Juniper Village Spearly Center: Infection Failures CO
DENVER, CO - A recent inspection at Juniper Village - the Spearly Center revealed widespread failures in infection control practices, including staff members not wearing required protective equipment during wound care and housekeeping personnel not properly sanitizing high-touch surfaces in resident rooms.
Infection Control Violations Put Vulnerable Residents at Risk
Federal inspectors documented multiple instances where nursing staff failed to follow Enhanced Barrier Precautions (EBP) while providing wound care to residents with serious pressure ulcers and infections. The violations, observed during an April 2025 inspection, showed a pattern of staff members across different shifts and positions failing to wear protective gowns during high-contact care activities.
During wound care for a resident identified as R45, who had a stage 3 pressure ulcer on the sacrum and a deep tissue injury on the left heel, inspectors observed three different staff members - a Certified Nurse Aide, a Registered Nurse, and a Nurse Manager - performing wound care without wearing required protective gowns. The Nurse Manager did follow proper hand hygiene protocols between steps but failed to don the required gown before beginning the procedure.
Enhanced Barrier Precautions require healthcare workers to wear both gloves and gowns when performing high-contact activities with residents who have wounds or indwelling medical devices. These precautions are designed to prevent the transmission of multidrug-resistant organisms (MDROs) that can cause serious infections in vulnerable populations. When staff members skip these protective measures, they risk spreading dangerous bacteria between residents, potentially causing life-threatening infections in individuals whose immune systems are already compromised.
The medical significance of this violation cannot be understated. Pressure ulcers, particularly stage 3 wounds that extend through the full thickness of skin into subcutaneous tissue, create open pathways for bacteria to enter the body. When proper barrier precautions are not followed, bacteria from one resident's wound can be transmitted to another resident via contaminated clothing or skin of healthcare workers. In elderly residents with weakened immune systems, such infections can lead to sepsis, a potentially fatal whole-body inflammatory response to infection.
Critical Hand Hygiene Failures During Active Wound Care
Perhaps even more concerning was the observation of the Assistant Director of Nursing failing to change gloves after removing soiled wound packing from resident R78's infected wound. The ADON removed contaminated packing material from within the wound using a sterile swab, then continued to handle clean supplies and repack the wound without changing her gloves.
This represents a fundamental breach of sterile technique that dramatically increases the risk of wound infection. When contaminated gloves touch clean wound packing material, bacteria from the soiled dressing can be directly introduced into the wound bed. For a wound that requires packing, which indicates significant depth and tissue loss, introducing bacteria deep into the tissue can result in severe complications including osteomyelitis (bone infection), systemic infection, and delayed or prevented wound healing.
The ADON, when interviewed after the observation, acknowledged that "she should have changed her gloves after taking out the old packing." This admission reveals an understanding of proper protocol that was not followed in practice, suggesting a breakdown in the facility's infection control culture rather than a simple knowledge gap.
Inadequate Staff Training Despite Policy Implementation
The facility's Director of Nursing, who also served as the Infection Preventionist, admitted during interviews that while he had educated staff about Enhanced Barrier Precautions when the policy was introduced in summer 2024, "somehow, they had forgotten about the other reasons for EBP precautions." He stated that staff had previously used EBP correctly for a resident with a fungal infection but had lost focus on implementing the precautions for all qualifying conditions.
Multiple staff members interviewed revealed concerning gaps in their understanding of infection control requirements. The ADON stated she "did not think she had any training regarding EBP and was not aware that they were supposed to be wearing gowns for dressing changes," despite being in a supervisory position. A newly hired Licensed Practical Nurse reported not remembering learning about EBP precautions during orientation.
The widespread nature of these violations across multiple staff members and different levels of nursing hierarchy indicates a systemic failure in the facility's infection control program. When supervisory staff are unaware of basic infection control requirements, it becomes impossible to ensure that direct care staff are following proper protocols.
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
JUNIPER VILLAGE - THE SPEARLY CENTER in DENVER, CO was cited for violations during a health inspection on April 25, 2025.
The Nurse Manager did follow proper hand hygiene protocols between steps but failed to don the required gown before beginning the procedure.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.