Juniper Village - the Spearly Center

Inspectors wroteBased on record review and interviews, the facility failed to ensure two (#65 and #124) of eight residents were kept free from abuse out of 41 sample residents. Specifically, the facility failed to protect Resident #124 from physical abuse by Resident #65 and protect Resident #65 from physical abuse by Resident #124.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure all drugs and biologicals were properly stored, secured and labeled in accordance with accepted professional standards for three of five medication storage carts and one of three medication storage rooms. Specifically, the facility failed to:-Ensure a Schedule IV controlled medication was properly stored in a refrigerator;-Ensure medications were labeled with open dates; and, -Ensure expired medications were properly disposed of.

Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection on one of three units Specifically, the facility failed to:-Ensure Resident #122's oral stimulator was kept in a sanitary location;-Ensure housekeeping staff performed hand hygiene while cleaning resident rooms;-Ensure housekeeping staff wait the appropriate amount of dwell time.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure an environment free from risk of accidents and hazards for one (#77) of five residents reviewed for accident hazards out of 37 sample residents. R77 had severe cognitive impairments. On 3/19/25, the resident took a piece of bread from another resident's plate and ate it. R77 choked and required the Heimlich maneuver (abdominal thrusts used to clear food from a person's airway that is choking) to clear the food from his airway. The resident's care plan directed staff to assist R77 with controlling his rate of eating, monitoring the resident's bite sizes to ensure the resident did not choke and monitoring the resident to avoid the resident stuffing food into his mouth. Additionally, R77 was prescribed a mechanically altered diet. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented in order to facilitate improvement in the lives of nursing home residents through continuous attention to quality of care, quality of life, and resident safety. Specifically, the quality assurance and performance improvement (QAPI) program committee failed to identify and address concerns related to accidents and safety of residents, which rose to the level of immediate jeopardy and created a situation that a serious adverse outcome was likely.

Inspectors wroteBased on observations, record review and interview, the facility failed to ensure menus were followed to meet the resident's nutritional needs. Specifically, the facility failed to follow correct portions sizes to ensure adequate nutrition was provided to the residents.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure food was prepared, distributed and served under sanitary conditions in the main kitchen and one of two nourishment refrigerators. Specifically, the facility failed to: -Ensure safe and appropriate storage of food items in the nourishment room refrigerators; -Ensure ready-to-eat foods were handled in a sanitary manner to prevent cross-contamination in the main kitchen; and, -Maintain a clean and sanitary kitchen to prevent the harborage of pests.

Inspectors wroteBased on observations, interviews and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease. Specifically, the facility failed to: -Ensure enhanced barrier precautions (EBP) were followed for R45 and R78, -Ensure proper hand hygiene was followed during wound care for R78, -Ensure housekeeping staff followed appropriate hand hygiene processes when cleaning resident rooms; and, -Ensure high touch surfaces in residents' rooms were cleaned.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents and their representatives had a right to participate in the development and implementation of their person-centered plan of care for two (#102 and #41) of four residents out of 37 sample residents. Specifically, the facility failed to invite R102's and R41's representatives to participate in the care conferences to review the resident's plan of care.

Inspectors wroteBased on record review and interviews, the facility failed to provide written notification of room changes for one (#55) of two residents reviewed for notifications out of 37 sample residents. Specifically, the facility failed to: -Provide timely written notification of a room change and the reasoning to R55's; and, -Honor R55's room preferences.

Inspectors wroteBased on record review and interviews, the facility failed to develop a comprehensive care plan for one (#110) of three residents reviewed for care planning out of 37 sample residents to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. Specifically, the facility failed to ensure a comprehensive care plan was developed to address R110's functional abilities and activities of daily living (ADL).

