Below average — CMS composite of the measures below.
The next survey window likely opens around December 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 Manderley Health Care Center during CMS and state inspections, most recent first.
Failure to follow physician orders affected three residents. One resident with orthostatic hypotension received Midodrine even when BP was above the ordered hold parameters or when BP was not obtained. A second resident had an order for weekly VS, but the record lacked documentation that they were taken. A third resident with CHF and edema had missed daily weights and weight gains that met reporting thresholds, but the record lacked documentation of MD notification or reasons weights were not obtained.
Kitchen sanitation and unlabeled resident snack food: Staff observed breadcrumbs on a tray with a toaster, an unlabeled inhaler stored beside seasoning spices, stained frozen bottles of water used to cool tea, crumb-littered clean dishes, an uncovered trash can with food residue, and a flour tub with a scoop left inside. The resident snack refrigerator also contained a dated meal container and a sealed snack tray with no resident name, room number, or date.
A resident with moderate cognitive impairment and diagnoses including anemia, HTN, hypothyroidism, and a seizure disorder had standing orders for periodic lab monitoring, including Depakote level, TSH, Free T4, and A1C. The record lacked results for several ordered tests that were due in two separate monitoring periods, and the DON confirmed the labs were missed and should have been completed.
Surveyors found food items stored directly on the floor, undated opened juice containers, and salt packets on the floor in kitchen storage areas. Multiple gnats were observed throughout the kitchen, landing on unopened food packages, a coffee machine, and uncovered cooked meat, as well as flying around food prep areas and trash cans. Staff confirmed that food should be dated and not stored on the floor, and facility policies required clean storage and proper labeling, which were not followed.
A persistent gnat infestation was observed in the kitchen, with gnats found on food packaging, around food preparation areas, and near equipment. Staff interviews and pest control records confirmed the issue had been ongoing for months, with insufficient measures taken to eliminate the pests. The deficiency had the potential to affect nearly all residents.
A facility failed to treat a resident with dignity during meal service. A CNA stood over a resident in a wheelchair, repeatedly calling her name while feeding her, despite available seating. The resident, with moderate cognitive impairment and multiple diagnoses, relied on staff for eating assistance. The facility's policy requires treating residents with respect and dignity, which was not followed.
The facility failed to protect resident confidentiality by leaving sensitive information visible on unattended medication carts in two separate incidents. On one occasion, a computer screen displaying a resident's information was left unlocked, and on another, a CNA Report Sheet and medication cards with resident names were exposed. Staff and mobile residents passed by these carts, potentially compromising privacy.
The facility failed to follow physician's orders for medication hold parameters for two residents. One resident received Coreg despite heart rates below the prescribed threshold, while another received Midodrine when blood pressure exceeded limits. The facility's policy requires checking vital signs before administering medications, but this was not consistently done, leading to deficiencies in care.
A resident with severe cognitive impairment and multiple diagnoses experienced a delay in UTI treatment. Although a UA/CS was ordered on a Saturday, the urine sample was not collected until Wednesday, and results were available by Friday. Despite this, antibiotic treatment was not initiated until the following Monday. The facility's policy to follow prescriber orders promptly was not adhered to.
The 100-Hall Medication Cart was left unlocked and unattended, with several staff members, including CNAs and an RN, passing by without securing it. The facility's policy requires secure storage of medications, which was not followed. Mobile residents were nearby, increasing potential risk.
A resident with severe cognitive impairment and multiple diagnoses experienced delays in obtaining necessary laboratory tests, including a PT/INR blood test and a urinalysis. The facility faced challenges with lab sample collection and processing due to scheduling and logistical issues, resulting in delayed test results and subsequent treatment.
The facility was found to have deficient food storage practices, with expired and unlabeled food items observed in the kitchen. Expired lactose-free milk and brown gravy were not discarded as per policy, potentially affecting 45 residents. A staff member confirmed the oversight during an interview.
A facility failed to follow infection control guidelines for a resident with a urinary catheter. The catheter bag was observed on the floor, contrary to policy, and staff did not adhere to enhanced barrier precautions during care. The resident, with neurogenic bladder and obstructive uropathy, was dependent on staff for all care. The facility's policies required catheter bags to be off the floor and the use of gowns and gloves during high-contact activities.
