Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Spruce Manor Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found multiple environmental and equipment issues across all nursing units, including rusty Hoyer lifts in several shower rooms, a dirty exterior ice machine, and a handrail with a missing edge piece exposing a nail. Resident rooms had stained privacy curtains, peeling paint, exposed wallboard, brown-stained ceiling tiles, and missing top covers on air conditioning units. One room had non-adjustable blinds that left part of the window open, making the toilet visible from the street, along with worn toilet caulking. Additional findings included a broken window screen on the floor, duct tape over a floor drain near a bathtub, and a dirty slipper left in a shower area, demonstrating a failure to maintain a safe, clean, and comfortable environment.
A resident with anxiety and dementia had a PRN lorazepam order written without a specified stop date, allowing administration every two hours as needed for anxiety. Staff administered the medication multiple times over two months, and there was no documented evidence that a physician re-evaluated the PRN psychotropic order after 14 days. The DON confirmed that the order lacked an end date, resulting in a failure to prevent potential chemical restraint related to psychotropic medication use.
The facility failed to complete accurate MDS assessments for two residents. One resident with documented PTSD and night terrors in the care plan was incorrectly coded on the MDS as not having PTSD in the active diagnoses section. Another resident with depression, schizophrenia, and obsessive-compulsive disorder had a standing order for the antidepressant fluvoxamine and received it during the MDS review period per the MAR, yet the MDS medication section was coded to show no antidepressant use. These inaccuracies were confirmed by the Administrator and the DON.
A resident with diabetes mellitus and end-stage kidney disease receiving ongoing hemodialysis did not receive care consistent with the facility’s hemodialysis policy and physician orders. The policy required staff to assess and document pre- and post-dialysis information, including vital signs, pre- and post-treatment weights, medications, meals, fluids, lab work, and any alerts, and to communicate this information with the dialysis provider before and after each treatment. Record review showed repeated failures to obtain and document this required information, including ordered pre- and post-dialysis weights, over multiple months. The Administrator confirmed that required communication and documentation between the facility and the dialysis provider did not occur as required.
A resident with senile degeneration of the brain and a stage 4 sacral pressure ulcer required daily wound treatment under an order and care plan that called for enhanced barrier precautions. During an observed dressing change, an LPN removed and reapplied gloves multiple times without performing hand hygiene and repeatedly took clean gloves from a uniform pocket. The LPN also failed to wear a gown during this high-contact wound care, contrary to facility policies requiring EBP and appropriate PPE use. The DON confirmed that proper PPE and hand hygiene were not used during the procedure.
The facility failed to develop or implement comprehensive care plans for two residents with specific needs identified in their assessments. A resident with depression, dementia, anxiety, and hallucinations did not have interventions for psychotropic medication included in their care plan. Another resident with dementia, depression, and partial blindness lacked interventions for psychotropic medication and vision in their care plan. The DON confirmed the absence of documented evidence addressing these care areas.
The facility failed to provide appropriate continence management for a resident with urinary incontinence. The facility did not review underlying conditions or complete a continence evaluation and 72-hour tracking form upon admission, as required by policy. The resident, who was alert and required substantial assistance with toileting, was frequently incontinent and not placed on a toileting program.
The facility failed to develop and implement an individualized plan for a resident with PTSD, despite a psychiatric consultation noting a history of trauma. The DON confirmed the absence of an assessment or care plan addressing the resident's PTSD symptoms or triggers.
