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)
26.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
413% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
27% occupied
Based on a April 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate 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
Routine
Deficiencies: 2
Date: Dec 4, 2025
Visit Reason
The inspection was conducted to assess compliance with medication storage, infection prevention and control programs, and housekeeping procedures at Juniper Village - the Spearly Center.
Findings
The facility failed to ensure proper labeling, storage, and disposal of medications, maintain an effective infection prevention and control program, and ensure housekeeping staff performed proper hand hygiene and adhered to chemical dwell times during cleaning.
Deficiencies (2)
F 0761: The facility failed to ensure all drugs and biologicals were properly labeled with open dates, stored securely including controlled substances, and expired medications were disposed of correctly.
F 0880: The facility failed to maintain an infection control program by not keeping Resident #122's oral stimulator sanitary, not ensuring housekeeping staff performed hand hygiene, and not waiting appropriate dwell times for disinfectants.
Report Facts
Medication storage carts with deficiencies: 3
Medication storage rooms with deficiencies: 1
Expired medications observed: 7
Dwell time for disinfectant: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Observed medication carts with unlabeled open dates on medications. |
| LPN #1 | Licensed Practical Nurse | Observed medication carts with expired and unlabeled medications. |
| ADON #1 | Assistant Director of Nursing | Responsible for auditing medication carts and storage rooms weekly. |
| DON | Director of Nursing | Interviewed regarding medication labeling responsibilities and infection control importance. |
| CNA #2 | Certified Nurse Aide | Observed handling Resident #122's oral stimulator without hand hygiene. |
| LPN #4 | Licensed Practical Nurse | Interviewed about Resident #122's behavior with oral stimulator. |
| Speech Therapist | Speech Therapist | Provided information on oral stimulator use and discontinuation for Resident #122. |
| Infection Preventionist | Infection Preventionist | Interviewed about infection control issues related to oral stimulator and cleaning procedures. |
| HK #1 | Housekeeper | Observed failing to perform hand hygiene between glove changes and not waiting disinfectant dwell time. |
| HK #2 | Housekeeper | Observed failing to perform hand hygiene between glove changes and not waiting disinfectant dwell time. |
| Maintenance Supervisor | Maintenance Supervisor | Interviewed about disinfectant dwell time requirements. |
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
Routine
Census: 37
Deficiencies: 11
Date: Apr 25, 2025
Visit Reason
Routine state inspection survey of Juniper Village - the Spearly Center to assess compliance with regulatory requirements including resident care, safety, infection control, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to ensure resident participation in care planning, inadequate notification of room changes, incomplete care plans, failure to provide appropriate treatment and care, inadequate pressure ulcer care, failure to provide adequate supervision to prevent accidents, failure to follow menus and portion sizes, unsanitary food handling and storage, incomplete hospice documentation, ineffective quality assurance program, and lapses in infection prevention and control practices.
Deficiencies (11)
F0553: Facility failed to ensure residents and their representatives participated in development and implementation of person-centered care plans for two residents.
F0559: Facility failed to provide timely written notification of room changes and honor room preferences for one resident.
F0656: Facility failed to develop a comprehensive care plan addressing functional abilities and ADLs for one resident.
F0684: Facility failed to ensure two residents received treatment and care according to physician orders and professional standards.
F0686: Facility failed to provide timely assessment, interventions, and notifications for pressure ulcers for one resident, resulting in wound progression.
F0689: Facility failed to provide adequate supervision and accident hazard prevention for one resident with choking risk, resulting in immediate jeopardy.
F0803: Facility failed to follow menu portion sizes, providing less than prescribed vegetable servings to residents.
F0812: Facility failed to ensure safe food storage, sanitary handling of ready-to-eat foods, and maintain a clean kitchen free of pests.
F0849: Facility failed to ensure hospice services met professional standards including accessible documentation and consistent communication for one resident.
F0867: Facility failed to operate an effective quality assurance program to identify and address repeat deficiencies and resident safety concerns.
F0880: Facility failed to maintain an infection prevention and control program including proper use of enhanced barrier precautions, hand hygiene, and environmental cleaning.