Failure to Follow Physician Orders for Medication Parameters, Vital Signs, and Weights
Penalty
Summary
The facility failed to follow physician orders related to medication hold parameters for a resident with dementia, anxiety, depression, bipolar disorder, and orthostatic hypotension. The resident had an order for Midodrine 2.5 mg after each meal with instructions to hold the medication if systolic blood pressure was greater than 115 or diastolic blood pressure was greater than 65. The EMAR showed the medication was administered on multiple occasions when blood pressure values were above the ordered limits, and on some occasions when blood pressure was not obtained before administration. The facility also failed to document weekly vital signs for a resident with diabetes, renal insufficiency, coronary artery disease, and seizure disorder. The resident had an open-ended physician order, starting 10/29/2025, for blood pressure, heart rate, temperature, and respiratory rate to be obtained once a week in the evenings on Wednesdays. The resident's record lacked documentation of any weekly vital signs after the order was entered. The DON stated the order was entered into the computer, but no weekly vital sign assessments were documented. For another resident with hypertension, anemia, congestive heart failure, lower extremity edema, and dementia, the facility failed to obtain ordered daily weights on multiple days and failed to document notification of the physician for weight gains that met the ordered reporting thresholds. The resident had an order for daily weights and for staff to notify the MD if there was a weight gain of more than three pounds in one day or five pounds in one week. The record showed several missed weights and several weight increases, including gains of 6.1 pounds, 3.3 pounds, and 3.4 pounds, but the progress notes did not document physician notification or reasons the weights were not obtained.
Kitchen sanitation and unlabeled resident snack food
Penalty
Summary
The facility failed to maintain the kitchen in a sanitary manner during multiple kitchen observations. During the initial kitchen tour, a large enclosed meal tray cart had a tray on top with a toaster sitting on it and the tray was heavily littered with breadcrumbs. An unlabeled respiratory medication inhaler was sitting on top of the cart within an inch of a bottle of seasoning spices, and the Dietary Manager identified the inhaler as the cook's because she had asthma. The walk-in freezer contained two frozen bottles of water, one a green two-liter bottle and one a clear old juice bottle, both stained brown, which the Dietary Manager said were regularly used to cool pitchers of prepared iced tea. An open rack of dishes with small bowls and plates was littered with crumbs, and a large trash can at the end of a food prep table was over half full, had no lid in place, and had a lid with a six-to-eight-inch hole and food stuck around the hole. In the dry storage room, a large blue tub labeled flour filled 10/4/24 contained a small amount of flour and a scoop, and an eight-inch hole in the floor was covered with a towel with two open-ended pipes extending over it. The resident snack refrigerator also contained unmarked food items. It held a Styrofoam meal container dated 01/20/2026 in a plastic grocery bag, which the RN identified as being for a resident admitted from another facility over the weekend, and a small sealed snack tray with no resident name, room number, or date. During interview, the Administrator stated there was no policy related to staff personal items in the kitchen food prep area. The facility's Food from Outside Sources policy required visitors and family members to label food and beverages with the resident's name, room number, and date, and to use a perishable food use-by date of 3 days from the date brought into the facility.
Missed Ordered Blood Tests
Penalty
Summary
The facility failed to obtain ordered blood tests for one resident reviewed for laboratory services. The resident had a Quarterly MDS assessment dated 01/06/2026 showing moderate cognitive impairment and diagnoses that included anemia, hypertension, hypothyroidism, and a seizure disorder. Current medication orders included Synthroid 25 mcg daily and Depakote Sprinkles 500 mg twice daily. The resident also had an open-ended physician order, dated 10/15/2024, to obtain Depakote level, CMP, CBC, TSH, Free T4, and Hemoglobin A1C every six months in September and March. The record lacked results for Depakote level, TSH, T4, and A1C that should have been obtained in March 2025 and September 2025. The DON confirmed in interview that the Depakote, TSH, T4, and A1C blood tests were not obtained in those months and stated the tests were missed and should have been completed.
Deficient Food Storage, Labeling, and Pest Control in Kitchen
Penalty
Summary
Surveyors observed multiple failures in food storage and handling within the facility's kitchen. Raw premade frozen hamburger patties and popsicles were found lying directly on the floor of the walk-in freezer, and salt packets were observed on the floor of the dry food storage area. Additionally, opened and undated containers of nectar thick orange and cranberry juice were found in the refrigerator. Kitchen staff confirmed that all opened food and drink items should be dated and disposed of if undated, and the Dietary Manager acknowledged that food should not be stored on the freezer floor. Further observations revealed a significant presence of gnats throughout the kitchen and dry food storage areas. Gnats were seen landing on unopened food packages, including cereal and canned cheese, as well as on a partially used hotdog bun package and the buttons of a coffee machine. Multiple gnats were also observed flying around the trash can, food preparation areas, and uncovered precooked sliced meat. Staff were seen preparing raw chicken while gnats were present in the area. Facility policies required clean storage areas and proper labeling and dating of food items, but these standards were not met during the survey.
