orders for PT/INR monitoring, and staff did not follow up with the PCP to clarify lab orders, resulting in a significant oversight in the resident's anticoagulation therapy management.
A resident with moderately impaired cognition developed a large mass on her lower back, which was not immediately communicated to her representative. The mass was first noticed by a CNA and assessed by an LPN, who did not document the finding or notify the family. The PCP later identified the mass as a psoas muscle abscess, leading to an ER visit. The facility lacked a policy for family notification, contributing to the delay.
The facility failed to meet professional standards in medication administration for two residents, as nursing staff did not prime insulin pens before administering insulin. Observations revealed that a RN and an LPN administered insulin without priming the pens, contrary to manufacturer instructions. The facility's policy lacked specific guidance on insulin pen use, contributing to this deficiency.
The facility exceeded the acceptable medication error rate with a 7.69% error rate during a medication pass. Two residents received insulin without the pens being primed, contrary to manufacturer instructions. The facility's policy lacked specific guidance on insulin pen use, and the DON confirmed the expectation to follow manufacturer instructions.
The facility failed to ensure medication carts were locked when not in use. On two occasions, an LPN left a cart unlocked and unattended, allowing residents to pass by. The facility's policy requires drugs to be stored in locked compartments when not in use.
A CNA failed to follow proper infection control practices during catheter care for a resident with an indwelling catheter. The CNA did not change gloves after touching multiple surfaces and cleaning urine spillage, contrary to facility policy. The DON confirmed the breach in infection control procedures.
A facility failed to ensure a resident had prescription medication readily available following discharge. The discharge summary indicated that the facility had arranged pharmacy services, but the pharmacy did not have the medications. The resident missed their medication for two days due to a lapse in communication and protocol.
Failure to Monitor Anticoagulation Therapy
Penalty
Summary
The facility failed to obtain a physician order for a resident who was admitted on Coumadin/warfarin after being discharged from the hospital. The resident, who had a history of acute strokes and atrial fibrillation, required monitoring of therapeutic levels of Coumadin to prevent future strokes. However, upon admission to the facility, there was no order to monitor the resident's INR levels, which are crucial for ensuring the effectiveness and safety of anticoagulation therapy. The resident's clinical records indicated that he was admitted to the hospital with several complex medical conditions, including atrial fibrillation and heart valve issues, and was discharged with a prescription for Coumadin. Despite this, the facility did not conduct any PT/INR tests from the time of admission until three weeks later when the resident was readmitted to the hospital for pneumonia. At that time, the hospital found the resident's INR level to be critically high at 8.85, far above the therapeutic range of 2-3, indicating a significant oversight in monitoring by the facility. Interviews with hospital staff and the resident's primary nurse practitioner revealed that the facility staff failed to follow up with the primary care provider to clarify lab orders for PT/INR monitoring. The resident's primary medical doctor had visited the facility but was not informed about the lack of PT/INR orders. This lack of communication and follow-up contributed to the resident's dangerously high INR levels, which could have led to severe health complications.
Failure to Notify Resident's Representative of Change in Condition
Penalty
Summary
The facility failed to notify a resident's representative of a change in condition for a resident with moderately impaired cognition. The resident was found to have a large raised area on her lower back, which was first observed by a CNA during a bath. The CNA reported the finding to an LPN, who assessed the area as soft, intact, and without redness or pain. Despite recognizing the abnormality, the LPN did not document the assessment or notify the resident's representative, opting instead to schedule the resident for a provider's evaluation the following week. The resident's primary care provider (PCP) examined the area five days later and noted a significant mass on the resident's lower back, which was causing discomfort. The PCP recommended sending the resident to the emergency room for further evaluation. The emergency room identified a psoas muscle mass/abscess extending into the abdominal wall and subcutaneous fat. The resident's representative was not informed of the situation until after the PCP's evaluation and subsequent hospital referral. Interviews with facility staff revealed inconsistencies in the handling and communication of the resident's condition. The LPN admitted to not notifying the resident's representative due to uncertainty about the cause of the mass, intending to wait for the doctor's assessment. The facility lacked a policy for family notification, which contributed to the delay in informing the resident's representative about the significant change in the resident's condition.
Failure to Prime Insulin Pens Before Administration
Penalty
Summary
The facility failed to meet professional standards of quality in medication administration for two residents, as observed during a survey. Specifically, the nursing staff did not prime insulin pens before administering insulin to the residents, which is a necessary step to ensure the correct dosage is delivered. During observations, a Registered Nurse administered Novolog insulin to a resident without priming the pen, and a Licensed Practical Nurse administered both Novolog and Tresiba insulin to another resident without priming either pen. This oversight was noted during the administration of insulin shots in the residents' arms. The facility's insulin administration policy, revised in September 2014, lacked specific instructions for insulin pen administration, although it stated that nursing staff should follow manufacturer instructions. Interviews with the Director of Nursing confirmed that the expectation was for nurses to adhere to these instructions. The manufacturer inserts for both Novolog and Tresiba pens clearly state the necessity of priming the pens by injecting 2 units of insulin before administering the prescribed dose to avoid injecting air and ensure the correct dosage. The failure to follow these instructions led to the deficiency noted in the report.