Report Facts
Residents in sample: 37
Days delayed for wound care orders: 11
Days delayed for skin integrity care plan update: 18
Dead cockroaches on glue trap: 13
Dead cockroaches on glue trap in trash can: 15
Residents requiring intake assistance: 14
Scoop size difference: 1.33
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Manager #1 | Nurse Manager | Interviewed regarding supervision of resident R77 and wound care practices. |
| Licensed Practical Nurse #3 | LPN | Interviewed regarding wound care and medication administration for resident R46. |
| Director of Nursing | DON | Interviewed regarding infection control, quality assurance, and resident supervision. |
| Assistant Director of Nursing #1 | ADON | Interviewed regarding wound care and hospice services. |
| Dietary Manager | Dietary Manager | Interviewed regarding food service, menu compliance, and kitchen sanitation. |
| Certified Nurse Aide #7 | CNA | Observed preparing sandwich with bare hands in nourishment room. |
| Infection Preventionist #1 | IP | Interviewed regarding enhanced barrier precautions and hand hygiene education. |
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
Enforcement
Deficiencies: 2
Date: Dec 11, 2024
Visit Reason
The inspection was conducted due to an elopement incident involving Resident #1 who left the facility unsupervised and was later found deceased. The visit aimed to investigate the circumstances of the elopement, assess facility compliance with safety and supervision requirements, and evaluate corrective actions taken.
Findings
The facility failed to provide adequate supervision and safety measures to prevent Resident #1's elopement, which resulted in his death. Staff had conflicting understanding of supervision levels, failed to document interventions, and did not secure emergency exit doors properly. The facility also failed to maintain an effective quality assurance program to prevent repeat deficiencies related to resident safety.
Deficiencies (2)
F689: The facility failed to ensure a nursing home area was free from accident hazards and provided adequate supervision to prevent accidents, resulting in Resident #1 eloping and subsequent death.
F0867: The facility failed to implement an effective quality assurance program to identify and address safety concerns, leading to repeated deficiencies and serious adverse outcomes.
Report Facts
Date of survey completion: Dec 11, 2024
Date of elopement incident: Nov 30, 2024
Date resident found: Dec 2, 2024
Time staff education completed: Dec 3, 2024
Distance resident found from facility: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator | NHA | Provided plan to remove immediate jeopardy and interviewed regarding incident and corrective actions |
| Director of Nursing | DON | Interviewed regarding resident supervision, elopement assessment, and facility corrective actions |
| Licensed Practical Nurse #1 | LPN | Interviewed about resident behavior and incident response |
| Licensed Practical Nurse #2 | LPN | Admitted resident and provided information on resident behavior and safety awareness |
| Certified Nurse Aide #1 | CNA | Observed resident attempting to leave and assisted in search |
| Licensed Practical Nurse #3 | LPN | Provided information on resident wandering behavior |
| Social Service Director | SSD | Interviewed about elopement assessments and resident monitoring |
| Maintenance Director | Maintenance Director | Interviewed about door locking procedures and facility safety checks |
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
Complaint Investigation
Deficiencies: 1
Date: Oct 23, 2024
Visit Reason
The inspection was conducted following a complaint investigation regarding an incident where Resident #2 sustained bilateral distal femoral fractures during a Hoyer lift transfer on 2024-09-13.
Complaint Details
The investigation was triggered by a complaint related to Resident #2's injury during a Hoyer lift transfer. The deficiency was substantiated as the facility failed to prevent the injury. The facility corrected the practice prior to the onsite investigation on 2024-10-23.
Findings
The facility failed to ensure proper handling and alignment of Resident #2's lower extremities during a Hoyer lift transfer, resulting in bilateral femoral fractures. The facility corrected the deficient practice prior to the onsite investigation and implemented staff reeducation and use of full body slings for transfers.
Deficiencies (1)
F 0689: The facility failed to ensure Resident #2's lower extremities were handled without undue pressure and maintained in alignment during a Hoyer lift transfer, resulting in bilateral distal femoral fractures on 2024-09-13 requiring hospitalization and surgery.
Report Facts
Residents reviewed for accidents: 4
Sample residents: 7
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Interviewed regarding the incident of Resident #2's injury during Hoyer lift transfer. |
| LPN #1 | Licensed Practical Nurse | Interviewed about Resident #2's complaints of pain and subsequent actions taken. |
| DON | Director of Nursing | Interviewed about staff training, root cause analysis, and interventions following Resident #2's injury. |
| NHA | Nursing Home Administrator | Provided follow-up communication regarding staff education and corrective actions. |
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: 7
Date: May 23, 2024
Visit Reason
The inspection was conducted due to complaints and concerns regarding residents' rights, dignity, abuse, neglect, grievance resolution, and environmental conditions at Juniper Village - the Spearly Center.
