Inspection Reports for
Juniper Village – the Spearly Center
2205 W 29TH AVE, DENVER, CO, 80211-3803
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
14.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
175% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
28
21
14
7
0
Census
Latest occupancy rate
37 residents
Based on a April 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Dec 4, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to medication storage, infection prevention and control, and housekeeping practices.
Findings
The facility was found deficient in properly storing, labeling, and disposing of medications, maintaining infection control practices including sanitation of resident equipment and hand hygiene, and ensuring housekeeping staff followed proper cleaning protocols including chemical dwell times and hand hygiene between glove changes.
Deficiencies (2)
Failure to ensure all drugs and biologicals were properly stored, secured, and labeled, including improper storage of a Schedule IV controlled medication in a refrigerator, lack of open dates on medications, and failure to dispose of expired medications.
Failure to maintain an infection control program, including failure to keep Resident #122's oral stimulator in a sanitary location, failure of housekeeping staff to perform hand hygiene while cleaning resident rooms, and failure to wait appropriate dwell time for disinfectant chemicals.
Report Facts
Medication storage carts inspected: 5
Medication storage rooms inspected: 3
Expired medications observed: 7
Dwell time for disinfectant: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Observed medication carts and noted missing open dates on medications |
| LPN #1 | Licensed Practical Nurse | Observed medication carts with expired eye drops |
| ADON #1 | Assistant Director of Nursing | Responsible for auditing medication carts and storage rooms weekly |
| LPN #3 | Licensed Practical Nurse | Observed expired medications and improper storage of refrigerated medication |
| RN #5 | Registered Nurse | Observed expired medications and planned disposal |
| RN #4 | Registered Nurse | Observed expired risperidone injection in medication storage room |
| Director of Nursing | Director of Nursing | Interviewed regarding medication labeling and disposal responsibilities |
| Hospice Registered Nurse | Hospice Registered Nurse | Interviewed regarding Resident #122's oral stimulator use |
| Director of Rehabilitation | Director of Rehabilitation | Interviewed regarding oral stimulator use and infection control recommendations |
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Interviewed about Resident #122's behavior |
| Speech Therapist | Speech Therapist | Interviewed regarding oral stimulator use and discontinuation |
| Infection Preventionist | Infection Preventionist | Interviewed regarding infection control issues with oral stimulator and cleaning protocols |
| Housekeeper #1 | Housekeeper | Observed failing to perform hand hygiene between glove changes and not waiting dwell time for disinfectant |
| Housekeeper #2 | Housekeeper | Observed failing to perform hand hygiene between glove changes and not waiting dwell time for disinfectant |
| Maintenance Supervisor | Maintenance Supervisor | Interviewed regarding dwell time for disinfectant solution |
Inspection Report
Annual Inspection
Census: 37
Deficiencies: 11
Date: Apr 25, 2025
Visit Reason
The inspection was conducted as part of the annual recertification survey to assess compliance with regulatory requirements and resident care standards.
Findings
The facility was found deficient in multiple areas including resident participation in care planning, notification of room changes, comprehensive care planning, treatment and care according to orders, pressure ulcer care, accident hazard prevention, menu compliance, food safety and sanitation, hospice services coordination, quality assurance program effectiveness, and infection prevention and control practices.
Deficiencies (11)
Failed to ensure residents and their representatives participated in the development and implementation of person-centered plans of care.
Failed to provide timely written notification of room changes and honor resident room preferences.
Failed to develop a comprehensive care plan addressing resident's functional abilities and activities of daily living.
Failed to ensure treatment and care were provided according to physician's orders and professional standards.
Failed to provide timely assessment, interventions, and wound care documentation for pressure ulcers, resulting in worsening of wounds.
Failed to provide adequate supervision and implement care-planned interventions to prevent choking incidents, resulting in immediate jeopardy that was later removed.
Failed to follow menu extensions and provide correct portion sizes to meet residents' nutritional needs.
Failed to ensure food was stored, prepared, and served under sanitary conditions, including proper labeling, handling of ready-to-eat foods, and pest control.
Failed to ensure hospice services met professional standards including accessible documentation and consistent communication.
Failed to operate an effective quality assurance program to identify and address facility compliance concerns, including repeated deficiencies related to resident safety and accidents.
Failed to maintain an infection prevention and control program including proper use of enhanced barrier precautions, hand hygiene during wound care, housekeeping hand hygiene, and cleaning of high touch surfaces.
