Julia Manor Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Julia Manor Nursing and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Aug 14, 2023

  Based 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. The findings include: The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility with the 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. A care plan is a guide that addresses the unique needs of each resident. […]

• Immediate jeopardy, isolatedF684Aug 14, 2023

  Based 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. The findings include: The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility with the 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. A care plan is a guide that addresses the unique needs of each resident. […]

• Immediate jeopardy, isolatedF689Aug 14, 2023

  Based 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. The findings include: 1) Elopement occurs when residents who are incapable of protecting themselves from harm are able to successfully leave the facility unsupervised and unnoticed and possibly enter into harm's way. On 7/19/23 at 10:45 AM, a review of Resident #84 ' s medical record was conducted. […]

• Actual harm, isolatedF689May 1, 2026

  Based 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.The findings include:1.Review done on 4/28/26 at 11:37 PM of the annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #10 was cognitively impaired and had severe vision impairment. The MDS assessment also indicated Resident #10 was dependent with eating, oral hygiene, toileting hygiene, showering/bathing, upper and lower body dressing, and personal hygiene. […]

• Actual harm, isolatedF688Aug 14, 2023

  Based 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. The findings include: 1. Resident # 41 was a long-term resident of the facility with mild cognitive impairment. […]