Greenway Manor: Failed to Report Suspected Abuse - WI
When a state surveyor walked into Greenway Manor on December 23, 2025, the allegation against a certified nursing assistant had already been sitting for three weeks. The CNA, identified in inspection records as CNA D, had been accused of abusing a resident during a whirlpool bath. The facility had found out. The clock had started. And then, for three weeks, the state heard nothing.
The Director of Nursing, identified as DON B, told the surveyor exactly how it came to light: another CNA, identified as CNA G, had sent a message. DON B acknowledged that without that message, the facility might never have known at all.
The surveyor asked DON B when the allegation should have been reported to the state. DON B said the day it occurred, within two hours. The surveyor didn't have to point out the gap. Three weeks had passed.
The resident at the center of the allegation is identified in the report only as R1. What happened to R1 during the whirlpool with CNA D is not spelled out in the inspection findings. What is spelled out is what the facility did — and didn't do — afterward.
CNA D was removed from the floor. That much happened. DON B told the surveyor the facility interviewed the CNAs involved, and also interviewed R1 and one other resident, R2, described as the only two residents on that hall who could communicate and who had received whirlpool baths from CNA D.
The surveyor asked whether all residents should have been interviewed.
DON B said yes.
The surveyor asked whether all staff should have been interviewed.
DON B said the facility had only interviewed the CNAs with direct knowledge of the alleged incident.
There was no full staff canvass. There was no house-wide skin assessment completed after the allegation came in. DON B told the surveyor that skin checks had been completed as part of the residents' regular weekly assessments — not as a targeted response to the abuse allegation. The surveyor asked directly whether a sweep of skin assessments had been completed on all residents after the allegation was reported. DON B said no.
The education piece unraveled the same way. DON B told the surveyor that education on abuse reporting had been provided to staff verbally. The surveyor asked if it had been documented. DON B said it had not. Then DON B said something that the inspection report captured without editorializing: if it was not documented, it was not done.
That was the Director of Nursing's own standard, applied to her own facility's response.
Later that afternoon, the surveyor sat down with the Nursing Home Administrator, identified as NHA A. The administrator's account of what a proper investigation looks like was detailed and, in most respects, accurate. Report to the state within two hours of learning about it. Complete the investigation and submit it within five days. Interview staff who are aware of what happened. Interview a sample of residents depending on the nature of the allegation.
NHA A drew a distinction: a general allegation would call for interviewing all residents; a specific allegation might not. For a specific allegation, the focus would be on the staff involved, the residents involved, and the area of the facility where it happened.
The surveyor asked whether the facility would provide education to staff. NHA A said education would be provided to staff involved in the investigation.
Not all staff. Staff involved in the investigation.
The inspection report documents what the facility failed to provide: evidence that it had taken steps to prevent further abuse to R1 and to other residents. The investigation, by the facility's own admission and by the standards its own leadership described, was not thorough.
What makes the Greenway Manor findings land differently than a standard paperwork violation is the sequence of acknowledgments. No one disputed what the rules required. DON B could recite the two-hour reporting window. NHA A could walk through the components of a proper investigation almost point by point. The surveyor wasn't educating anyone about what the process was supposed to look like. The surveyor was documenting the distance between what the leadership knew and what they actually did.
DON B's statement that undocumented education should be treated as education that never happened is, in a narrow sense, a show of professional accountability. In a broader sense, it is a description of a facility that spent three weeks doing less than its own director believed was required, and then acknowledged it plainly when asked.
The whirlpool bath is where the allegation originates. It is also the specific context that makes the missing skin sweep significant. If a CNA is accused of abusing a resident during a bath, the question of whether other residents who bathed with that CNA show any signs of injury is not a procedural formality. It is the most direct way to find out whether the harm extended beyond R1. Greenway Manor did not do it. DON B confirmed it. The weekly skin checks that did occur were not designed for that purpose and were not conducted in response to the allegation.
The report notes that only R1 and R2 were interviewed because they were identified as the only communicative residents on that hall who had received whirlpool baths from CNA D. That framing, taken on its own, has a certain logic. But DON B also told the surveyor that all residents should have been interviewed. Those two statements coexist in the record without resolution.
CNA G's message is the reason this investigation exists at all. DON B acknowledged that without it, the facility would not have found out. The report does not describe what CNA G saw, or when, or why it took three weeks for the message to prompt any contact with the state. The record simply notes that DON B cited CNA G's statement when telling the surveyor the alleged incident had occurred three weeks prior.
The facility's response to the allegation, as documented, amounted to removing one CNA from the floor, interviewing a narrow group of staff and two residents, and providing verbal guidance to some portion of the workforce that was never written down and, by the DON's own reckoning, cannot be confirmed as having happened.
R1, the resident who was in that whirlpool bath, is not described further in the inspection report. Their condition after the allegation, whether they were assessed beyond the regular weekly skin check schedule, what they said when interviewed, none of that appears in the findings. The report is focused on the facility's process, and the facility's process is what failed.
The surveyor's final finding was direct: Greenway Manor failed to provide evidence sufficient to prevent further abuse to R1 and to other residents. The investigation into the alleged abuse was not thorough.
Three weeks passed between the whirlpool and the surveyor's arrival. In that time, the state heard nothing, most staff were never asked what they knew, and no one walked the halls checking whether anyone else had been hurt.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Greenway Manor from 2025-12-23 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
GREENWAY MANOR in SPRING GREEN, WI was cited for abuse-related violations during a health inspection on December 23, 2025.
The CNA, identified in inspection records as CNA D, had been accused of abusing a resident during a whirlpool bath.
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.