Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Juliette Manor during CMS and state inspections, most recent first.
A CNA witnessed another CNA yell, swear, and deny care to a resident with intact cognition, instructing the resident to urinate in their brief. The witnessing CNA did not immediately report the incident to administration, resulting in a delay that violated facility policy requiring prompt reporting of abuse allegations.
A resident with multiple medical conditions and intact cognition was subjected to verbal abuse by a CNA, who yelled and instructed the resident to urinate in their brief instead of providing bathroom assistance. The incident was not immediately reported by the witnessing CNA, and staff did not intervene or ensure the resident's protection at the time. The facility's investigation lacked thorough documentation of staff education on abuse prevention and reporting, and there were ongoing concerns about staff not responding to call lights and telling residents to urinate in their briefs.
The facility failed to provide appropriate therapeutic diets to residents with specific dietary needs, such as cardiac and renal diets. During a meal service, residents received incorrect food items, contrary to their prescribed diets. Dietary staff were unaware of the specific requirements, leading to the deficiency.
A resident with moderate cognitive impairment reported that a CNA was rough during care and yelled at them, but the facility failed to report the allegation to the NHA or SA in a timely manner. The incident was initially reported to a nurse, who observed redness and distress in the resident, but the facility's policy requiring immediate reporting was not followed.
A resident reported that a CNA was rough and yelled during care, leading to a grievance. Despite the facility's policy requiring immediate removal of the alleged perpetrator, the CNA continued to work with other residents until days later. The facility's delayed response in removing the CNA from resident care highlights a deficiency in handling abuse allegations.
A facility failed to maintain proper infection control when an RN did not perform hand hygiene during a wound vac dressing change for a resident with a history of ESBL. The RN touched potentially contaminated surfaces before removing the resident's bandages, contrary to the facility's infection control policy. The resident had surgical wounds and required enhanced barrier precautions.
A resident with a history of inappropriate behavior, including being on the sex offender registry, was not adequately supervised, leading to multiple incidents involving other residents. The facility failed to revise the resident's care plan or implement effective safety measures, resulting in ongoing risk. Staff were confused about the safety plan, and a safety plan visual was missing from the resident's door.
Failure to Timely Report Alleged Abuse and Denial of Care
Penalty
Summary
Staff failed to report an allegation of abuse in a timely manner for one resident. A Certified Nursing Assistant (CNA) witnessed another CNA enter a resident's room, yell, point, and swear at the resident, and instruct the resident to urinate in their brief. The resident, who had intact cognition and was responsible for their own healthcare decisions, reported that this CNA had previously told them to urinate in their brief. The incident occurred in the early morning, but the witnessing CNA did not immediately report the event to administration as required by facility policy. Instead, the CNA waited until returning to the facility later that day to report the incident to a Registered Nurse (RN), several hours after the event took place. The facility's policy requires immediate reporting of any witnessed or reported abuse to the Administrator, with allegations of abuse to be reported to the State Agency within two hours. The investigation confirmed that there was a delay in care for the resident, as the CNA who committed the abuse did not provide assistance or change the resident's brief when requested. The investigation also substantiated that the CNA acted deliberately and with willful intent by yelling at the resident and denying care.
Failure to Investigate and Respond to Abuse Allegation
Penalty
Summary
A deficiency occurred when the facility failed to thoroughly investigate and respond to an allegation of abuse involving a resident with hemiplegia, hemiparesis, major depressive disorder, nicotine dependence, and a contracture to the left hand. The resident, who had intact cognition and was responsible for their own healthcare decisions, reported that a CNA entered their room, yelled, swore, and instructed the resident to urinate in their brief instead of providing assistance to the bathroom. The incident was witnessed by another CNA, who did not immediately report the event but instead waited until later in the day to notify a nurse. The facility's policy required immediate removal of the alleged perpetrator and prompt reporting, but staff did not intervene at the time of the incident or ensure the resident's immediate protection. The investigation into the incident was incomplete. Although the facility suspended the accused CNA and contacted law enforcement, the documentation of staff education on abuse prevention and reporting was lacking. Several staff members, including those directly involved or present during the incident, did not have signed confirmation that they received or understood the required education. Additionally, the facility did not provide evidence of comprehensive, all-staff education following the incident, despite ongoing concerns about staff telling residents to urinate in their briefs and not responding to call lights in a timely manner. The facility's call light logs showed significant delays in response to the resident's requests for assistance, with call lights remaining on for extended periods. Interviews with staff revealed that the resident's needs were not promptly addressed, and there were multiple reports of similar issues occurring beyond the initial incident. The lack of immediate intervention, delayed reporting, and insufficient documentation of staff education contributed to the facility's failure to ensure a safe environment free from abuse and neglect, as required by policy and regulation.
