Julia Manor Nursing and Rehabilitation Center

Inspectors wroteBased on record reviews, review of facility policy and procedures, and interviews the facility failed to ensure residents were free from avoidable accidents. This was true for 2 of 3 sampled residents (Residents #10 and #14). This failure resulted in harm to Resident #10. The facility implemented a plan of correction with a compliance date of 3/23/2026.

Inspectors wroteBased on record review, observation, and staff interview, the facility failed to ensure that care and services were provided in accordance with professional standards of nursing practice for 2 of 5 residents reviewed (Residents #1 and #15). This included failure to follow accepted standards of medication administration, including the five rights of medication administration (right resident, right medication, right dose, right route, and right time) and failure to adhere to manufacturer's guidelines for medication administration.1. Resident #1 was admitted to facility on 9/20/24 with a diagnosis of diabetes. Review done on 4/28/26 at 8:52pm of Quarterly minimum data set (MDS) assessment dated [DATE] indicated that Resident #1 was cognitively intact with a diagnosis of diabetes and received insulin injections daily. [...]

Inspectors wroteBased on record review and staff and resident interviews, the facility failed to provide dignity and respect for 1(R1) of 3 sampled residents, who preferred to have their bedpan near him/her, but instead moved it away from him/her telling them that they caused a mess while using it.

Inspectors wroteBased on record review, staff and resident interviews, the facility failed to prevent verbal abuse by staff for 2 (R3 and R5) of 2 sampled residents.

Inspectors wroteBased on record review, observation, and staff interview, the facility failed to ensure proper medication labeling, storage, handling, and administration practices in accordance with pharmacy services policies and procedures and manufacturer's guidelines for 2 of 5 residents reviewed (Residents #1 and #15). This resulted in the administration of medication labeled for another resident and improper alteration of medication despite Do Not Crush instructions.1. Resident #1 was admitted to facility on 9/20/24 with a diagnosis of diabetes. Review done on 4/28/26 at 8:52pm of Quarterly minimum data set (MDS) assessment dated [DATE] indicated that Resident #1 was cognitively intact with a diagnosis of diabetes and received insulin injections daily. [...]

Inspectors wroteBased on record review, observation, and staff interviews the facility failed to ensure that the medication error rate was less than 5% for 5 residents reviewed during medication pass observations. Administration of insulin to Resident #1 using an insulin pen labeled for another resident (wrong resident medication), and alteration of medication for Resident #15 by opening a medication labeled Do Not Crush (improper administration), were observed. This was evidenced by 2 medication errors out of 29 opportunities observed (6.89%), which exceeds the allowable error rate of 5%.1. Resident #1 was admitted to facility on 9/20/24 with a diagnosis of diabetes. Review done on 4/28/26 at 8:52pm of Quarterly minimum data set (MDS) assessment dated [DATE] indicated that Resident #1 was cognitively intact with a diagnosis of diabetes and received insulin injections daily. Review done on 4/28/26 at 8: [...]

Inspectors wroteBased on observations, record reviews, and interviews, it was determined that the facility failed to ensure that residents were served meals according to a predetermined menu that incorporated the residents' preferences. This deficient practice has the potential to affect all residents.

Inspectors wroteBased on observations and interviews, it was determined that the facility failed to ensure that: 1) food was stored in accordance with professional standards, and 2) clean dishes were stored and maintained in a manner to prevent contamination. This practice has the potential to affect all the residents in the facility.

Inspectors wroteBased on observations and interviews, it was determined that the facility failed to ensure linens were processed appropriately to prevent cross contamination. This deficient practice had the potential to affect all residents of the facility.

Inspectors wroteBased on interviews, record reviews, and observations, it was determined that the facility failed to develop person-centered, resident-specific care plans. This was evident for 1 (Resident #92) of 1 resident reviewed for insulin use and 2 (Residents #4 and #13) of 3 residents reviewed for activities.

Inspectors wroteBased on interviews and record reviews, it was determined that the facility failed to reassess the effectiveness of resident care plans and revise them to address resident-specific needs. This was evident for 3 (Resident #4, #13, and #60) of 3 residents reviewed for activities.

Inspectors wroteBased on record review, interviews, and observations, it was determined that the facility failed to ensure that residents received their meals at an appropriate and palatable temperature. This deficient practice has the potential to affect all residents who receive meals from the facility's kitchen.