Failure to Maintain Effective Pest Control Program Resulting in Gnat Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a persistent gnat infestation in the kitchen area. Multiple observations revealed gnats flying near the dry food storage area, landing on unopened food items such as cereal and canned cheese, and congregating around a commercial coffee machine and trash cans. Staff interviews confirmed that the gnat problem had been ongoing for months, with the issue worsening as the weather warmed. The kitchen drain had a history of clogging from food debris, and although a plumber and chemical supplier had recently addressed the drain, the gnat presence persisted. Pest control service records indicated inconsistent targeting of gnats and incomplete documentation of kitchen-specific treatments. The facility's pest control policy required prompt action when pests were observed in the kitchen, but observations and interviews indicated that the measures taken were insufficient to eliminate the infestation. The presence of gnats on food packaging, food preparation areas, and equipment posed a potential risk to nearly all residents in the facility. The deficiency was identified through direct observation, staff interviews, and review of pest control service records, which highlighted ongoing pest issues and inadequate resolution.
Failure to Ensure Dignified Meal Assistance
Penalty
Summary
The facility failed to treat a resident in a dignified manner during a meal service, as observed in the Main Dining Room. Certified Nurse Aide (CNA) 6 was seen standing upright next to a resident's wheelchair, repeatedly calling the resident's name to gain her attention while spooning food into her mouth. This occurred despite several empty chairs being available in the dining room, and another staff member was seated while assisting another resident at the same table. The resident, identified as moderately cognitively impaired with diagnoses including diabetes, hypertension, dementia, anxiety, depression, and psychotic disorder, was dependent on staff for eating assistance. The facility's Resident Rights policy, revised in June 2023, mandates that employees treat all residents with kindness, respect, and dignity, which was not adhered to in this instance.
Failure to Maintain Resident Record Confidentiality
Penalty
Summary
The facility failed to maintain the confidentiality of resident records during two separate observations. On the 100 Hall Medication Cart, Resident 249's information was visible on a computer screen that was left unattended from 2:17 P.M. to 2:39 P.M. on 01/27/25. During this time, several staff members, including CNAs and a Laundry Aide, walked by the cart without securing the screen. RN 3 interacted with the cart but did not lock the computer screen before leaving. Mobile residents were also present in the vicinity, potentially exposing sensitive information. Similarly, on 01/29/25, the 300 Hall Medication Cart was left unattended with a CNA Report Sheet and empty medication cards, including one for Resident 27, visible on top. Multiple staff members and an independently mobile resident passed by the cart during the observation period from 10:37 A.M. to 10:45 A.M. A QMA later confirmed that resident names should not be visible on the medication carts. The facility's policy, revised in 10/2017, mandates the protection of resident confidentiality and limits access to personal and medical records to authorized personnel.
Failure to Follow Medication Hold Parameters for Two Residents
Penalty
Summary
The facility failed to adhere to physician's orders regarding medication hold parameters for two residents, leading to deficiencies in quality of care. Resident 15, who was moderately cognitively impaired and diagnosed with coronary artery disease, diabetes, and hypertension, was prescribed Coreg with specific hold parameters for heart rate and blood pressure. Despite these orders, the resident received the medication multiple times when their heart rate was at or below the threshold of 60 beats per minute, as documented in the Electronic Medication Administration Record (EMAR) for October 2024, December 2024, and January 2025. The Consultant Pharmacist had previously noted these discrepancies and recommended staff education, but the issue persisted. Similarly, Resident 24, who was cognitively intact and had diagnoses including hypertension and chronic pain syndrome, was prescribed Midodrine with hold parameters for blood pressure. The EMAR for November and December 2024, and January 2025, showed that the resident received the medication on several occasions when their blood pressure exceeded the specified limits. During an interview, a registered nurse indicated that she would check vital signs before administering medications with hold parameters, but the records showed that this protocol was not consistently followed. The facility's policy on medication administration, revised in December 2012, requires that medications be administered safely and as prescribed, with vital signs checked if necessary. However, the repeated administration of medications against the hold parameters for both residents indicates a failure to comply with this policy, resulting in the identified deficiencies.
