Scenic Hills at the Monastery: Wound Doc Failures - IN
The expectation wasn't being met.
Inspectors examining the care of Resident 2, who had developed a sacral pressure wound, found the clinical record missing basic documentation, measurements, drainage descriptions, and tissue assessments that nurses are trained to record every time they assess a wound. There was no documentation showing that LPN 10 had ever notified LPN 5, or anyone else, about the wound's condition or changes.
A sacral pressure wound sits at the base of the spine, one of the most vulnerable spots on a bedridden or chair-bound person's body. Left unmonitored, pressure wounds can deepen through layers of skin and tissue into muscle and bone. The difference between a Stage 2 wound and a Stage 4 can be a matter of weeks, and it often hinges on whether nurses are catching changes and reporting them.
At Scenic Hills, the system for catching those changes had gaps that multiple staff members described openly to inspectors.
LPN 5, interviewed on May 18, explained that physicians and nurse practitioners only examined wounds when nurses specifically asked them to, and that any such contact should have been documented in the clinical record with new orders. She also noted that the facility had recently switched documentation systems. Previously they used a program called Wound Zoom, which took photographs and measured wounds automatically. She acknowledged the automated measurements weren't always accurate. Now documentation was supposed to go into a wound management system and a Treatment Administration Record, known as a TAR.
What nurses were actually entering into the TAR, the Director of Nursing explained during an interview on May 21, was a check mark. The check mark indicated a wound dressing had been changed and that weekly skin assessments were completed. If something was abnormal, the DON said, a nurse would put in a progress note. The clinical record, she acknowledged, should contain descriptions of what the wound looks like, its size, signs of infection, and the resident's pain level.
There was no indication that documentation at that level existed for Resident 2.
The facility's regional consultant, also interviewed on May 21, put the minimum standard plainly: at least measurements, drainage, and tissue type. She said photographs had served as that documentation under the old Wound Zoom system.
The photographs were the record. When the system changed, it isn't clear from the inspection findings that anything replaced them.
What's clear is that when inspectors went looking for documentation of how Resident 2's sacral wound had been tracked, communicated, and managed, they didn't find it. They found a check mark confirming a dressing change. They found nurses who knew, in interviews, what should have been written down. They found a facility leadership that could not point to a policy requiring any of it.
The executive director's explanation, that accurate documentation would be expected as normal nursing standard, is the kind of answer that sounds reasonable until you consider what it means in practice. Without a written policy, there is no consistent training, no accountability mechanism, and no way to identify when the standard is slipping before a wound does.
Inspectors rated the deficiency as causing minimal harm or the potential for actual harm, and noted that few residents were affected. The inspection was completed May 22, 2026.
Resident 2's sacral wound, and what happened to it while its changes went unrecorded, remains a question the clinical record cannot answer.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Scenic Hills At the Monastery from 2026-05-22 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: October 31, 2026 · Our methodology
SCENIC HILLS AT THE MONASTERY in FERDINAND, IN was cited for violations during a health inspection on May 22, 2026.
The expectation wasn't being met.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.