The Manor at Greendale

In the surveyor’s words

From the most serious findings on record at The Manor at Greendale, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF550Feb 27, 2025

  35031 Based on observation, medical record review, resident interview, and staff interview the facility failed to ensure residents seated at the same table were served meals together. This directly affected four residents, #08, #20, #33, and #55, in the main dining room and one resident, #64, in the memory care dining room. The facility census was 73. Findings include: 1. Observation on 02/24/25 at 12:35 P.M. revealed two Residents, #33 and #49, seated at one table, three residents, #08, #37, and #58, seated at another, and three residents, #20, #52, and #55, seated at a third table. Meals were delivered on a cart from the adjacent kitchen and delivered to Residents #49, #37, #58, and #52, leaving at least one resident at the three tables without being served. […]

• No harm, potential for more than minimal, patternF880Feb 27, 2025

  49742 Based on observation, staff interview, resident interview, review of the medical record, and review of facility policy, the facility failed to ensure staff used appropriate hand hygiene while distributing meal trays to residents. This affected seven residents (#1, #2, #4, #5, #17, #32 and #33) served meal trays on the C-Hall, with the potential to affect all 14 residents (#1, #2, #4, #5, #7, #11, #17, #22, #32, #33, #37, #52, #58, and #222) residing on C-Hall who receive meal trays. The facility also failed to ensure staff wore appropriate personal protective equipment (PPE) when entering a resident room who was in droplet precaution. This affected one resident (#2) of one resident reviewed for transmission-based precautions (TBP). […]

• No harm, potential for more than minimal, isolatedF657Aug 11, 2026

  Based on review of the medical record, interview, and policy review, the facility failed to ensure a care plan with interventions for enhanced barrier precautions (EBP) was initiated. This affected one (#8) of three residents reviewed for care planning. The facility census was 64. Findings include:Review of the medical record for Resident #8 revealed an admission date of 06/29/26. Diagnoses included Type II diabetes mellitus, hypertension, atrial fibrillation, and lumbosacral plexus disorder.Review of the second modification of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had mild cognitive impairment. The resident was frequently incontinent of bowel and bladder. The resident was dependent on staff for toileting, bathing, and transfers. […]

• No harm, potential for more than minimal, isolatedF686Aug 11, 2026

  Based on observation, review of the medical record, interview, and policy review, the facility failed to ensure wound assessments were timely and accurately completed, failed to clarify physician orders, failed to monitor skin breakdown, and failed to ensure interventions to promote wound healing were completed per physician orders. This affected one (#8) of three residents reviewed for pressure ulcers. The facility identified eight residents with pressure ulcers. The facility census was 64.Findings include:Review of the medical record for Resident #8 revealed an admission date of 06/29/26. Diagnoses included lumbosacral plexus disorder, atrial fibrillation, Type II diabetes mellitus, and hypertension. […]

• No harm, potential for more than minimal, isolatedF690Aug 11, 2026

  Based on observation, medical record review, interview, and review of the facility policy, the facility failed to ensure physician orders were in place for the care of a suprapubic catheter. This affected one (#12) of one resident identified by the facility as having a suprapubic catheter. The facility census was 64.Findings include:Review of the medical record for Resident #12 revealed an admission date of 06/12/26. Diagnoses included peripheral vascular disease, chronic kidney disease, and obstructive and reflux uropathy. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #12 had intact cognition. Additional review of the MDS revealed Resident #12 had an indwelling catheter. […]