Manatee Springs Rehabilitation and Nursing Center

Inspectors wroteBased on observations, interviews, and record review, the facility failed to protect the resident's right to be free from neglect by failing to respond to an exit door alarm and provide supervision to prevent an elopement for one resident (#2) out of residents sampled. On 1/15/26 at approximately 2:30 a.m., Resident #2 exited the facility, unwitnessed by staff, through a second-floor stairwell door with an audible alarm sounding. The resident walked down two flights of stairs and exited to the back of the facility through a second alarmed door sounding. Resident #2 walked approximately 170 yards through a parking lot, across a four-lane road with a 40 mile per hour (mph) speed limit, and into a neighborhood where he was found by local police. Resident #2 sustained a left forehead laceration and left elbow skin tear as a result of a fall. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to respond to two exit door alarms and provide adequate supervision to prevent one resident (#2), who was severely cognitively impaired and identified as a fall and elopement risk, from exiting the facility out of four residents sampled for risk of elopement. On 1/15/26 at approximately 2:30 a.m., Resident #2 exited the facility, unwitnessed by staff, through a second-floor stairwell door with an audible alarm sounding. The resident walked down two flights of stairs and exited to the back of the facility through a second alarmed door sounding. Resident #2 walked approximately 170 yards through a parking lot, across a four-lane road with a 40 mile per hour (mph) speed limit, and into a neighborhood where he was found by local police. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure nursing staff were knowledgeable and competent to provide care and services to prevent an elopement for one resident (#2) out of four sampled residents when they failed to respond to exit door alarms. On 1/15/26 at approximately 2:30 a.m., Resident #2 exited the facility, unwitnessed by staff, through a second-floor stairwell door with an audible alarm sounding. The resident walked down two flights of stairs and exited to the back of the facility through a second alarmed door sounding. Resident #2 walked approximately 170 yards through a parking lot, across a four-lane road with a 40 mile per hour (mph) speed limit, and into a neighborhood where he was found by local police. Resident #2 sustained a left forehead laceration and left elbow skin tear as a result of a fall. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure appropriate certification for Nursing Aides within four months of the dates of hire for four (Staff members A, B, C, and D) of four staff members reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to thoroughly and accurately identify resident specific triggers related to Post Traumatic Stress Disorder (PTSD) and develop a resident specific plan of care to prevent re traumatization for two Residents (#32 and #56) out of two residents reviewed with diagnoses of PTSD.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure medications were inaccessible to unauthorized staff, residents, and visitors for four (#24, #111, #58 and #34) of 58 residents sampled, and in one of five medication carts left unlocked on one (1st) of two floors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three (#6, #25, and #33 ) of seven residents observed for assisted dining in hall 100 received a dignified dining experience during two of four days of survey.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure confidentiality of records was maintained for one resident (#58) of 59 residents on Hall 100, and failed to ensure two of five medication cart computer screens on Hall 100 were locked.

Inspectors wroteBased on record review and interview, the facility failed to complete the Preadmission Screening and Resident Reviews (PASARRs) for residents with a mental disorder and individuals with intellectual disability following qualifying mental health diagnosis for five (#43, #18,#24, #31 and #56) of nine residents reviewed for PASARRs .

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure negative wound pressure was monitored and maintained for one (#94) of one sampled resident, and failed to ensure an upper extremity elevation support wedge was ordered and monitored after application for one (#47) of two residents sampled for positioning devices. Findings Included: 1. On 6/17/24 at 2:01 p.m., during an interview and observation, Resident #94 was laying in bed. His negative pressure wound machine tubing was hanging on the floor. The machine was not functioning. On 6/18/24 at 10:07 a.m., Resident #94 was observed without the negative pressure wound machine connected. Resident #94 said the negative pressure wound machine causes pain and always comes off the day after replacement. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure splints were applied to prevent the decrease of range of motion for two (#50 and #88) of eight sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure respiratory equipment was stored appropriately on one (1st) of 2 floors, for three (#51, #24 and #6) of nine residents observed. The facility also failed to ensure tracheostomy care and suctioning was provided according to standards of practice for one (#59) of one resident sampled with a tracheostomy tube.

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure adequate staffing in the kitchen in order to provide residents with timely meals, during three of four meal services observed on 4/6/2022 and 4/7/2022. It was determined one hundred and nine residents out of one hundred and fourteen residents in the building receive meal trays and meal service.

Inspectors wroteBased on observations, interviews and record review, the facility did not ensure respiratory equipment was stored appropriately during three days of four days surveyed, for one floor (second floor) of two floors in the facility, and for nine residents (#56, #28, #52, #51, #102, #213, #313, #314 and #315) of 15 residents receiving respiratory care.

Inspectors wroteBased on observations, interviews and record review the facility failed to ensure one resident (#62) out of thirty-three residents was properly assessed and monitored for self-administration of eye drop medications.

Inspectors wroteBased on interview and record reviews, the facility failed to ensure behavior monitoring was in place for one resident (#59) out of five residents sampled for unnecessary medications.

Inspectors wroteBased on observations, interviews and record review, the facility did not ensure medications were inaccessible to unauthorized staff, residents, and visitors for one resident (#70) out of thirty-three residents, and for one (second floor medication cart) of two medications carts observed.

Inspectors wroteThe facility failed to ensure food preferences and meal choices were honored for one resident (#94) out of two residents investigated for choices, during two meals observed on 4/5/2022 and 4/7/2022. It was determined Resident #94 had expressed his food preferences related to not receiving eggs during the breakfast meal to multiple staff members and he continued to receive eggs on a routine basis.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that ordered splinting interventions for preserving range of motion and mobility were in place for two (Resident #161, Resident #23) out of four residents sampled for range of motion.

Inspectors wroteBased on observations, interviews, and record review the facility did not ensure that a controlled substance was locked and stored in a permanently affixed compartment and separate from other medications in one (Hibiscus) of two medication storage rooms.