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Deficiency Records for Julia Manor Nursing and Rehabilitation Center
A list of the most recent deficiencies for Julia Manor Nursing and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Julia Manor Nursing and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-14 | 2023-10-27 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2023-08-14 | 2023-10-27 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-07-19 | 2023-10-15 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-07-19 | 2023-10-15 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-07-19 | 2023-10-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-07-19 | 2023-10-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-07-19 | 2023-10-15 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-07-19 | 2023-10-15 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-07-19 | 2023-10-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-07-19 | 2023-10-15 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-07-19 | 2023-10-15 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-08-14 | 2023-10-06 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-08-14 | 2023-10-06 | N |
| Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). | Health | 2023-08-14 | 2023-10-06 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-08-14 | 2023-10-06 | N |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2023-08-14 | 2023-10-06 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-08-14 | 2023-10-06 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-08-14 | 2023-10-06 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-08-14 | 2023-10-06 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-08-14 | 2023-10-06 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2023-08-14 | 2023-10-06 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-08-14 | 2023-10-06 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-08-14 | 2023-10-06 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-08-14 | 2023-10-06 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-08-14 | 2023-10-06 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-08-14 | 2023-10-06 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-08-14 | 2023-10-06 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-08-14 | 2023-10-06 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-08-14 | 2023-10-06 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-08-14 | 2023-10-06 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-08-14 | 2023-10-06 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-08-14 | 2023-10-06 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-08-14 | 2023-10-06 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-08-14 | 2023-10-06 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-14 | 2023-10-06 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-08-14 | 2023-10-06 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-08-14 | 2023-10-06 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-14 | 2023-10-06 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-08-14 | 2023-10-06 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-08-14 | 2023-10-06 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-14 | 2023-10-06 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-08-14 | 2023-10-06 | Y |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2023-08-14 | 2023-10-06 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-08-14 | 2023-10-06 | Y |
| Ensure that a resident does not develop patterns of decreased social interaction and/or increased withdrawn, angry, or depressive behaviors, unless unavoidable. | Health | 2023-08-14 | 2023-10-06 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-14 | 2023-10-06 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-08-14 | 2023-10-06 | Y |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2023-08-14 | 2023-10-06 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-08-14 | 2023-10-06 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-08-14 | 2023-10-06 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-06-14 | 2019-07-12 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2019-06-14 | 2019-07-12 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-06-14 | 2019-07-12 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-06-14 | 2019-07-12 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-06-14 | 2019-07-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-06-14 | 2019-07-12 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-06-14 | 2019-07-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-06-14 | 2019-07-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-06-14 | 2019-07-12 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-06-14 | 2019-07-12 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-06-14 | 2019-07-12 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2019-06-14 | 2019-07-12 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-06-05 | 2019-06-28 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2019-06-05 | 2019-06-28 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2019-06-05 | 2019-06-28 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2017-12-22 | 2018-01-22 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2017-12-22 | 2018-01-22 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2017-12-22 | 2018-01-22 | N |
| Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting. | Health | 2017-12-22 | 2018-01-22 | N |
| Assess the resident when there is a significant change in condition | Health | 2017-12-22 | 2018-01-22 | N |
| Ensure each resident receives an accurate assessment. | Health | 2017-12-22 | 2018-01-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-12-22 | 2018-01-22 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2017-12-22 | 2018-01-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2017-12-22 | 2018-01-22 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2017-12-22 | 2018-01-22 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2017-12-22 | 2018-01-22 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2017-12-22 | 2018-01-22 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2017-12-22 | 2018-01-22 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2017-12-22 | 2018-01-22 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2017-12-22 | 2018-01-22 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2017-12-21 | 2018-01-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-12-21 | 2018-01-19 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2017-12-21 | 2018-01-19 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2017-12-21 | 2018-01-19 | N |
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