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure two (#46 and #98) of three residents received treatment and care in accordance with professional standards of practice out of 37 sample residents. Specifically, the facility failed to: -Ensure physician's orders to treat R46's skin condition on his hands were followed; and, -Ensure R98's skin rash was addressed in a timely manner.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide the necessary treatment and services to treat and prevent pressure injuries for one (#45) of three residents reviewed for pressure ulcers out of 37 sample residents. Specifically, the facility failed to: -Provide timely assessment by a qualified person; -Provide timely interventions and treatment after new wounds were found; -Notify key individuals (hospice, wound specialist, primary physician) to ensure timely interventions, assessments, and updated care plans, were in place to avoid wounds from worsening; and, -Ensure wound care documentation was thorough and accurate.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the hospice services provided met professional standard and principles that applied to individuals providing services in the facility for one (#78) of four residents reviewed for hospice services out of 37 sample residents. Specifically, the facility failed to ensure the hospice agency's notes were easily accessible to the facility staff and had consistent communication and documentation of hospice care visits and updates.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure that one (#1) of three sample residents and other residents residing on the facility's third floor remained as free from accidents as possible. Resident #1 was admitted to the facility on [DATE] for long-term care. The resident was severely cognitively impaired and impulsive with poor safety awareness. At the time of admission, he was assessed not to be at risk for elopement. However, after admission, staff reported he was always on the move, standing near the doors and observing people passing in and out. By 11/30/24, the resident had become increasingly agitated and made several attempts to leave, setting off alarms when he attempted to open the doors. At approximately 1:08 p.m. that day, the resident eloped from the facility. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented in order to facilitate improvement in the lives of nursing home residents through continuous attention to quality of care, quality of life, and resident safety. Specifically, the quality assurance and performance improvement (QAPI) program committee failed to identify and address concerns related to accidents and safety of residents, which rose to the level of immediate jeopardy and created a situation that a serious adverse outcome was likely.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#2) of four residents reviewed for accidents out of seven sample residents remained free from accidents. Resident #2, who was non-weight bearing with a history of osteoporosis and was known to be at risk for pathological fractures (fractures caused by disease processes rather than trauma), sustained bilateral distal femoral fractures (thigh bone above the knee) during a transfer with a mechanical (Hoyer) lift into a wheelchair. During the facility's investigation, it was identified that the type of Hoyer sling being used was a split leg sling which required the sling straps to be placed under and crossed around the thighs while the resident was being lifted out of bed and being transferred to the wheelchair. [...]

Inspectors wroteBased on observations, record review, and interviews, the facility failed to provide residents residing on the second and third floors of the facility, including Residents #1, #182, #74, #73, #75, #92, #103, #67, #87, #95, #102, #14, #76, #115, #68, #7, #77, #112, #57, and #8, with an environment that supported and enhanced each resident's dignity, self-worth, sense of satisfaction, and control over their lives. Observations and interviews with residents and staff revealed facility practices that showed a disregard for residents' quality of life and were inconsistent with the facility Resident Rights policy to provide residents with a holistic program that provided respect, dignity, and compassion. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure four (#118, #32, #49 and #90) of four residents reviewed for abuse out of 56 sample residents were kept free from abuse. Specifically, the facility failed to: -Implement person-centered interventions to prevent a resident to resident altercation between Resident #118 and Resident #32; and, -Implement person-centered interventions to prevent a resident to resident altercation between Resident #90 and Resident #49.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to ensure that six (#118, #126, #121, #115, #72 and #20) of nine residents out of 56 sample residents were free from involuntary seclusion and were receiving the least restrictive approach for their needs. Specifically, the facility failed to ensure Residents #118, #126, #121, #115, #72 and #20, who resided on the secure locked unit, had the required documentation to justify such restrictions.

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to ensure garbage and refuse was properly disposed of and the dumpster lid was closed to prevent harborage to pests and insects in one of one dumpster area. Specifically, the facility failed to ensure the dumpster lids were closed and the surrounding environment was maintained in a cleanly manner.

Inspectors wroteBased on observations and interviews the facility failed to ensure residents on one of three units had the right to a dignified existence. Specifically, the facility failed to answer call lights in a timely manner on the second floor.

Inspectors wroteBased on interviews and record review, the facility failed to ensure one (#181) of three residents out of 56 sample residents were provided prompt efforts by the facility to resolve grievances. Specifically, the facility failed to provide a satisfactory resolution to Resident #181's grievance, which the resident representative had communicated to staff on multiple occasions, regarding the resident's missing glasses.

Inspectors wroteBased on record review and interviews, the facility failed to thoroughly investigate an allegation of neglect involving one (#8) of two residents reviewed for neglect out of 56 sample residents. Specifically, the facility failed to conduct a thorough investigation to determine the cause of reddened skin and blisters found on Resident #8's left and right thigh.

Inspectors wroteBased on record review and interviews, the facility failed to provide services in accordance with currently accepted professional principles for one (#3) of five residents reviewed for catheter care management out of 11 sample residents. Resident #3 was admitted to the facility on [DATE] for long term care. He had a diagnosis of dementia with behaviors, Parkinson's disease and kidney disease. On 9/10/23 the resident developed signs of a urinary tract infection (UTI). He was sent to the emergency room (ER) for the evaluation and returned to the facility the next day (9/11/23) with an indwelling urinary catheter. Upon the resident's readmission from the ER, the facility failed to assess the resident for the need of the urinary catheter and did not document its presence and care. [...]