Delayed Treatment of UTI in Resident
Penalty
Summary
The facility failed to treat a urinary tract infection (UTI) in a timely manner for a resident who was severely cognitively impaired and had multiple diagnoses, including Parkinson's disease, dementia, and urinary retention. On a Saturday, new physician's orders were received to obtain a urinalysis and culture and sensitivity (UA/CS) for the resident. However, the urine sample was not collected until the following Wednesday, and the results were reported on Friday. The lab report indicated the presence of multiple bacteria, including Klebsiella pneumoniae and Proteus mirabilis, with varying microbial loads. Despite the availability of the UA/CS results on Friday, the facility did not initiate antibiotic treatment until the following Monday, when a new physician's order was received to administer Fosfomycin. The first dose of the antibiotic was given later that evening. During an interview, the Director of Nursing indicated that the facility could have contacted the physician and pharmacy to start the antibiotic over the weekend, but this was not done. The facility's policy requires following and carrying out prescriber orders in accordance with applicable guidelines, which was not adhered to in this case.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to store medications appropriately as observed with the 100-Hall Medication Cart. During a continuous observation, the medication cart was found unlocked and unattended from 2:17 P.M. to 2:39 P.M. on 01/27/25. Throughout this period, several staff members, including Certified Nurse Aides (CNAs), a Registered Nurse (RN), and a Laundry Aide, walked by the cart without securing it. RN 3 interacted with the cart but did not lock it before leaving. The facility's policy, revised in April 2007, mandates that all drugs and biologicals be stored securely, which was not adhered to in this instance. Mobile residents were present in the vicinity of the unattended cart, posing a potential risk.
Delayed Laboratory Services for Resident
Penalty
Summary
The facility failed to obtain timely laboratory services for a resident, specifically a blood test and a urinalysis. The resident, who was severely cognitively impaired and diagnosed with conditions including Parkinson's disease, dementia, and aortic valve disorder, had physician's orders for weekly PT/INR blood tests due to warfarin administration. However, the lab was unable to collect the PT/INR sample on multiple occasions, leading to a delay in obtaining the necessary blood test. The sample was eventually collected and resulted within the therapeutic range, but the Director of Nursing expressed a preference for the test to have been conducted earlier. Additionally, there was a delay in obtaining a urinalysis and culture for the same resident. Despite new physician's orders for these tests, the urine sample was not collected and sent to the lab in a timely manner. The sample was collected and refrigerated, but due to the lab's limited pickup schedule, it was not processed until several days later. The lab report indicated the presence of multiple bacteria, and a new physician's order was received to administer an antibiotic. The Director of Nursing and RN indicated that the facility had to ship samples if collected on days the lab did not visit, but there was uncertainty about the lab's location and the process for shipping samples.
Deficient Food Storage Practices
Penalty
Summary
The facility failed to store foods in a sanitary manner, as observed during a kitchen inspection. Specifically, there were unlabeled and outdated food items, including a half gallon of lactose-free 2% milk and a metal pan of brown gravy, both of which were expired. These items were not discarded as per the facility's policy, which mandates that leftover food should be used within three days or discarded, and all foods should be covered, labeled, and dated. This deficiency was identified during an interview with a staff member who confirmed that the expired items should have been thrown out. The issue had the potential to affect 45 of the 47 residents who receive food from the kitchen.
Infection Control Deficiency in Urinary Catheter Care
Penalty
Summary
The facility failed to adhere to infection control guidelines concerning urinary catheter care for a resident with a neurogenic bladder and obstructive uropathy, who was moderately cognitively impaired and dependent on staff for all care. During observations, the resident's urinary catheter bag was found lying on the floor on multiple occasions, with the urine appearing cloudy. A Qualified Medication Aide acknowledged that the catheter bag should be kept off the floor and below bladder level, as per the facility's policy. The facility's policy on catheter care, revised in September 2014, explicitly stated that catheter tubing and drainage bags should not be on the floor. Additionally, the facility did not follow enhanced barrier precautions during urinary catheter care for the same resident. A Certified Nurse Aide (CNA) entered the resident's room without donning a gown, despite being involved in high-contact care activities. The facility's policy on Enhanced Barrier Precautions, updated in April 2024, required the use of gowns and gloves during such activities to prevent the spread of multi-drug resistant organisms. The CNA involved acknowledged the failure to adhere to these precautions, which were necessary due to the resident's use of an indwelling medical device.
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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 Osgood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Silver Memories Health Care | 4.3 mi | ★★★★★ | 11 | 0 |
| Ripley Crossing | 8.3 mi | ★★★★★ | 12 | 0 |
| St Andrews Health Campus | 12.7 mi | ★★★★★ | 7 | 0 |
| Waters Of Batesville, The | 13.1 mi | ★★★★★ | 15 | 0 |
| Waters Of Dillsboro-ross Manor, The | 14.3 mi | ★★★★★ | 11 | 0 |
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