Spurgeon Manor

In the surveyor’s words

From the most serious findings on record at Spurgeon Manor, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Mar 25, 2021

  Based on record review, physician and staff interviews, the facility failed to adequately assess and provide timely interventions and notify the physician of a resident's change in condition for 1 of 12 residents reviewed (Resident #47). Following the condition change, the resident who was a full code, experienced [CONDITION(S)] and the facility failed to perform CPR (cardio pulmonary resuscitation) as required. This situation resulted in immediate jeopardy (IJ) which was removed on [DATE] when the facility provided staff education and reviewed their policy. The facility reported a census of 46 residents. Findings include: 1. A Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #47 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Actual harm, isolatedF689Mar 25, 2021

  Based on record review, resident and staff interview, facility policy review, and manufacturer recommendations, the facility failed to perform proper follow up and investigation to determine the cause of a burn injury after a resident had an e-stim treatment for 1 of 1 residents reviewed who had an e-stim treatment (Resident #24) and failed to remove equipment from operation when found the equipment defective or broken, which resulted in a resident sustaining skin tears to her legs for 1 of 12 sampled residents reviewed (Resident #37). The facility reported a census of 46 residents. Findings include: 1. […]

• No harm, potential for more than minimal, patternF812Sep 25, 2025

  Based on observations, staff interviews and recommendations from the Food Code United States Public Health and Safety 2017, the facility failed to properly thaw/defrost meat and serve food under appropriate sanitary conditions to prevent, reduce or eliminate potential hazards. The facility reported a census of 49 residents.Findings Include:1. On 09/22/2025 at 10:03 AM during the initial kitchen tour, observed roast thawing in water in the sink without continuous running water. At 12:55 PM the roast remained submerged in the water in the sink. When questioning the Certified Dietary Manager (CDM) about the roast that was in the water in the sink, he said that he had forgotten about the roast in the sink. […]

• No harm, potential for more than minimal, isolatedF656Apr 22, 2026

  Based on clinical record review, staff interviews and policy review the facility failed to develop a care plan to address suicidal ideations and interventions for suicidal precautions for 1 of 3 residents (Residents #1) reviewed for comprehensive care plans. The facility reported a census of 50 residents.Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. The MDS identified Resident #1 required partial/moderate assistance with bed mobility and transfers. The MDS included diagnoses of vascular dementia with anxiety disorder and depression. […]

• No harm, potential for more than minimal, isolatedF880Sep 25, 2025

  Based on observation, clinical record review, staff interviews, and policy review the facility failed to maintain infection control practices for 1 of 3 residents reviewed (Resident #6). The facility failed to ensure use of enhanced barrier precautions (EBP) when required. The facility reported a census of 49 residents. Findings include:The Minimum Data Set (MDS) for Resident #6, dated 7/10/25, included diagnoses of Alzheimer's and obstructive uropathy (blockage in the urinary tract). The MDS identified the resident was dependent on staff for toilet hygiene. The MDS indicated the resident had a suprapubic catheter (tube into the lower abdomen to drain urine from the bladder). The MDS indicated the resident had a BIMS score of 7, indicating moderate cognitive impairment. […]