Juniper Village - The Spearly Center

During the recertification survey on 5/23/24 F-F689 was cited at a L level scope and severity, immediate jeopardy to resident health or safety, widespread.

During the abbreviated survey on 12/11/24 F-F689 was cited at a L level scope and severity, immediate jeopardy to resident health or safety, widespread.

During the recertification survey on 4/25/25 F-F689 was cited at a J level scope and severity, immediate jeopardy to resident health or safety, isolated.

During the recertification survey on 5/23/24 F-F867 was cited at a F level scope and severity, no actual harm with potential for more than minimal harm that is not immediate jeopardy, widespread.

During the abbreviated survey on 12/11/24 F-F867 was cited at a F level scope and severity, no actual harm with potential for more than minimal harm that is not immediate jeopardy, widespread.

During the recertification survey on 4/25/25 F-F867 was cited at a F level scope and severity, no actual harm with potential for more than minimal harm that is not immediate jeopardy, widespread.

II. Cross-reference citation Cross-reference F-F689: The facility failed to provide appropriate supervision at meal times for Resident R77, who had a history of choking.

08/28/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 04/25/2025 Juniper Village - the Spearly Center 2205 W 29th Ave Denver, CO 80211 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

The facility's failure to provide supervision and assistance at meal times for a resident with a history of choking created a situation where a serious outcome was likely to occur and created an immediate jeopardy situation.

III. Staff interviews

The Nursing Home Administrator (NHA) was interviewed on 4/10/25 at 4:30 p.m. The NHA said the facility held a monthly QAPI meeting. The NHA said the facility team members, including the interdisciplinary team (IDT), also met daily and discussed potential risks to residents. The NHA said each day during the daily meeting, the team reviewed resident risks identified, how the risks were monitored and the expected outcome.

The NHA said the facility developed corrective actions for identified risks that resulted from a collaborative discussion with the IDT. The NHA said there was a documentation binder that contained the problem that was identified, a system put in place or improved upon and how that situation was monitored. The NHA said each day any new issue that was identified was monitored. The NHA said a facility consultant performed an additional review of the facility's plan of correction. -However, the facility failed to identify Resident R77 was not assisted and monitored during meal times, according to his care planned interventions, to ensure Resident R77 did not choke. 08/28/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 04/25/2025 Juniper Village - the Spearly Center 2205 W 29th Ave Denver, CO 80211 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide and implement an infection prevention and control program. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50690 Based 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 Resident R45 and Resident R78, -Ensure proper hand hygiene was followed during wound care for Resident R78, -Ensure housekeeping staff followed appropriate hand hygiene processes when cleaning resident rooms; and, -Ensure high touch surfaces in residents' rooms were cleaned.

I. EBP and hand hygiene failures A. Professional reference According to the Centers for Disease Control and Prevention (CDC), Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDRO)'s, (4/2/24), retrieved on 4/15/25 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html, Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employ target gown and glove use during high contact resident activities.

EBP may be indicated (when contact precautions do not otherwise apply) for residents with any of the following: wounds or indwelling medical devices, regardless of MDRO colonization status and infection or colonization with an MDRO.

Examples of high contact resident care activities requiring gown and glove use for EBP include: dressing, bathing/showering, transferring, providing hygiene, changing linens changing briefs or assisting with toileting, device care or use (central line urinary catheter, feeding tube, tracheostomy/ventilator), wound care (any skin opening requiring a dressing).

According to the CDC Clinical Safety, Hand Hygiene for Healthcare Worker (2/17/24), retrieved on 4/15/25 from https://www.cdc.gov/clean-hands/hcp/clinical-safety,

08/28/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 04/25/2025 Juniper Village - the Spearly Center 2205 W 29th Ave Denver, CO 80211 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Know when to clean your hands: immediately before touching a patient, before performing an aseptic task such as placing an indwelling device or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or patient's surroundings,

after contact with blood, body fluids or contaminated surfaces and immediately after glove removal.

B. Observations

During a continuous observation of wound care on 4/9/25, beginning at 11:30 a.m. and ending at 12:00 p.m.,

the following was observed: Certified Nurse Aide (CNA) #5 donned (put on) gloves and turned Resident R45 on his side. Registered Nurse (RN) #1 donned gloves and applied skin prep to Resident R45's left heel deep tissue injury (DTI). -However, CNA #5 and RN #1 failed to don a gown prior to high contact care for Resident R45.

Nurse Manager (NM) #2 washed her hands and gathered supplies. NM #2 donned gloves and removed the old, dirty dressing covering Resident R45's stage 3 pressure ulcer on the sacrum. NM #2 changed gloves and sanitized her hands after removing the dirty dressing. NM #2 cleansed the wound with saline and applied skin prep around the wound. She then applied calcium alginate soaked in Dakin's solution into the wound bed, covered the wound with a Mepilex dressing, dated and initialed the dressing. She changed gloves and performed hand hygiene between each step in the process. -However, NM #2 did not don a gown prior to starting wound care.

During a continuous observation on 4/9/25, beginning at 2:37 p.m. and ending at 3:15 p.m., the following was observed: Assistant Director of Nursing (ADON) #1 and Licensed Practical Nurse (LPN) #1 entered Resident R78's room with wound care supplies on a sterile field created on top of a movable table. ADON #1 washed her hands and donned gloves before beginning Resident R78's wound care. LPN #1 also donned gloves and assisted ADON #1 by holding Resident R78 in position. ADON #1 prepared the supplies on the sterile field and then used a sterile swab to remove the soiled packing from within Resident R78's wound. -However, ADON #1 and LPN #1 failed to don a gown prior to starting Resident R78's wound care.