Inspectors wroteBased on record review, observations, and interviews, it was determined that the facility failed to treat residents with respect and dignity during mealtime. This was evident for 3 out of 5 meal observations during the survey.

Inspectors wroteBased on observation and interviews it was determined that the facility failed to ensure a sanitary and homelike environment. This was found during random observations of two residents' rooms (Resident #97 and #67) and 1 out of the 2 nursing units.

Inspectors wroteBased on medical record review, resident and staff interviews and observations, it was determined that the facility failed to ensure that the activities of Daily living needs of a dependent resident were adequately provided and documented. This was evident for 3 of 5 residents (Residents #20, #58, and #60) reviewed for ADL care.

Inspectors wroteBased on interviews and record review, it was determined that the facility failed to ensure a resident received treatment and care in accordance with professional standards by not including diabetes-related interventions in the care plan. This was evident for 1 (Resident #92) of 1 resident reviewed for insulin use.

Inspectors wroteBased on record review, interview and observation it was determined that the facility failed to ensure adequate supervision and staff assistance during a resident's mechanical lift transfer. This was evident for 1 (Resident #90) of 5 residents reviewed for activities of daily living during the recertification survey.

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to have an effective process to ensure that medication recommendations made by the pharmacist were delivered to the physician for review. This was evident for 1 (Resident #10) of 5 residents reviewed for unnecessary medications during a survey.

Inspectors wroteBased on records review and interviews, it was determined that the facility failed to ensure residents were free from unnecessary medications. This was evident for 1 (Resident #8) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview and review of medical records it was determined that the facility failed to ensure medication error rate of less than 5% as evidenced by 3 errors out of 29 opportunities. These errors were identified for 2 (Resident #73 and #10) out of the three residents observed during the medication administration observation task.

Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to ensure education was provided to residents and/or responsible parties (RP) regarding the benefits and potential risks associated with the COVID 19 vaccine. This was evident for 1 (Resident #31) of 5 residents reviewed for immunizations.

Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to ensure that their residents were free from abuse and neglect. This was evident for 2 (#112 and #107) out of 26 residents reviewed for abuse and neglect.

Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to ensure that residents received optimal quality of care that aligned with standards of professional practice. This was evident for 4 (Residents #112, #107, #118, and #86) of 84 residents reviewed during the survey.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility 1) failed to prevent a cognitively impaired resident from exiting the facility, unsupervised, for an unknown amount of time. This was found to be evident for 1 (#84) of 16 residents reviewed for accidents.

Inspectors wroteBased on record review, interview, and observation, it was determined that the facility failed to have a system in place to ensure that therapist recommendations were conveyed to nursing when a resident was discharged from therapy resulting in a failure to provide treatment to prevent a decrease in range of motion. This deficient practice resulted in harm to Resident #41 due to the development of a contracture. This was found to be evident for 2 (Resident #41 and Resident #8) out of 3 residents reviewed for position, mobility, and rehabilitation.

Inspectors wroteBased on record review and interview, it was determined that facility staff failed to provide nutritional services for their residents that aligned with professional standards of practice. This deficient practice resulted in harm to Resident #112 due to a weight loss of 31% of their body weight in 3 months. This was evident for 1 (#112) of 5 residents reviewed for nutrition.

Inspectors wroteBased on medical record review, facility documentation review, and interview, it was determined that the facility administration failed to identify allegations of abuse and thoroughly investigate them to determine the cause to implement a plan of correction and failed to allow residents to exercise their rights freely. This was evident throughout the annual survey and had the potential to affect all residents.

Inspectors wroteBased on interview and record review, it was determined that the facility failed to offer and/or obtain advance directives for residents. This was evident for 5 (#10, # 30, # 98, #94, and #13) of 16 residents reviewed for advanced directives.

Inspectors wroteBased on record review, policy review and staff interview, it was determined that the facility failed to implement their abuse prevention policies and procedures. This was evident for one out of one abuse policy reviewed.

