Health inspection·April 12, 2024

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to provide treatment and services to restore bladder continence to the extent possible for one of two sampled residents who had urine incontinence. (Resident 92) Findings include: Review of facility policy entitled, Policy Continence Management Program, last reviewed February 16, 2024, revealed that upon admission the nurse was to interview the resident and review any underlying conditions that may affect the resident's ability to participate in a continence management program. Staff was to identify candidates for a bladder incontinence program who required limited to extensive assistance in toilet use and could benefit from a prompted or scheduled toileting plan. A continence evaluation was to be conducted to determine if a 72 hour bowel and bladder tracking was indicated for the resident. If the tracking was indicated, the licensed nurse was to instruct the nursing assistants to fill out the 72 hour bowel and bladder tracking form. Clinical record review revealed that Resident 92 was admitted to the facility on [DATE], and had diagnoses that included anxiety, a history of sepsis, osteoarthritis, and urinary incontinence. The Minimum Data Set assessment dated [DATE], revealed that the resident was alert and oriented, was frequently incontinent of bladder, and required substantial assistance with toileting. The assessment indicated a discharge goal of partial to moderate assistance with toileting and the assessment also indicated that the resident was not on a toileting program. A review of the care plan initiated February 5, 2024, revealed that the resident was incontinent of bladder. At the time of admission, there was no documented evidence that the facility reviewed underlying conditions that may have affected the ability for the resident to participate in a continence management program. In addition, there was no documented evidence that a continence evaluation was completed for 72 hours to track bowel and bladder continence for the resident as per the facility policy until February 19, 2024, 17 days after the resident had been admitted to the facility. On February 21, 2024, a nurse documented that Resident 92 was incontinent of bladder, required assist of one person for transfers and for assistance with toileting. The note further indicated that the resident was alert and oriented and able to make her needs known. A nurse noted on March 4 and 7, 2024, that the resident was incontinent of bladder. Review of bladder documentation from March 10, 2024, through April 9, 2024, revealed that she had been incontinent of urine at least 50 times. In an interview on April 12, 2024, at 11:08 a.m., the Director of Nursing stated that the facility (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 395226 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395226 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spruce Manor Nursing & Rehabilitation Center 220 S. Fourth Avenue West Reading, PA 19611 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)