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.
Environmental Cleaning Deficiencies Compound Infection Risks
Beyond the direct care violations, inspectors also documented failures in environmental cleaning that further compromised the facility's infection control efforts. Housekeeping staff were observed failing to clean and sanitize critical high-touch surfaces including door knobs, light switches, and call lights in resident rooms. These surfaces, which are frequently touched by both residents and staff throughout the day, serve as reservoirs for pathogens when not properly disinfected.
Additionally, housekeeping staff failed to change gloves when moving from cleaning bathroom areas to bedroom areas within the same room. This practice can spread fecal bacteria and other bathroom contaminants to surfaces where residents eat, take medications, and receive care. The combination of inadequate surface disinfection and improper glove use creates multiple opportunities for cross-contamination within resident living spaces.
The Maintenance Director acknowledged that high-touch surfaces should be cleaned "at least twice per week unless the resident had an infection," though current infection control guidelines recommend daily cleaning of high-touch surfaces in healthcare settings. He also admitted learning only on the day of the interview that housekeeping staff should change gloves when moving between dirty and clean areas of a room.
Repeated Quality Assurance Failures
The facility's history of repeated citations for quality assurance and performance improvement violations reveals an ongoing inability to identify and correct serious care deficiencies. The facility was cited for the same quality assurance violation (F867) at the highest scope and severity level during three consecutive surveys - in May 2024, December 2024, and April 2025. This pattern demonstrates that despite previous citations and submitted plans of correction, the facility has been unable to implement effective systems to monitor and ensure quality care.
The Nursing Home Administrator described a system where the facility held monthly Quality Assurance and Performance Improvement (QAPI) meetings and daily interdisciplinary team meetings to discuss resident risks. However, as the Administrator acknowledged, the facility failed to identify that R77 was not being properly supervised during meals despite having a documented history of choking - a potentially life-threatening oversight that the quality assurance system should have caught.
Additional Issues Identified
Beyond the major infection control and quality assurance failures, inspectors documented several other violations that contributed to the pattern of substandard care. The facility failed to provide appropriate supervision at meal times for a resident with a documented choking history, creating what inspectors described as "an immediate jeopardy situation" where "a serious outcome was likely to occur."
The inspection report also revealed that despite having documentation systems in place including a binder containing identified problems and monitoring plans, these systems failed to prevent or detect the widespread infection control violations and supervision failures. The facility's consultant, brought in to review plans of correction, had also failed to identify these critical gaps in care delivery.
Medical Context and Industry Standards
The violations documented at Juniper Village represent failures to meet basic healthcare standards that have been established for decades. Proper hand hygiene and use of personal protective equipment are considered the most fundamental and effective measures for preventing healthcare-associated infections. The Centers for Disease Control and Prevention's guidelines for infection control in long-term care facilities are clear and specific about when protective equipment must be worn and when hand hygiene must be performed.
The consequences of infection control failures in nursing homes can be severe. Elderly residents often have multiple chronic conditions, compromised immune systems, and reduced ability to fight infections. What might be a minor infection in a younger, healthier person can quickly become life-threatening in a frail nursing home resident. Multidrug-resistant organisms, which Enhanced Barrier Precautions are specifically designed to prevent spreading, are particularly dangerous because they limit treatment options when infections do occur.
The facility's infection control failures are particularly concerning given the presence of residents with serious wounds requiring complex care. Stage 3 pressure ulcers and wounds requiring packing represent significant tissue damage that requires meticulous wound care technique to promote healing and prevent infection. When basic infection control measures are not followed, these wounds become breeding grounds for dangerous bacteria that can spread throughout the facility.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Juniper Village - the Spearly Center from 2025-04-25 including all violations, facility responses, and corrective action plans.
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