Failure to Follow Therapeutic Diets for Residents
Penalty
Summary
The facility failed to ensure that therapeutic diets were followed for five residents, resulting in a deficiency. Residents with specific dietary needs, such as cardiac and renal diets, did not receive the appropriate meals as prescribed. For instance, three residents with cardiac diet orders received mashed potatoes with gravy and a raspberry pocket instead of the prescribed baked potato and fruit. Similarly, a resident on a renal diet did not receive the required garden salad and fruit, and another resident with a combined cardiac/diabetic/renal diet did not receive the necessary baked potato, garden salad, or fruit. The deficiency was identified during a surveyor's review of medical records and diet orders, as well as observations during a lunch meal service. Interviews with dietary staff revealed a lack of awareness and adherence to the specific dietary requirements. The Dietary Aid was unaware that different diet orders required different desserts, and the Dietary Manager acknowledged that staff should have followed the menus for therapeutic diets, ensuring the availability of appropriate food items for residents with special dietary needs.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse in a timely manner involving a resident, identified as R2, who reported that a Certified Nursing Assistant (CNA-F) was rough during care and yelled at them. The incident occurred during the night shift from 1/18/25 to 1/19/25, but the allegation was not reported to the Nursing Home Administrator (NHA) or the State Agency (SA) promptly. The facility's policy requires immediate reporting of abuse allegations, but the incident was not reported until 1/20/25, and the NHA did not sign off on the grievance until 1/24/25. R2, who has moderate cognitive impairment and several medical conditions, including hypertensive heart disease and type 2 diabetes, reported that CNA-F was rough when cleaning them after using the bathroom, causing pain. R2 also stated that CNA-F raised their voice when R2 moved a table, causing items to fall. Despite R2's complaints, CNA-F continued with the care, leading R2 to demand that CNA-F leave the room. The incident was initially reported to a nurse, RN-I, who observed redness in R2's groin and buttocks and noted R2's distress. The Director of Nursing (DON) and NHA were informed of the incident after a delay, and the facility did not report the allegation to the SA. The NHA considered the incident a care issue rather than abuse, partly because CNA-F was a long-term employee with no prior abuse concerns. However, the facility's policy mandates reporting such allegations within two hours if they involve abuse, which was not adhered to in this case.
Failure to Immediately Remove CNA Following Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident, identified as R2, who reported that a Certified Nursing Assistant (CNA-F) was rough during care and yelled at them. R2 expressed that they did not want CNA-F to care for them anymore. Despite this, CNA-F attempted to re-enter R2's room to take vital signs, leading to R2 yelling at CNA-F to leave. The facility's policy required immediate removal of the alleged perpetrator from resident care, but CNA-F was not removed or supervised during resident care until several days later. R2, who had moderate cognitive impairment and was their own person, reported the incident to staff, and a grievance was filed. The grievance investigation revealed that CNA-F admitted to raising their voice at R2 and reported the incident to a nurse. Interviews with other staff and residents were conducted, but no additional concerns were noted. However, the Director of Nursing (DON) did not act on the email notification of the incident until after CNA-F had worked another shift, during which they continued to care for other residents. The facility's failure to immediately remove CNA-F from resident care, as per their abuse prevention policy, resulted in a delay in protecting R2 and potentially other residents from further harm. The Nursing Home Administrator (NHA) acknowledged that CNA-F was removed from R2's care but continued to work with other residents until the investigation was completed. This inaction highlights a deficiency in the facility's response to allegations of abuse, as they did not adhere to their policy of immediate removal pending investigation.
Infection Control Breach During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by an incident involving a registered nurse (RN) who did not adhere to proper hand hygiene protocols during a wound vac dressing change for a resident. The resident, who had a history of extended-spectrum beta lactamase (ESBL) and was on enhanced barrier precautions, was observed during a dressing change where the RN did not perform hand hygiene after touching potentially contaminated surfaces, such as a wheelchair and a garbage can, before proceeding to remove the resident's bandages. This action was contrary to the facility's infection control policy, which mandates hand hygiene before and after resident contact and prior to performing any aseptic procedures. The resident involved had been admitted with surgical wounds following a hospital stay for a lower leg thromboembolism and critical limb ischemia, and had undergone vascular surgery. The resident's medical record indicated moderate cognitive impairment and a need for enhanced barrier precautions due to a history of antibiotic-resistant bacteria. During the survey, the Director of Nursing confirmed that the RN should have completed hand hygiene and donned clean gloves before removing the dressings, acknowledging the lapse in following the infection control protocol.
Inadequate Supervision and Safety Measures for Resident with Inappropriate Behavior
Penalty
Summary
The facility failed to ensure appropriate supervision and safety measures for residents, leading to several incidents involving a resident with a history of inappropriate behavior. This resident, who was on the sex offender registry, made lewd comments to another resident and asked a different resident to expose themselves. Despite these incidents, the facility did not adequately revise the resident's care plan to provide sufficient supervision or implement effective safety measures. The facility's policy required immediate protection and thorough investigation upon reports of misconduct, but these were not consistently followed. For instance, after the resident entered another resident's room without permission, the facility did not conduct a thorough investigation or interview other residents and staff. The safety plan for the resident was not effectively communicated to staff, as evidenced by the lack of a safety plan visual on the resident's door and staff confusion about the safety plan's existence and details. Additionally, the facility's response to incidents was inadequate. Security was informed and asked to visit more frequently, but no substantial changes were made to the resident's care plan. The facility's failure to implement and communicate effective safety measures and supervision contributed to the ongoing risk to residents, as demonstrated by repeated incidents involving the same resident.
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Illustrative
What surveyors actually found near you
We read the 97 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Berlin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Whispering Pines Nursing And Rehab, Llc | 10 mi | ★★★★★ | 2 | 0 |
| Edenbrook Omro | 10.3 mi | ★★★★★ | 35 | 0 |
| Eden Rehab Suites And Green House Homes | 16.5 mi | ★★★★★ | 5 | 0 |
| Markesan Resident Home | 18.1 mi | ★★★★★ | 4 | 0 |
| Bethel Home | 18.7 mi | ★★★★★ | 11 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.