Juniper Village - The Spearly Center

In the surveyor’s words

From the most serious findings on record at Juniper Village - The Spearly Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF689Dec 11, 2024

  Based 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 [DATE], 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. […]

• Immediate jeopardy, widespreadF689May 23, 2024

  Based on observations, interviews, and record review, the facility failed to have a plan to ensure staff were trained and had the necessary equipment to emergently evacuate residents from the facility, affecting the safety of all 130 facility residents. Review of the facility floor plans, observations, and interviews revealed three facility emergency exits that led to two outdoor courtyards. Each exit had an EXIT sign that pointed to the courtyard doors. Observation of the outdoor courtyards revealed one of the courtyards had three exits through gates secured with padlocks that required a key to unlock. Staff reported they did not know where to locate a key to release the padlocks on the gates. The second outdoor courtyard revealed one exit through a gate. […]

• Immediate jeopardy, patternF675May 23, 2024

  Based 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. […]

• Immediate jeopardy, patternF880Jan 30, 2023

  Based on observations, record review and interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, observations and interviews revealed the nursing staff lacked knowledge, training, and equipment to manage the residents' routine and emergency blood glucose monitoring needs. […]

• Immediate jeopardy, isolatedF689Apr 25, 2025

  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. […]