Report Facts
Sample residents reviewed: 37
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Dead cockroaches: 28
Days delay: 18
Days delay: 20
Days delay: 11
Days delay: 8
Days delay: 22
Meals audited: 3
Meals audited: 1
Meals audited: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NM #1 | Nurse Manager | Interviewed regarding wound care, resident supervision, and infection control practices |
| RN #1 | Registered Nurse | Observed and interviewed regarding wound care and resident assessments |
| ADON #1 | Assistant Director of Nursing | Interviewed regarding wound care and hospice services |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding wound care and infection control practices |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding hospice services |
| CNA #1 | Certified Nurse Aide | Interviewed regarding hospice services |
| CNA #3 | Certified Nurse Aide | Interviewed regarding resident care and repositioning |
| CNA #4 | Certified Nurse Aide | Interviewed regarding resident supervision and choking risk |
| CNA #5 | Certified Nurse Aide | Observed providing wound care |
| DM | Dietary Manager | Interviewed regarding menu compliance and food safety |
| NHA | Nursing Home Administrator | Interviewed regarding quality assurance and immediate jeopardy removal plan |
| DON | Director of Nursing | Interviewed regarding infection control, wound care, and resident supervision |
| IP #1 | Infection Preventionist | Interviewed regarding infection control education and practices |
| IP #2 | Infection Preventionist | Interviewed regarding infection control education and practices |
| MTD | Maintenance Director | Interviewed regarding housekeeping and pest control |
| SSD | Social Services Director | Interviewed regarding hospice services and care conferences |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Dec 11, 2024
Visit Reason
The inspection was conducted following a complaint and incident involving a resident elopement from the facility on 11/30/2024, which resulted in the resident's death. The investigation focused on the facility's failure to prevent the elopement and ensure resident safety.
Complaint Details
The investigation was triggered by a complaint and incident involving Resident #1 eloping from the facility on 11/30/2024. The resident was found 10 miles away in critical condition and later pronounced deceased. The complaint focused on the facility's failure to prevent the elopement and ensure resident safety.
Findings
The facility failed to provide adequate supervision and safety measures to prevent Resident #1's elopement, which led to his death. Staff had conflicting understanding of supervision levels, lacked proper documentation and interventions, and failed to secure emergency exit doors. Immediate jeopardy was identified due to widespread potential for serious harm to residents.
Deficiencies (4)
Failure to ensure the facility was free from accident hazards and provide adequate supervision to prevent accidents, resulting in Resident #1 eloping and subsequent death.
Failure to secure emergency exit doors and boiler room doors, allowing residents access to unsecured exits.
Failure to document resident behaviors and implement appropriate care plans and supervision for elopement risk.
Failure to operate an effective Quality Assurance and Performance Improvement (QAPI) program to identify and address safety concerns, leading to repeat deficiencies.
Report Facts
Resident age: 65
Psychotropic medication dosage: 5
Time resident eloped: 13.08
Distance resident found from facility: 10
Date of survey completion: Dec 11, 2024
Date of incident: Nov 30, 2024
Date resident found: Dec 2, 2024
Date of education completion: Dec 3, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding resident supervision, elopement assessment, and facility corrective actions |
| Nursing Home Administrator | Nursing Home Administrator (NHA) | Interviewed regarding facility policies, door security, and corrective actions following elopement |
| Licensed Practical Nurse #1 | LPN | Interviewed about resident behavior and incident on 11/30/24 |
| Licensed Practical Nurse #2 | LPN | Admitted resident and provided information on resident's behavior and safety awareness |
| Certified Nurse Aide #1 | CNA | Observed resident attempting to leave on 11/30/24 and assisted in search |
| Licensed Practical Nurse #3 | LPN | Provided information on resident's wandering behavior |
| Social Service Director | Social Service Director (SSD) | Interviewed about elopement assessments and resident monitoring |
| Staff member who exited emergency door | Interviewed about following emergency exit door protocol on 11/30/24 | |
| Maintenance Director | Maintenance Director | Interviewed about door security and maintenance following incident |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 23, 2024
Visit Reason
The inspection was conducted following a complaint investigation triggered by an incident on 9/13/2024 where Resident #2 sustained bilateral distal femoral fractures during a transfer with a mechanical Hoyer lift.
Complaint Details
The complaint investigation was substantiated. Resident #2 sustained bilateral distal femoral fractures on 9/13/24 during a Hoyer lift transfer due to improper sling use. The facility conducted an investigation, identified root causes, and implemented corrective actions including staff reeducation and use of full body slings.
Findings
The facility failed to ensure Resident #2's lower extremities were handled without undue pressure and proper alignment during a Hoyer lift transfer, resulting in bilateral femoral fractures requiring hospitalization and surgery. The facility corrected the deficient practice prior to the onsite investigation and implemented staff reeducation and systemic changes to prevent recurrence.
Deficiencies (1)
Failure to ensure Resident #2's lower extremities were handled appropriately without undue pressure and alignment during a Hoyer lift transfer, resulting in bilateral femoral fractures.