Inspectors wrote3) On 8/8/23 review of Resident #76's medical record and MD00187490 revealed the resident was admitted in 2021 with diagnoses that included, but were not limited to, dementia and diabetes. The resident is dependent on staff for asssistance with activities of daily living. On 1/6/23 between 3:00 - 4:00 PM, the resident was noted to have a discoloration to the right chin and scratches to the left upper arm. The physician and the responsible representative were notified on 1/6/23 and an investigation was initiated by the facility. Review of email confirmation documentation revealed the initial report of this injury of unknown origin was sent to the State Survey Agency on 1/8/23 at 11:35 AM. On 8/8/23 at 11:51 AM, surveyor reviewed the concern with the Director of Nursing regarding the late reporting of this injury of unknown origin. [...]

Inspectors wroteBased on review of facility reported incident investigations and interview, it was determined the facility failed to thoroughly investigate allegations of abuse, injuries of unknown origin and misappropriation of property. This was evident for 7 (#48, #37, #35, #76, #112, #102 and #8) out of 19 resident's reviewed for abuse and an additional three residents (#17, #302, and #303) identified during these investigations.

Inspectors wrote3) On 8/9/23 review of Resident #107's medical record revealed the resident was admitted to the facility in April 2022 with diagnosies that included, but were not limited to, diabetes and high blood pressure. Further reveiw of the medical record revealed a physician order, in effect from April 2022 until the resident's discharge in January 2023 for monthly weight. No weight was found for the month of October. A Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 11/6/22 failed to reveal documentation of a weight. Section K0200 B. Weight was noted to be blank. Section K0300 Weight Loss of 5% or more in the last month or loss of 10% or more in last 6 months was documented as 0 for No or unknown. [...]

Inspectors wroteBased on review of the medical record and interview with staff, it was determined that the facility staff failed to provide residents/representatives with a copy of their baseline care plan that included a summary of the resident's medication. This was evident for 3 (#82, #106 and #86) of 84 residents reviewed during the survey.

Inspectors wroteBased on medical record review and interview, it was determined that the facility failed to ensure the primary care providers reviewed the resident's total program of care during required visits and failed to ensure that notes related to those visits were completed and signed in a timely manner. This was found to be evident for 5 (Resident #107, #58, #117, #9 and #8 ) out of 84 residents reviewed during the survey.

Inspectors wroteBased on observation, family and resident interviews, review of medical records, facility documents, facility reports and complaints, it was determined that the facility failed to have sufficient nursing staff to meet the needs of the residents. This was evident for 2 of 2 nursing units.

Inspectors wroteBased on record review, observation and interview, it was determined that the facility staff failed to ensure that residents were able to exercise their right of self-determination, as evidenced by failing to ensure a resident was able to choose his/her preference for bathing and failed to accommodate resident choices when a policy affecting resident smoking was significantly changed. This was evident for 3 (#11, #48, and #8) of 3 residents reviewed for choices.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to notify the physician and the resident representative when a resident had a significant weight loss. This was evident for 2 (#45 and #118) of 84 residents reviewed during the survey.

Inspectors wroteBased on document review, interview, and observation, it was determined that the facility failed to provide a safe place for the resident to keep valuable items. This was evident for 1 (Resident #8) out of 2 residents reviewed for personal property.

Inspectors wroteBased on review of the medical records and other pertinent documentation, it was determined that the facility failed to protect a resident from misappropriation of narcotics. This was found to be evident for one (Resident #43) out of 4 residents reviewed in relation to a facility self report of drug diversion.

Inspectors wroteBased on review of facility documentation, resident records, and interviews, It was determined the facility failed to ensure that the residents had an environment that was free from involuntary seclusion. This was evident for 1 (Resident #25) of 19 residents reviewed for abuse.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility failed to notify the resident/resident representative in writing of a transfer/discharge of a resident along with the reason for the transfer. This was evident for one (Resident #7) of two residents reviewed for hospitalization and one (Resident #25) of four residents reviewed for discharge.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility failed to orient, prepare, and document a resident's preparation for a transfer to the hospital. This was identified for 1 (Resident #7) of 2 residents reviewed for hospitalization.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility failed to notify the resident/resident representative in writing of the bed hold policy when the resident was transferred/discharged from the facility to an acute care facility. This was evident for one (Resident #7) of two residents reviewed for hospitalization and one (Resident #25) of four residents reviewed for discharge.

