Manderley Health Care Center

In the surveyor’s words

From the most serious findings on record at Manderley Health Care Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Jul 21, 2025

  Based on observation and interview, the facility failed to follow appropriate food handling guidelines related to food storage, open dating, and protecting food and drinks from gnats. This deficient practice had the potential to affect 47 of 48 residents receiving food and drink items from the kitchen. Findings include: 1.a. During an observation, on 07/21/25 at 8:07 A.M., of the facilities kitchen refrigerators, freezers, and dry food storage the following was observed: - a raw premade frozen hamburger patty was lying on the floor of the freezer in the back left corner of the kitchens walk in freezer, - Two popsicles were lying on the floor under the shelves in the walk-in freezer, - An undated, half full, opened half gallon of nectar thick orange juice was in the refrigerator, - An… […]

• No harm, potential for more than minimal, widespreadF925Jul 21, 2025

  Based on observation, interview, and record review, the facility failed to ensure an effective pest control program was maintained and the facility was free of gnats. This deficient practice had the potential to affect 47 of 48 residents residing in the facility. Findings include:During an observation and interview, on 07/21/25 at 8:07 A.M., in the kitchen there were multiple gnats observed flying in the air near the dry food storage area. Upon entering the dry storage room, the number of gnats increased. Five gnats landed on an unopened bag of cereal on a shelf at eye level. Three gnats landed on an unopened can of cheese approximately four feet off the ground on a metal shelf. A blue light was in the dry food storage area, plugged into the wall inside the doorway. […]

• No harm, potential for more than minimal, widespreadF812Jan 27, 2023

  Based on observation, interview, and record review, the facility failed to store food and provide a clean kitchen environment for 2 of 2 kitchen observations. This deficient practice had the potential to effect 41 of 41 residents who receive food from the kitchen. Findings include: During an initial tour observation and interview on 01/23/23 at 9:39 A.M., the walk-in refrigerator contained the following: - a container of chicken noodle soup, 1/4 full, dated 12/27/22, - a 1 gallon sized, resealable storage bag with approximately four pieces of corn bread, dated 01/12/23. The Dietary Manager indicated the food should have been disposed. The dry storage room exterior walls had visible a black, dotted substance 6 to 12 inches above the base boards. […]

• No harm, potential for more than minimal, patternF684Jan 28, 2026

  Based on record review, and interview, the facility failed to follow physician's orders related to cardiac medication hold parameters, obtaining vital signs and weights, and notifying the physician of weight changes for 3 of 17 residents reviewed for Quality of Care. (Residents 3, 40 and 14)Findings include: 1.Resident 3's clinical record was reviewed on 01/21/2026 at 2:34 P.M. A Quarterly Minimum Data Set (MDS) assessment, dated 12/31/2025, indicated the resident was cognitively intact. […]

• No harm, potential for more than minimal, patternF812Jan 28, 2026

  Based on observation, interview, and record review, the facility failed to maintain the kitchen in a sanitary manner for 2 of 3 kitchen observations and unmarked random food containers in the resident snack refrigerator for 1 of 1 resident snack refrigerators observed. Findings include: During the initial kitchen tour with the Dietary Manager (DM), on 01/20/2026 at 10:33 A.M., the following was observed: -a large, enclosed meal tray cart had a tray on top with a toaster sitting on the tray. The tray was heavily littered with breadcrumbs. […]