Complaint Details
The complaint investigation included allegations of neglect, abuse, failure to respond to call lights, grievance resolution failures, improper secure unit placement, and restrictions on residents' rights and freedoms. The investigation found substantiated issues including neglect of Resident #8 with second-degree burns and multiple violations impacting residents' dignity and safety.
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 investigation of neglect allegations, and provision of an environment supporting residents' dignity and rights. Observations and interviews revealed multiple restrictions on residents' freedoms and inadequate staff responsiveness, creating an immediate jeopardy situation.
Deficiencies (7)
F0550: The facility failed to ensure residents' right to a dignified existence by not answering call lights timely on the second floor, causing residents to feel uncared for.
F0585: The facility failed to provide prompt efforts to resolve a grievance regarding missing blue prescription glasses for Resident #181, with incomplete investigation and unresolved reimbursement.
F0600: The facility failed to protect residents from abuse by not implementing person-centered interventions to prevent resident-to-resident altercations involving Residents #118, #32, #49, and #90.
F0603: The facility failed to ensure six residents on the secure unit had required documentation justifying involuntary seclusion and secure unit placement.
F0610: The facility failed to thoroughly investigate neglect allegations involving Resident #8's second-degree burns from hot water, including failure to interview involved staff and monitor shower water temperatures.
F0675: The facility failed to provide residents on the second and third floors with an environment that supported dignity, self-worth, and control, imposing unjustified restrictions on residents' daily lives and freedoms, creating immediate jeopardy.
F0814: The facility failed to ensure proper disposal of garbage and refuse, with dumpster lids left open and trash on the ground, contributing to pest harborage.
Report Facts
Residents affected: 46
Residents affected: 84
Resident council members interviewed: 7
Burn size: 4
Wound size left thigh: 15
Wound size left thigh width: 13
Wound size right thigh: 6.5
Wound size right thigh width: 4
Rodent bait consumption: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| ADON #2 | Assistant Director of Nursing | Observed ignoring call lights and involved in neglect investigation of Resident #8. |
| NHA | Nursing Home Administrator | Provided facility policies, interviewed regarding call light system and resident rights, and provided removal plan for immediate jeopardy. |
| DON | Director of Nursing | Interviewed regarding abuse investigations, neglect investigation, and secure unit placement. |
| CNA #8 | Certified Nurse Aide | Interviewed about call light system and resident care. |
| CNA #9 | Certified Nurse Aide | Interviewed about showering Resident #8 and water temperature checks. |
| DSM | Dining Services Manager | Interviewed about dumpster area cleanliness and staff responsibilities. |
| ESD | Environmental Services Director | Interviewed about water temperature checks and pest control. |
| RN #3 | Registered Nurse | Interviewed about secure unit placement and resident behaviors. |
| LPN #4 | Licensed Practical Nurse | Interviewed about secure unit placement documentation. |
| SSD | Social Services Director | Interviewed about resident to resident altercations and secure unit placement. |
Inspection Report
Immediate Jeopardy
Census: 130
Deficiencies: 12
Date: May 23, 2024
Visit Reason
The inspection was conducted to investigate multiple regulatory compliance concerns including resident rights, abuse prevention, life safety, complaint investigations, and quality of care issues.
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 provide trauma-informed care, failure to maintain a safe environment including emergency evacuation barriers, failure to investigate a resident's injury, failure to maintain proper food safety and sanitation, failure to post accurate staffing information, and failure to provide an environment supporting residents' dignity and quality of life. These deficiencies created immediate jeopardy to resident health and safety.
Deficiencies (12)
F 0550: The facility failed to ensure residents' right to a dignified existence by not answering call lights timely on the second floor, causing residents to feel uncared for.
F 0600: The facility failed to protect residents from abuse by not implementing person-centered interventions to prevent resident-to-resident altercations involving four residents.
F 0603: The facility failed to ensure six residents on the secure unit had required documentation justifying involuntary seclusion and restrictions.
F 0610: The facility failed to thoroughly investigate an allegation of neglect involving one resident who sustained second degree burns from a shower, including failure to interview staff and monitor water temperatures.
F 0675: The facility failed to provide residents on the second and third floors with an environment that supported dignity, self-worth, and control, restricting residents' choices and access to activities, visitors, and personal funds.
