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Deficiency Records for Juniper Village - The Spearly Center
A list of the most recent deficiencies for Juniper Village - The Spearly Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Juniper Village - The Spearly Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-06-05 | 2024-09-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-06-05 | 2024-09-16 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-06-05 | 2024-06-13 | N |
| Provide large enough exits. | Fire Safety | 2024-06-05 | 2024-06-10 | N |
| 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. | Fire Safety | 2024-06-05 | 2024-06-07 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-06-05 | 2024-06-07 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-06-05 | 2024-06-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-06-05 | 2024-06-07 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-06-05 | 2024-06-07 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-06-05 | 2024-06-07 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-06-05 | 2024-06-07 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-06-05 | 2024-06-07 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-06-05 | 2024-06-07 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-06-05 | 2024-06-06 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-06-05 | 2024-06-06 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-06-05 | 2024-06-06 | N |
| Ensure medical gas and vacuum systems have documented maintenance programs. | Fire Safety | 2024-06-05 | 2024-06-06 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-06-05 | 2024-06-06 | N |
| 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. | Health | 2024-05-23 | 2024-05-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-05-23 | 2024-05-24 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2024-05-23 | 2024-05-24 | N |
| Post nurse staffing information every day. | Health | 2024-05-23 | 2024-05-24 | N |
| 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. | Health | 2024-05-23 | 2024-05-24 | N |
| 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. | Health | 2024-05-23 | 2024-05-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-05-23 | 2024-05-24 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-05-23 | 2024-05-24 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-05-23 | 2024-05-24 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-05-23 | 2024-05-24 | Y |
| Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). | Health | 2024-05-23 | 2024-05-24 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-05-23 | 2024-05-24 | Y |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2024-05-23 | 2024-05-24 | Y |
| Dispose of garbage and refuse properly. | Health | 2024-05-23 | 2024-05-24 | Y |
| Establish emergency prep training and testing. | Fire Safety | 2024-05-23 | 2024-05-24 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-12-19 | 2024-01-10 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-05-24 | 2023-07-15 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-02-28 | 2023-04-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-02-28 | 2023-04-06 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-02-28 | 2023-04-06 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-02-28 | 2023-03-29 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-02-28 | 2023-03-29 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-02-28 | 2023-03-29 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-02-28 | 2023-03-29 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-02-28 | 2023-03-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-02-28 | 2023-03-28 | N |
| Have an externally vented heating system. | Fire Safety | 2023-02-28 | 2023-03-14 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2023-02-28 | 2023-03-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-01-30 | 2023-02-28 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2023-01-30 | 2023-02-23 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2023-01-30 | 2023-02-23 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-01-30 | 2023-02-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-30 | 2023-02-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-30 | 2023-02-23 | N |
| 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. | Health | 2023-01-30 | 2023-02-23 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-01-30 | 2023-02-23 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-01-30 | 2023-02-23 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-01-30 | 2023-02-23 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-01-30 | 2023-02-23 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-01-30 | 2023-02-23 | Y |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2021-10-19 | 2021-12-01 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-10-19 | 2021-12-01 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-10-19 | 2021-12-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-10-19 | 2021-12-01 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-10-19 | 2021-12-01 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-10-19 | 2021-12-01 | N |
| Have an externally vented heating system. | Fire Safety | 2021-10-19 | 2021-12-01 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2021-10-19 | 2021-12-01 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-10-19 | 2021-11-20 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2021-10-19 | 2021-11-15 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-10-19 | 2021-11-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-10-19 | 2021-11-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-10-19 | 2021-11-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-10-19 | 2021-10-26 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2021-09-30 | 2021-10-21 | N |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2021-09-30 | 2021-10-21 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-09-30 | 2021-10-21 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-09-30 | 2021-10-21 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-09-30 | 2021-10-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-30 | 2021-10-21 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-09-30 | 2021-10-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-10-19 | 2021-10-21 | N |
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