Report Facts
Residents affected: 4
Deficiency correction date: Sep 25, 2024
Staff education dates: Staff education on Hoyer lift transfer competency occurred on 9/16/24 and 9/25/24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Interviewed regarding the incident and transfer of Resident #2 using Hoyer lift with split leg sling |
| LPN #1 | Licensed Practical Nurse | Interviewed about Resident #2's complaints of pain and subsequent actions taken |
| DON | Director of Nursing | Interviewed about staff meetings, root cause analysis, and corrective actions including reeducation and use of full body slings |
| NHA | Nursing Home Administrator | Provided follow-up email detailing responsibility for interventions and staff education |
Inspection Report
Deficiencies: 7
Date: May 23, 2024
Visit Reason
The inspection was conducted to assess compliance with resident rights, grievance resolution, abuse prevention, secure unit placement justification, neglect investigation, and environmental safety in a nursing home facility.
Findings
The facility failed to ensure timely response to call lights, proper grievance resolution, prevention of resident-to-resident abuse, appropriate secure unit placement documentation, thorough neglect investigation, and maintenance of a safe environment. Residents reported restrictions on personal freedoms, inadequate privacy, limited access to funds and visitation, and dissatisfaction with facility practices. Observations confirmed these issues, including unaddressed call lights, improper disposal of refuse, and lack of privacy for phone calls.
Deficiencies (7)
Failure to answer call lights in a timely manner on the second floor, causing residents to feel neglected.
Failure to provide prompt efforts to resolve grievances, specifically regarding missing prescription glasses for Resident #181.
Failure to implement person-centered interventions to prevent resident-to-resident altercations between Residents #118 and #32, and Residents #90 and #49.
Failure to ensure proper documentation and justification for secure unit placement for six residents.
Failure to thoroughly investigate neglect allegation involving second degree burns on Resident #8's thighs.
Failure to provide an environment that supports and enhances residents' dignity, self-worth, satisfaction, and control, including restrictions on personal freedoms and inadequate responsiveness to call lights.
Failure to ensure garbage and refuse were properly disposed of and dumpster lids were closed to prevent pest harborage.
Report Facts
Residents affected: 46
Residents affected: 84
Resident council members interviewed: 7
Personal needs account daily withdrawal limit: 5
Burn size: 4
Burn wound size left thigh: 15
Burn wound size left thigh width: 13
Burn wound size right thigh: 6.5
Burn wound size right thigh width: 4
Rodent bait consumption: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing #2 | Assistant Director of Nursing | Observed ignoring call lights and involved in neglect investigation |
| Certified Nurse Aide #8 | Certified Nurse Aide | Interviewed about call light system and resident care |
| Nursing Home Administrator | Nursing Home Administrator | Provided facility policies, interviews, and removal plan for immediate jeopardy |
| Director of Nursing | Director of Nursing | Interviewed about resident behaviors, investigations, and care plans |
| Social Services Director | Social Services Director | Interviewed about grievance process, resident to resident altercations, and secure unit placement |
| Dining Services Manager | Dining Services Manager | Interviewed about trash disposal and dumpster maintenance |
| Environmental Services Director | Environmental Services Director | Interviewed about water temperature and pest control |
| Certified Nurse Aide #9 | Certified Nurse Aide | Interviewed about showering resident with burns |
| Registered Nurse #3 | Registered Nurse | Interviewed about resident behaviors and secure unit placement |
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Interviewed about secure unit placement documentation |
Inspection Report
Census: 130
Deficiencies: 14
Date: May 23, 2024
Visit Reason
The inspection was conducted to investigate multiple regulatory compliance concerns including resident rights, abuse prevention, involuntary seclusion, emergency preparedness, fall prevention, medication storage, food service, sanitation, and quality assurance.
Findings
The facility was found to have multiple deficiencies including failure to ensure timely response to call lights, failure to prevent resident-to-resident abuse, failure to document and justify secure unit placement, failure to thoroughly investigate neglect allegations, failure to provide an environment supporting residents' dignity and quality of life, failure to ensure safe emergency evacuation plans and training, failure to investigate and prevent falls, failure to provide trauma-informed care, failure to post accurate staffing information, failure to secure medication carts, failure to follow posted menus, failure to maintain kitchen sanitation, failure to handle food utensils properly, failure to maintain dumpster area cleanliness, and failure to implement an effective quality assurance program.
Deficiencies (14)
Facility failed to answer call lights in a timely manner on the second floor, causing residents to feel neglected.
Facility failed to prevent resident-to-resident abuse and failed to implement person-centered interventions after altercations.