ADON #1 grabbed a new sterile swab, folded new packing material over the top and placed it on her sterile field.

ADON #1 flushed the wound with saline (salt water), dabbed around the wound with sterile gauze and used

the swab to press the new, clean packing into the wound. -However, ADON #1 failed to change gloves after removing the soiled packing from Resident R78's wound.

ADON #1 removed her gloves, washed her hands, donned new gloves, and applied a skin protectant around

the wound. She placed sterile gauze over the wound and secured all four sides with paper tape. She removed her gloves, wrapped the supplies up within the sterile field, threw out the supplies and sanitized her hands.

08/28/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 04/25/2025 Juniper Village - the Spearly Center 2205 W 29th Ave Denver, CO 80211 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some C. Staff interviews ADON #1 and LPN #1 were interviewed together on 4/9/25 at 3:36 p.m. ADON #1 said normally, only gloves were worn when doing dressing changes, even if the wound was infected. She said EBP was worn when there were weeping wounds or wounds with resistant organisms. She said 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. She said the wound doctor had not been wearing a gown for dressing changes. She said she should have changed her gloves after taking out the old packing.

LPN #1 said she just started orientation at the facility and did not remember learning about EBP precautions.

The Director of Nursing (DON), who was also the facility's Infection Preventionist (IP #1), and IP #2 were interviewed together on 4/10/25 at 10:18 a.m. The DON said he educated staff about EBP last summer (2024) when the policy came out. He said there were isolation carts for residents with catheters, wounds and other infections. He said the staff had used EBP for a previous resident that had a fungal infection, but somehow, they had forgotten about the other reasons for EBP precautions. He said EBP was needed for high-contact activities like bathing, dressing, incontinence care and linen changes for those residents. He said face shields were provided for residents with catheters to protect from splashing. He said he did not realize the focus had been lost until yesterday (4/9/25). He said he had started adding orders and care plans for EBP in the residents' electronic medical record (EMR).

IP #2 said that she had already started re-educating staff about hand hygiene and EBP. IP #2 said the packet for new employees had information on EBP but somehow it had been forgotten. She said she would also address hand hygiene and EBP at the upcoming skills fair in August 2025.

II. Housekeeping failures A. Professional reference According to Assadian O, Harbarth S, Vos M, et al. Practical Recommendations for Routine Cleaning and Disinfection Procedures in Healthcare Institutions: A Narrative Review. The Journal of Hospital Infection, (July 2021) 113:104-114, retrieved on 3/21/25 from https://www.journalofhospitalinfection.com/article/S0195-6701(21)00105-5/fulltext, High-touch surfaces are usually close to the patient, are frequently touched by the patient or nursing staff, come into contact with the skin and, due to increased contact, pose a particularly high risk of transmitting pathogens (virus or microorganism that can cause disease).

Contaminated surfaces, particularly those that are touched frequently, act as reservoirs for pathogens and contribute towards pathogen transmission. Therefore, healthcare hygiene requires a comprehensive approach. This approach includes hand hygiene in conjunction with environmental cleaning and disinfection of surfaces and clinical equipment.

B. Observations

08/28/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 04/25/2025 Juniper Village - the Spearly Center 2205 W 29th Ave Denver, CO 80211 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

During a continuous observation on 4/8/25, beginning at 9:13 a.m. and ending at 9:53 a.m., the following was observed:

An unidentified Housekeeper (HK) sanitized her hands and donned gloves. She entered room [ROOM NUMBER], which was a triple occupancy room. The HK sprayed the bathroom toilet with Oxivir 5 sanitizer, wet a clean cloth with water from the sink and wiped the outside, rim of the toilet seat and sides. She scrubbed the inside of the toilet with the toilet brush and flushed the toilet. She wiped the top and outsides of

the toilet again with the cloth and then placed the used cloth in a bag on her supply cart outside the room. -The HK failed to change gloves after cleaning a dirty area (the bathroom) before moving to a clean area (the bedroom).

The HK then sprayed the mirror and sink with glass and multi-surface cleaner and wiped the area with clean cloths. She placed the used cloths in the bag on the cart and grabbed new ones. She cleaned the surfaces of the bedroom furniture, bed frames and lights for the three resident areas, changing cloths between steps.

She cleaned the windows with a new cloth and window cleaner. She swept and then mopped the floor, using new mop heads for each resident area. At 9:53 a.m. the HK removed her gloves, exited room [ROOM NUMBER] and sanitized her hands. -The HK failed to clean and sanitize the high touch areas in room [ROOM NUMBER] including door knobs, light switches and the call lights.

C. Staff interviews

The Maintenance Director (MTD) was interviewed on 4/10/25 at 3:45 p.m. The MTD said it was necessary that the housekeeping staff changed their gloves before entering each room for cleaning. He said the staff should remove their gloves before leaving the room and wash or sanitize their hands afterward. The MTD said the housekeeping staff required high touch surfaces like call lights and door knobs to be cleaned at least twice per week unless the resident had an infection. He said he just learned today that gloves should be changed twice during a room clean, so he planned to do education on that. 08/28/2025