Juniper Village - the Spearly Center

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Smoke Deficiencies

Provide properly protected cooking facilities.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Administration Deficiencies

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Smoke Deficiencies

Provide properly protected cooking facilities.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Services Deficiencies

Have elevators that firefighters can control in the event of a fire.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Nutrition and Dietary Deficiencies

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Resident Rights Deficiencies

Allow resident to participate in the development and implementation of his or her person-centered plan of care.

Resident Rights Deficiencies

Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Administration Deficiencies

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Administration Deficiencies

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Honor each resident's preferences, choices, values and beliefs.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).

Nutrition and Dietary Deficiencies

Dispose of garbage and refuse properly.

Resident Rights Deficiencies

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Smoke Deficiencies

Provide properly protected cooking facilities.

Egress Deficiencies

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Nutrition and Dietary Deficiencies

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Administration Deficiencies

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Egress Deficiencies

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Emergency Preparedness Deficiencies

Establish emergency prep training and testing.

Egress Deficiencies

Have properly located and lighted "Exit" signs.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

Quality of Life and Care Deficiencies

Provide care or services that was trauma informed and/or culturally competent.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Egress Deficiencies

Provide large enough exits.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure medical gas and vacuum systems have documented maintenance programs.

Nursing and Physician Services Deficiencies

Post nurse staffing information every day.

A licensure survey was completed on 4/7/25 to 4/25/25. One deficiency was cited. Based 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.Observations during the survey revealed R77 received menu items that were not consistent with his prescribed diet order. The staff failed to provide supervision during meals to ensure the resident did not take food from other residents' plates or monitor the resident' s bite sizes which put the resident at a continued risk of further choking incidents for R77.The failure to provide appropriate supervision during times of resident intake placed residents at risk for serious harm or death if not corrected immediately.On 4/25/25 at 10:11 a.m., a situation was identified, based o.. Based 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.R45, who was known to be at risk for pressure injuries, was admitted on 3/28/19. The resident had diagnoses of major depressive disorder, dementia, overactive bladder, hemiplegia (paralysis to one side of the body) and hemiparesis (one-sided muscle weakness) following a cerebral infarction (stroke).On 3/22/25 R45 developed a facility-acquired stage 2 pressure injury to his coccyx, however, the facility did not notify the physician, initiate further pressure ulcer interventions on the resident' s pressure ulcer care plan once the stage 2 pressure injury was identified, or obtain wound care orders until after the wound had worsened. On 3/27/25, the wound care physician documentation indicated R45' s pressure wound had worsened to a stage 3 pressure injury. Due to the facility' s failures to notify the physician, implement timely additional interventions following pressure injury development and implement orders for wound care until after worsening of the wound, R45 developed a facility-acquired stage 2 pressure injury, which worsened to a stage 3 pressure injury.Findings include:I. Professional referenceAccording to t..