Facility failed to ensure residents on the secure unit had required documentation to justify restrictions and secure unit placement.
Facility failed to thoroughly investigate neglect allegation involving burns to Resident #8's thighs.
Facility failed to provide an environment supporting residents' dignity, self-worth, and control, limiting residents' rights and causing immediate jeopardy.
Facility failed to have a plan and training to ensure safe emergency evacuation; physical barriers prevented evacuation, creating immediate jeopardy.
Facility failed to investigate and implement effective fall prevention interventions for Resident #45 after a fall with injury.
Facility failed to ensure trauma-informed care and assessments for residents with PTSD, including Residents #118 and #126.
Facility failed to post current nurse staffing information daily in a location accessible to residents and visitors.
Facility failed to ensure medication carts were locked when unattended and not within line of sight of nursing staff.
Facility failed to ensure food was served at appropriate temperatures and consistent with posted menus.
Facility failed to maintain kitchen sanitation including damaged tiles, unclean can opener, and improper handling of cups and silverware.
Facility failed to ensure dumpster lids were closed and surrounding area was clean to prevent pest harborage.
Facility failed to implement an effective quality assurance program to identify and address quality of life and emergency preparedness concerns.
Report Facts
Residents: 130
Fall incident date: 2024
Temperature: 128
Temperature: 130
Temperature: 98
Temperature: 82
Temperature: 80
Temperature: 110
Temperature: 114
Pest control rodent bait consumption: 75
Pest control rodent bait consumption: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Left medication cart unlocked and unattended |
| DON | Director of Nursing | Provided education on locking medication carts and fall prevention |
| DSM | Dining Services Manager | Interviewed regarding menu changes and kitchen sanitation |
| ESD | Environmental Services Director | Held keys to padlocks on emergency exit gates and responsible for training on evacuation |
| NHA | Nursing Home Administrator | Provided immediate jeopardy removal plan and interviewed about QAPI and evacuation |
| MD | Medical Director | Participated in QAPI and provided education |
| RN #1 | Registered Nurse | Described fall procedures and resident behavior |
| RN #2 | Registered Nurse | Described resident behavior and fall interventions |
| CNA #1 | Certified Nurse Aide | Described resident behavior and communication |
| LPN #3 | Licensed Practical Nurse | Described evacuation procedures and difficulties |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Dec 19, 2023
Visit Reason
The inspection was conducted to investigate the facility's compliance with appropriate catheter care and prevention of urinary tract infections following complaints related to catheter management for Resident #3.
Complaint Details
The investigation was complaint-driven, focusing on catheter care management for Resident #3. The complaint was substantiated as the facility failed to provide adequate catheter care and follow-up, resulting in actual harm to the resident.
Findings
The facility failed to provide appropriate catheter care and documentation for Resident #3, who developed multiple urinary tract infections and sepsis resulting in several hospitalizations. The facility did not assess the need for the catheter upon readmission, failed to document catheter care consistently, and delayed recommended urology follow-up.
Deficiencies (3)
Failure to assess and document the presence and care of an indwelling urinary catheter upon resident readmission.
Failure to schedule timely urology follow-up as recommended by the primary care physician.
Inconsistent and poor documentation of catheter care and related medical orders.
Report Facts
Residents reviewed for catheter care: 11
Residents with catheter care deficiency: 1
Hospitalizations: 3
Dates of hospitalizations: 9/10/23, 9/18/23, and 11/12/23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| PCP #1 | Primary Care Physician | Recommended urology follow-up and provided medical orders related to Resident #3's catheter care |
| Registered Nurse #1 | Registered Nurse | Interviewed regarding catheter care responsibilities and documentation |
| CNA #4 | Certified Nurse Aide | Interviewed about catheter care practices on the unit |
| Director of Nursing | Director of Nursing | Interviewed regarding catheter care management and documentation issues for Resident #3 |
| Nursing Home Administrator | Nursing Home Administrator | Provided facility policy and follow-up information regarding urology appointment scheduling |
Inspection Report
Deficiencies: 1
Date: May 24, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with residents' rights regarding the retention and disposition of personal belongings after their death.
Findings
The facility failed to ensure that the resident representatives for three residents (#7, #29, and #16) were given the opportunity to retrieve the residents' personal belongings after their deaths. Documentation and communication with the residents' powers of attorney (POA) regarding belongings were incomplete or missing.
Deficiencies (1)
Failed to ensure residents retained the rights to their personal belongings after death, including failure to notify POAs about the 30-day pickup period and lack of documentation of communication regarding belongings.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding the process of notifying families about residents' belongings and documentation practices. |
| Interim Social Services Director | Interim Social Services Director (ISSD) | Interviewed about communication with families regarding residents' belongings and documentation practices. |
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