Environmental and Equipment Cleanliness and Safety Deficiencies Across All Units
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment across all four nursing units. Surveyor observations over two days identified multiple pieces of resident care equipment, including several Hoyer lifts in different shower rooms, with rust along the length of their legs and above the front wheels. In the East 2 shower room, duct tape was found covering a floor drain next to the bathtub, and a dirty pink slipper was left on the floor in the third shower section. The ice machine in the second-floor dining room was dirty on the outside. A handrail next to one resident room had a missing edge piece that exposed a nail. Several air conditioning units in resident rooms were missing their top covers. Additional observations showed environmental disrepair and cleanliness issues in multiple resident rooms and bathrooms. Ceiling tiles above a bed had brown spots, and several privacy curtains had brown or dark brown stains. There was peeling paint and exposed wallboard in various locations, including behind a bed, in a bathroom, and behind a dresser, as well as scrapes on walls with peeling wallboard. One room had blinds that were not adjustable, leaving an approximately three-inch open window space that made the toilet visible from the street, and the toilet in that room had worn caulking. A broken window screen was found on the floor under a window in another room. These conditions were identified on West 1, East 1, [NAME] 2, and East 2 units and formed the basis for the cited deficiency under 28 Pa. Code 201.14(a) and 201.18(b)(1)(e)(2.1).
Lack of Timely Re-Evaluation and Stop Date for PRN Lorazepam Order
Penalty
Summary
The facility failed to ensure a resident was free from potential chemical restraint related to the use of a psychotropic medication. Clinical record review showed that a resident with anxiety and dementia had a physician order dated March 17, 2026, for lorazepam, an anti-anxiety medication, to be administered every two hours as needed for anxiety, without any stop date specified in the order. Review of the Medication Administration Record indicated that staff administered lorazepam once in March 2026 and five times in April 2026 under this PRN order. There was no documented evidence that the physician re-evaluated the continued use of this PRN anti-anxiety medication beyond 14 days. In an interview on April 24, 2026, at 11:00 a.m., the Director of Nursing confirmed that the order did not include a date indicating when staff were to stop administering the PRN lorazepam. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Inaccurate MDS Coding for Diagnoses and Antidepressant Use
Penalty
Summary
The facility failed to ensure that MDS assessments accurately reflected the current clinical status of two residents. For one resident with diagnoses including dementia, post-traumatic stress disorder (PTSD), and parasomnia, the care plan documented known PTSD and night terrors, yet the MDS assessment for the specified review period indicated in Section I (Active Diagnoses) that the resident did not have a diagnosis of PTSD. The Administrator confirmed this MDS assessment was inaccurate. For another resident with diagnoses including depression, schizophrenia, and obsessive-compulsive disorder, physician orders showed the resident had been receiving the antidepressant fluvoxamine since May 2025, and the February 2026 MAR documented administration of fluvoxamine during the MDS review period. However, the MDS assessment for that review period indicated in Section N (Medications) that the resident did not receive an antidepressant, and the DON confirmed this MDS assessment was inaccurate.
Failure to Monitor and Communicate Dialysis Treatment Information
Penalty
Summary
The facility failed to provide dialysis services consistent with its own policy, physician orders, and professional standards for one resident receiving hemodialysis. The facility’s Hemodialysis Care Policy required communication between the dialysis provider and facility staff before and after each treatment, including assessment and documentation of vital signs, pre-treatment weight, medications given before treatment, time of last meal, fluid intake, and any alerts. After treatment, staff were to obtain and document post-treatment weight, lab draws and results, medications administered during or after dialysis, food or fluids consumed at dialysis, and any new orders or alerts. A physician’s order also directed staff to record the resident’s pre- and post-dialysis weights. Resident 150 had diabetes mellitus with chronic end-stage kidney disease, no cognitive impairment per the MDS, and a care plan requiring ongoing hemodialysis with monitoring and communication with the dialysis provider to avoid complications. Clinical record review showed no evidence that the facility obtained or documented the required pre- and post-dialysis information, including ordered pre- and post-dialysis weights, on multiple occasions: eight times in one month, on any date in the following two months, and nine times in a subsequent month. In an interview, the Administrator confirmed that the facility failed to document the required communication between the facility and the dialysis provider, resulting in noncompliance with resident care and nursing services regulations.
