Julia Pound Care Center

In the surveyor’s words

From the most serious findings on record at Julia Pound Care Center, in the surveyor’s own words.

• Actual harm, isolatedF689Apr 22, 2025

  Based on review of facility policies, investigation reports, and clinical records, as well as staff interviews, it was determined that the facility failed to provide care in a safe manner for one of three residents reviewed (Resident 1) resulting in a fall with fractures. This deficiency was cited as past non-compliance. Findings include: A facility policy related to fall management, dated March 12, 2025, indicated that each resident is provided with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. The facility will ensure the resident environment remains as free of accident hazards as possible. Resident falls are analyzed and trended through the Performance Review process to maintain a safe environment. […]

• No harm, potential for more than minimal, patternF686Jun 25, 2026

  Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to provide care for pressure ulcers in accordance with professional standards of practice, by failing to ensure that recommendations from a wound consultant were reviewed with the attending physician and treatments for pressure ulcers were provided as ordered by the physician for four of 30 residents reviewed (Resident 2, 45, 46, 58) who had pressure ulcers. Findings include: A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated May 18, 2026, revealed that the resident had severe cognitive impairment, required assistance from staff, had diagnoses that included dementia and other psychotic… […]

• No harm, potential for more than minimal, patternF812Jun 25, 2026

  Based on review of policies, observations, and staff interviews, it was determined that the facility failed to ensure that food was served under sanitary conditions, in accordance with professional standards for food service safety. Findings include: The facility's policy regarding general sanitization of the kitchen, dated June 10, 2026, indicated that the food and nutrition services staff will maintain the sanitation of then kitchen through compliance with a written, comprehensive cleaning schedule. Cleaning and sanitation tasks for the kitchen will be outlined in a written cleaning schedule. The prep table shelves are scheduled to be cleaned 3 times a week.Observations in the main kitchen on June 25, 2026, at 9:20 a.m. […]

• No harm, potential for more than minimal, patternF812Jun 5, 2025

  Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that dietary staff wore appropriate hair coverings. Findings include: The facility's policy regarding personal hygiene, dated March 12, 2025, indicated that food is prepared, stored and distributed in a safe and sanitary manner preventing the spread of food borne illness. Observations in the 100-200 hall kitchenette during service for the lunch meal on June 2, 2025, at 11:48 a.m. revealed that Dietary Aide 3 was plating baked beans and hot dogs. Dietary Aide 3 had approximately three-inch tendrils of hair on each side of her head, and approximately two inches of loose hair on the nape of her neck that was not covered by her hairnet. […]

• No harm, potential for more than minimal, patternF760Dec 16, 2024

  Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that physician's orders were followed, resulting in significant medication errors for one of six residents reviewed (Resident 3). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 3, dated November 14, 2024, revealed that the resident was sometimes understood, could sometimes understand others, and had diagnosis which included diabetes and dementia. […]