Inspectors wroteBased on observation, medical record review, and interviews with facility staff, it was determined that the facility staff failed to develop and implement resident-centered care plans as evidenced by the failure to implement interventions to prevent injury related to wandering behavior and failure to address a resident's visual needs related to being legally blind. This was evident for 2 (#66, and #102) of 84 residents reviewed during the survey.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility staff failed to evaluate and update resident's plan of care after each assessment and have an effective system in place to ensure interdisciplinary team care plan meetings were scheduled to conduct the needed reviews and revisions. This was evident for 2 (Resident #84 and #8) of 84 residents reviewed during the survey.

Inspectors wroteBased on medical record review and interview, it was determined that the facility failed to ensure geriatric nursing assistants (GNA) provided activity of daily living care to dependent residents as needed. This was found to be evident for 2 (Resident #116, #106) out of 17 residents reviewed in relation to complaint investigations.

Inspectors wroteBased on medical record review and interview, it was determined that the facility failed to ensure that interventions for the prevention of pressure ulcers were implemented. This was found to be evident for 1 (Resident #106) out of 9 residents reviewed for facility reported pressure ulcers during the survey.

Inspectors wroteBased on record review, interviews, and observation, it was determined that the facility failed to review the dialysis book to monitor for complications after dialysis treatments. This was evident for (Resident # 41) 1 out of 1 resident reviewed for dialysis.

Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to have a process in place to ensure that all residents received informed trauma care. This was evident for 1 (#43) of 8 residents reviewed for behavioral/emotional care needs.

Inspectors wroteBased on observation, medical record review and interview, it was determined the facility failed to accurately assess a resident for the use of side rails, failed to explain the risks and benefits to the resident's representative and obtain a signed consent for the use of side rails, failed to obtain a physician's order and failed to create and implement a care plan for the use of side rails. This was evident for 1 (#7) of 16 resident(s) reviewed for accidents:

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility staff failed to ensure that residents were seen by an attending provider every 60 days at a minimum. This was evident for 1 (Resident #25) of 5 residents reviewed for unnecessary medication review; and 1 (Resident #117) of 16 residents reviewed for accidents.

Inspectors wroteBased on facility document review and interviews, it was determined that the facility failed to assess and monitor a residents psychological well-being following a resident to resident alleged sexual assault. This was evident for (Resident #7)1 out of 19 residents reviewed for abuse during a survey.

Inspectors wroteBased on observation, record review, and staff interview, it was determined that the facility staff failed to develop and implement a resident - centered dementia care plan with achievable care plan goals for residents with dementia. This was evident for 1 (#58) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on review of the medical records and other pertinent documentation and interviews, it was determined that the facility failed to have an effective system in place to identify potential diversion of controlled medications; and failed to ensure at least two nurses completed the narcotic count at each change of shift. This was found to be evident for two (Resident #43, and #67 ) out of four residents reviewed in relation to a facility self report of drug diversion and one out of three medication carts reviewed.

Inspectors wroteBased on medical record review and interview with staff, it was determined that the facility failed to ensure that irregularities identified by the pharmacist were reviewed by the attending physician, timely acted upon, and documented in the resident's medical record. This was evident for 3 (Resident #58, #9 and #28) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on medical record review and staff interviews, it was determined that the facility staff failed to ensure that a resident's medication regimen was free from unnecessary medication by failing to adequately monitor a resident for behavior related to psychotropic medication use. This was evident for 1 (#58) of 5 residents reviewed for unnecessary medications

Inspectors wroteBased on observation, interview, and pertinent documentation, it was determined that the facility failed to ensure medications were stored according to acceptable professional standards. This was evident for one medication storage refrigerator out of 2 storage refrigerators, reviewed during the survey.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to store and prepare food in accordance with professional standards for food service safety as evidenced by failure to enure staff wore hair nets in the food preparation area and failure to ensure potentially hazardous food items were cooled according to acceptable standards. This was evident during 2 out of 3 kitchen observations.