Medication Error Rate Exceeds 5% Due to Insulin Pen Misuse
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by a 7.69% error rate observed during a medication pass. During the observation, 39 medications were administered, and 3 errors were noted. Specifically, two residents were involved in the errors related to insulin administration. The errors were due to the failure of nursing staff to prime insulin pens before administration, which is necessary to ensure the correct dose is delivered and to avoid injecting air. Resident #22 was administered Novolog insulin without priming the pen, contrary to the manufacturer's instructions, which require an airshot to be done before each injection. Similarly, Resident #30 received both Novolog and Tresiba insulin without the pens being primed. The facility's insulin administration policy did not include specific instructions for insulin pen use, and the Director of Nursing confirmed that the expectation was for nurses to follow manufacturer instructions. The facility's census at the time was 60 residents.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to ensure that medication carts were locked when not in use, as observed on two separate occasions. On the first occasion, a medication cart was found unlocked and unattended in the west hall, with two residents self-propelling past it. The cart remained unattended for approximately five minutes before Staff C, an LPN responsible for the cart, returned to continue the medication pass. During an interview, the facility Administrator confirmed that it is expected for nurses to lock medication carts and computers when stepping away. On the second occasion, a medication cart was observed unlocked and unattended in the hallway by the main dining room. Several residents walked by the cart, and some were seated nearby. The staff member responsible for the cart was not present, and it was approximately two minutes before another staff member noticed the unlocked cart and secured it. Staff C, the LPN responsible for the cart, returned to the cart from another hallway four minutes after it was first observed unlocked. The facility's policy, revised in November 2020, requires that drugs and biologicals be stored in locked compartments when not in use, and that unlocked medication carts should not be left unattended.
Infection Control Breach During Catheter Care
Penalty
Summary
The facility failed to adhere to appropriate infection control practices during urinary catheter care for a resident with an indwelling catheter. The care plan for the resident, revised in January 2024, required maintaining enhanced barrier precautions and documenting intake and output. During an observation, a CNA, with the Director of Nursing (DON) present, prepared to empty the catheter bag. The CNA donned a gown and gloves, transferred the resident to the bathroom, and placed the resident on the toilet. However, the CNA touched multiple surfaces with the same gloves before and during the catheter care process, including the walker, gait belt, containers, handrail, and toilet. The CNA then used a sanitizing wipe on the bag port and began emptying the catheter bag without changing gloves. During the procedure, the container used to capture urine output fell, causing urine to splash onto the floor and the resident's legs. The CNA continued to use the same gloves to clean the spilled urine from the floor and the resident's legs before reattaching the catheter bag and transferring the resident back to the chair. The DON later stated that the CNA did not follow proper infection control practices, as gloves should have been changed after placing the resident on the toilet and after cleaning the urine spillage. The facility's policy on catheter care, revised in September 2014, emphasized maintaining clean technique and avoiding splashing when handling the catheter, tubing, or drainage bag.
Failure to Ensure Resident Had Medication Post-Discharge
Penalty
Summary
The facility failed to ensure that a resident had prescription medication readily available following discharge. Resident #3, who had a planned discharge, did not receive their medication for two days post-discharge. The discharge summary indicated that the facility had arranged pharmacy services, but the pharmacy did not have the medications. A family member inquired about the medications and requested the facility to fax the discontinued orders to the pharmacy. The Director of Nursing (DON) confirmed that the pharmacy had reached out to the clinic regarding the discharge medications, but the pharmacy never received the fax from the nursing home. This resulted in the resident missing their medication for two days. The Administrator revealed that the facility did not have a specific discharge protocol in place other than for care planning. The DON stated that this was the first instance where a resident did not receive their medication immediately after discharge. The facility typically did not use the pharmacy involved in this case, and moving forward, they planned to contact the pharmacy to ensure receipt of discharge medication orders. The deficiency highlights a lapse in communication and protocol regarding the discharge process, leading to the resident not having their necessary medications post-discharge.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Iowa Falls
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Village Of Ackley | 11 mi | ★★★★★ | 8 | 0 |
| Eldora Specialty Care | 14 mi | ★★★★★ | 10 | 0 |
| Rehabilitation Center Of Hampton | 14.6 mi | ★★★★★ | 2 | 0 |
| Franklin General Hospital | 15.1 mi | ★★★★★ | 0 | 0 |
| Hubbard Care Center | 15.8 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.