Failure to Implement Enhanced Barrier Precautions and Hand Hygiene During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control policies, specifically enhanced barrier precautions (EBP), appropriate use of personal protective equipment (PPE), and hand hygiene during wound care for one resident. Facility policy required EBP, including the use of gowns and gloves, for high-risk residents with wounds or indwelling devices during high-contact care activities such as wound care, dressing, bathing, transferring, hygiene, toileting, device care, and changing briefs and linens. The Clean Dressing Change Policy required use of clean technique, avoidance of direct contamination of materials and supplies, and performance of hand hygiene each time gloves were removed and new gloves applied. Clinical records showed that Resident 14 had senile degeneration of the brain and a stage 4 pressure ulcer on the sacrum, with care plan directives that EBP be implemented while the wound was present. A physician’s order directed daily application of medicated treatment and foam dressing to the pressure ulcer. During an observed dressing change for Resident 14’s sacral pressure ulcer, an LPN removed soiled gloves and applied clean gloves three times without performing hand hygiene at any point. The LPN obtained the clean gloves from her uniform pocket each time rather than from a clean supply source, and she did not wear a gown during the procedure, despite facility policy requiring EBP and PPE use for this type of high-contact wound care. After the dressing change, the LPN acknowledged that she had performed the dressing change without wearing a gown. The DON later confirmed that staff did not use appropriate PPE and that hand hygiene should have been performed prior to donning new gloves during the dressing change, indicating noncompliance with the facility’s infection prevention and control policies and state regulatory requirements.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop or implement comprehensive care plans for two residents, as identified in their comprehensive assessments. Resident 36, who has diagnoses including depression, dementia, anxiety, and hallucinations, had a Minimum Data Set (MDS) Care Area Assessment (CAA) summary indicating that psychotropic medication should be addressed in the care plan. However, there was no evidence that interventions for the psychotropic medication were included in the current care plan. Similarly, Resident 82, who has dementia, depression, and partial blindness, had an MDS CAA summary noting that psychotropic medication and vision should be addressed in the care plan, but there was no evidence of interventions for these areas in the current care plan. The Director of Nursing confirmed in an interview that there was no documented evidence that these care areas were addressed or implemented in accordance with the care plans, leading to the deficiency.
Failure to Provide Continence Management for Resident
Penalty
Summary
The facility failed to provide treatment and services to restore bladder continence for a resident with urinary incontinence. Upon admission, the facility did not review underlying conditions that could affect the resident's ability to participate in a continence management program. Additionally, the facility did not complete a continence evaluation or a 72-hour bowel and bladder tracking form until 17 days after the resident's admission, contrary to the facility's policy. The resident, who was alert, oriented, and able to make her needs known, was frequently incontinent of bladder and required substantial assistance with toileting. Despite this, the resident was not placed on a toileting program as indicated by the Minimum Data Set assessment. The care plan initiated on February 5, 2024, also noted the resident's bladder incontinence but did not include a continence management plan. The Director of Nursing confirmed that the continence evaluation and 72-hour tracking form were not initiated upon admission as required by the facility's policy. Furthermore, once the tracking form was initiated, there was incomplete documentation during the 72-hour period regarding the resident's continence status on certain shifts. The resident was documented as being incontinent of urine at least 50 times between March 10, 2024, and April 9, 2024. This lack of adherence to the facility's continence management policy resulted in a failure to provide appropriate care for the resident's urinary incontinence.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to develop and implement an individualized person-centered plan to provide trauma-informed care for a resident diagnosed with post-traumatic stress disorder (PTSD). Clinical record review revealed that the resident had diagnoses including PTSD, anxiety, and major depressive disorder. A psychiatric consultation noted a history of trauma related to emotional abuse. However, there was no assessment or care plan in the resident's clinical record addressing the PTSD diagnosis, symptoms, or triggers, nor were there resident-specific interventions to minimize triggers and/or re-traumatization. The Director of Nursing confirmed the absence of such an assessment or care plan.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near West Reading
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| West Reading Skilled Nursing And Rehabilitation Ce | 0.3 mi | ★★★★★ | 6 | 0 |
| Wyomissing Health And Rehabilitation Center | 0.7 mi | ★★★★★ | 17 | 0 |
| Highlands At Wyomissing | 1.8 mi | ★★★★★ | 0 | 0 |
| Mifflin Center | 2.4 mi | ★★★★★ | 7 | 0 |
| Transitional Sub-acute Unit | 2.6 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.