F 0689: The facility failed to have a plan ensuring staff were trained and equipped to evacuate residents emergently, with physical barriers (padlocks and clamps) preventing evacuation from outdoor courtyards.
F 0699: The facility failed to ensure trauma assessments and trauma-informed care plans were conducted for residents with PTSD, including identification of triggers and person-centered interventions.
F 0732: The facility failed to post daily nurse staffing information accurately and accessibly for residents and visitors.
F 0761: The facility failed to ensure medication carts were locked when unattended and within line of sight of nursing staff.
F 0803: The facility failed to ensure food was served at appropriate temperatures, menus were followed, kitchen surfaces were cleanable, the can opener was clean, and cups and silverware were handled properly.
F 0814: The facility failed to ensure dumpster lids were closed and the surrounding area was clean to prevent pest harborage.
F 0867: The facility failed to implement an effective QAPI program to identify and address quality of life and safety concerns, including immediate jeopardy issues.
Report Facts
Residents present: 130
Resident falls: 1
Resident council members interviewed: 7
Residents affected by abuse: 4
Residents affected by seclusion: 6
Residents affected by neglect: 1
Residents affected by dignity/environment issues: 46
Residents affected by dignity/environment issues: 84
Food temperature violations: 5
Broken tiles observed: 10
Rodent bait eaten: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Left medication cart unlocked and was educated to lock it |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including medication cart locking and fall investigation |
| NHA | Nursing Home Administrator | Provided removal plans and interviewed regarding QAPI and emergency evacuation |
| DSM | Dining Services Manager | Interviewed regarding menu changes, food safety, and dumpster cleanliness |
| ESD | Environmental Services Director | Held keys to padlocks on emergency exits and interviewed regarding pest control and emergency preparedness |
| RN #1 | Registered Nurse | Interviewed regarding fall procedures |
| RN #2 | Registered Nurse | Interviewed regarding Resident #45 fall and behaviors |
| CNA #1 | Certified Nurse Aide | Interviewed regarding Resident #45 fall and behaviors |
| LPN #4 | Licensed Practical Nurse | Interviewed regarding trauma care plan for Resident #126 |
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
Complaint Investigation
Deficiencies: 1
Date: Dec 19, 2023
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to provide appropriate catheter care and prevent urinary tract infections for Resident #3.
Complaint Details
The investigation was complaint-driven, focusing on Resident #3's catheter care management. The complaint was substantiated as the facility failed to provide adequate catheter care and follow-up, leading to actual harm.
Findings
The facility failed to assess and document the presence and care of an indwelling urinary catheter upon Resident #3's readmission from the hospital, resulting in multiple hospitalizations for catheter-associated urinary tract infections and sepsis. The facility also failed to schedule recommended urology follow-up and had inconsistent documentation of catheter care.
Deficiencies (1)
F 0690: The facility failed to provide appropriate care for residents with indwelling urinary catheters, resulting in Resident #3 developing catheter-associated urinary tract infections and sepsis with multiple hospitalizations. The facility did not assess the need for the catheter upon readmission, failed to document catheter presence and care, and did not schedule recommended urology follow-up.
Report Facts
Residents reviewed for catheter care: 11
Residents affected: 1
Hospitalizations: 3
Urine void volume: 200
Employees mentioned
| Name | Title | Context |
|---|---|---|
| PCP #1 | Primary Care Physician | Recommended urology follow-up and provided medical evaluations 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 about Resident #3's catheter care and documentation issues |
| 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. |
Inspection Report
Deficiencies: 1
Date: May 24, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulations regarding residents' rights to retain and retrieve personal belongings after death, following concerns about the facility's handling of deceased residents' property.
Findings
The facility failed to ensure that the personal belongings of three deceased residents (#7, #29, and #16) were properly managed and that their representatives were notified and given the opportunity to retrieve these belongings. Documentation and communication with residents' powers of attorney (POA) regarding belongings were incomplete or missing.
Deficiencies (1)
F 0557: The facility failed to ensure residents retained the rights to their personal belongings for three residents. Resident representatives were not properly notified or given the opportunity to retrieve belongings after death, and documentation of communication and inventory was incomplete.
Report Facts
Residents affected: 3
Sample residents: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding notification and documentation practices for residents' belongings |
| Interim Social Services Director | Interim Social Services Director (ISSD) | Interviewed about communication with families and documentation of residents' belongings |
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