Inspectors wroteBased on interview and record review, it was determined that the facility employed staff in positions that were outside their scope of practice in accordance with state laws. This was evident for 1 (Staff #14) of 2 Unit Managers.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility staff failed to keep complete and accurate medical records as evidenced by failing to ensure that physician visit progress notes were in a resident's electronic medical record and failure to ensure that staff documented the type of g-tube feeding that was being administered to a resident who had diabetes. This was evident for 6 (Residents #58, #117, #8, #107 and #106) out of 84 residents reviewed during the survey.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to maintain the unit floors in a safe and sanitary condition. This was evident for two nursing unit floors out of two nursing units observed during a survey. On 8/4/23 at 12:16 PM, surveyors observed deep cracks in the floor tile on several of the nursing unit hallways. Observations of the second-floor nursing unit revealed deep cracks in the tile at the threshold area to entrance of the East wing, entrance to the South wing and at the threshold entrance to the dining room. In addition, there were deep cracks in the floor tile in front of the nursing station, near the elevator. On 8/4/23 at 12:33 PM, observations of the third-floor nursing unit revealed deep cracks in the tile at the threshold area to entrance of East wing, entrance to the South wing and at the entrance to the dining room. [...]

Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to ensure that all staff were provided education regarding resident abuse. This was evident for 2 (Staff #88 and #89) of 7 staff reviewed for abuse training.

Inspectors wroteBased on surveyor observation, it was determined that the facility staff failed to ensure that the caulk around the base of the resident's toilets was maintained in a manner to facilitate cleaning and sanitizing. This was evident in 9 of 19 bathrooms located in resident bedrooms on the third floor of the facility.

Inspectors wroteBased on review of the medical record and interview with staff, it was determined that the facility staff failed to develop comprehensive person-centered care plans for each resident including measurable objectives. This was evident for 5 of 52 residents (Resident #7, #96, #6, #23 and #30) reviewed during the investigative phase of the survey. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care.

Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to provide written notice that Medicare coverage was ending. This was evident for 1 of 3 residents (Resident #311) reviewed for beneficiary protection notification.

Inspectors wroteBased on review of facility investigation of facility reported incidents and staff interviews, it was determined that the facility staff failed to protect residents from abuse. This was found to be evident for 2 of 15 residents (Resident #359 and #21) reviewed for possible abuse during the survey.

Inspectors wroteBased on review of the facility's investigation of a facility reported incident MD00133164 and staff interview, it was determined the facility failed to report an allegation of abuse to the appropriate agency. This was true for 1 out of 15 residents (Resident #359) reviewed for possible abuse during the investigative portion of the survey.

Inspectors wroteBased on record review and interview with staff, it was determined the facility staff failed to ensure resident MDS assessments were accurate and complete. This was evident for 1 of 16 residents (Resident #30) reviewed for Accidents. The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status.

Inspectors wroteBased on review of the medical record it was determined the facility failed to perform appropriate revisions to the care plan goals and interventions as resident care needs became apparent or changed over time as evidenced by failure to update interventions on a behavioral care plan and failure to update a change in a resident's Cardio Pulmonary Resuscitation (CPR) status. This was evident for 1 of 15 residents (Resident #92) reviewed for abuse and for 1 out of 1 resident (Resident #96) reviewed for Hospice and End of Life services. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care.

Inspectors wroteBased on resident and staff interview, review of the medical record and surveyor observation, it was determined that the facility staff failed to ensure that residents received treatment and care in accordance with professional standards of practice as evidenced by failure to identify and monitor resident bruises; failure to properly administer medication, and failure to inform the physician when the resident repeatedly refused or was unable to take a thyroid medication. This was evident for 3 out of the 52 residents (Resident #7, #6 and #57) with investigations completed during the survey.

Inspectors wroteBased on surveyor observation and interview with facility staff, it was determined the facility staff failed to ensure that the resident's environment remained as free of accident hazards as was possible by failing to ensure the resident's swing away bed rail was latched securely in place. This was evident for 1 of 16 residents (Resident #16) reviewed for accidents.

Inspectors wroteBased on observation and medical record review, it was determined that the facility failed to keep accurate medical records as evidenced by nursing staff signing off that the resident was assisted with restorative walking with assistance prior to being walked; and failed to clarify a medication order for a medication that was listed as an allergy. This was evident for 2 of 52 residents (Resident #61 and #359) reviewed during the survey.

Inspectors wroteBased on record review and staff interview, the facility failed to follow The Centers for Disease Control (CDC) and The Advisory Committee on Immunization Practices (ACIP) recommendations for vaccinations of residents. This was evident for 2 of the 5 residents (Residents #309 and #6) reviewed for immunizations under the facility task for infection control.

Inspectors wroteBased on surveyor observation and interview with staff, it was determined the facility failed to ensure a functioning call bell system for all residents. This was evident for 1 of 24 resident call bells observed during initial observations.