Juliette Manor
Juliette Manor in Berlin, WI — inspection on September 10, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
home and was still bothered by the incident. CNA-C returned to the facility the same day (8/27/25) at
interviewed NHA-A, Director of Nursing (DON)-B, and RN-F via phone conference. DON-B indicated
at approximately 4:00 PM. RN-F immediately educated CNA-C regarding reporting requirements and told CNA-C that CNA-C should have reported the incident to administration immediately. On 9/10/25 at 4:08 PM, Surveyor interviewed Regional Nurse Consultant (RNC)-G who stated the facility's policy indicates if there is no serious bodily injury, the facility has up to 24-hours to report.
Surveyor informed RNC-G of the regulation and reviewed the facility's policy with RNC-G.
The facility's policy indicates for alleged violations of abuse, OR if there is serious bodily injury, the facility must report the allegation to the SA immediately but no later than two hours after the allegation is made. RNC-G acknowledged the verbiage in the policy and confirmed the facility's investigation substantiated that abuse occurred.
525286 09/10/2025
Juliette Manor 482 Oak Street Berlin, WI 54923
the all staff education.On 9/10/25 at 4:08 PM, Regional Nurse Consultant (RNC)-G provided Surveyor
in all interactions.Addressing challenges: tone, respect, accountability.Customer service
and RN-E's signatures were not listed. RNC-G showed Surveyor CNA-C and RN-E's signatures from the 8/18/25 education.
When Surveyor asked the date that CNA-C and RN-E reviewed and signed the education, RNC-G stated RNC-G did not know when CNA-C and RN-E completed the education.RNC-G also provided Surveyor with a copy of the facility's LTC Behavioral Disturbance Policy and 3 copies of the LTC Resident Abuse Prevention and Reporting Policy. RNC-G indicated the policies were reviewed with CNA-C, RN-E, and CNA-H.
Surveyor reviewed the documentation and noted the following:The LTC Behavioral Disturbance Policy intended for CNA-C's education stated on the last page the education was completed by DON-B via phone on 8/27/25.
Education was completed by RN-F in person on 8/27/25.
The document included signatures from DON-B and RN-F.
The document did not include signed confirmation that CNA-C received and understood the education.The LTC Resident Abuse Prevention and Reporting Policy intended for CNA-C's education stated on the last page the education was completed by DON-B via phone on 8/27/25.
Education was completed by RN-F in person on 8/27/25.
The document included signatures from DON-B and RN-F.
The document did not include signed confirmation that CNA-C received and understood the education.The LTC Resident Abuse Prevention and Reporting Policy intended for CNA-H's education stated on the last page the education was completed with CNA-H on 8/27/25 as part of corrective action and signed by RN-F.
The document did not include signed confirmation that CNA-H received and understood the education.The LTC Resident Abuse Prevention and Reporting Policy intended for RN-E's education stated on the last page the education was completed with RN-E on 8/27/25 and signed by DON-B.
The document did not include signed confirmation that RN-E received and understood the education.On 9/10/25 at 4:08 PM, Surveyor interviewed RNC-G who stated the facility's policy indicates the facility has up to 24-hours to report.
Surveyor informed RNC-G of the regulation and reviewed the facility's policy with RNC-G.
The facility's policy states for alleged violations of abuse, the facility must report the allegation to the SA immediately but no later than two hours after the allegation is made or known.
RNC-G acknowledged the regulation and policy.
Surveyor reported to RNC-G that CNA-C reported continued instances after 8/27/25 of concerns with call light response times and staff telling residents to urinate in their briefs. RNC-G acknowledged the concern with staff retention regarding abuse prevention and reporting.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.