Spruce Manor Nursing & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Spruce Manor Nursing & Rehabilitation Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF584Apr 24, 2026

  Based on observation, it was determined that the facility failed to provide a safe, clean, and comfortable environment on four of four nursing units. (West 1, East 1, [NAME] 2, and East 2)Findings include: Observations on April 21, 2026, and April 22, 2026, between 8:40 a.m., and 12:50 p.m., revealed the following: The Hoyer lift in the [NAME] 1 shower room had rust along the length of the legs. There were two ceiling tiles with brown spots above the bed in room [ROOM NUMBER]. In room [ROOM NUMBER], the blinds on the window across from the toilet were not adjustable, exposing three inches of open window space, thereby making the toilet visible from the street across from the facility; the toilet also had worn caulking. […]

• No harm, potential for more than minimal, patternF755Mar 25, 2022

  Based on facility policy and documentation review, clinical record review, staff interview, and resident interview, it was determined that the facility failed to minimize the potential for diversion of controlled substances for one of five sampled residents (Resident 1) and on eight of eight medication carts. Findings include: Review of the facility policy entitled, Inventory Control of Controlled Substances, revised [DATE], revealed that the facility should maintain separate individual controlled substance records on all Schedule II medications and any medication with a potential for abuse or diversion in the form of a declining inventory using the Controlled Substances Declining Inventory Record, to include the quantity remaining and the name and signature of the person administering the… […]

• No harm, potential for more than minimal, isolatedF605Apr 24, 2026

  Based on clinical record review and staff interview, it was determined that the facility failed to ensure that residents were free from potential chemical restraints for one of five sampled residents who were ordered psychotropic medications. (Resident 80)Findings include:Clinical record review revealed that Resident 80 had diagnoses that included anxiety and dementia. On March 17, 2026, a physician ordered staff to administer an anti-anxiety medication, (lorazepam), every two hours as needed for anxiety. There was no date in the order that indicated when staff were to stop administering the as needed medication. Review of Resident 80's Medication Administration Record revealed that staff had administered the lorazepam one time in March 2026 and five times in April 2026. […]

• No harm, potential for more than minimal, isolatedF641Apr 24, 2026

  Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the Minimum Data Set (MDS) assessments were completed to accurately reflect the current status of two of 37 sampled residents. (Residents 7 and 145)Findings include: Clinical record review revealed that Resident 7 had diagnoses that included dementia, post-traumatic stress disorder (PTSD), and parasomnia (a disruptive sleep disorder involving abnormal behaviors such as sleepwalking, talking, or night terrors that occur while falling asleep, during sleep, or upon waking). Review of Resident 7's care plan revealed that the resident had known PTSD and night terrors. […]

• No harm, potential for more than minimal, isolatedF698Apr 24, 2026

  Based on review of facility policy, clinical record review, and staff interview, it was determined the facility failed to provide services consistent with professional standards, including monitoring, for one of two sampled residents receiving dialysis (the process of removing excess toxins and water from the blood). (Resident 150) Findings include:A review of the policy, Hemodialysis Care Policy, last reviewed January 23, 2026, revealed that communication between the dialysis provider and facility staff will occur before and after each hemodialysis treatment and as needed. Facility staff were to assess each resident's condition and communicate any concerns with the dialysis provider using the facility's Dialysis Communication Tool. […]