Manatee Springs Rehabilitation and Nursing Center

In the surveyor’s words

From the most serious findings on record at Manatee Springs Rehabilitation and Nursing Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Feb 4, 2026

  Based 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. […]

• Immediate jeopardy, isolatedF689Feb 4, 2026

  Based 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. […]

• Immediate jeopardy, isolatedF726Feb 4, 2026

  Based 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. […]

• No harm, potential for more than minimal, widespreadF802Apr 8, 2022

  Based 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. Findings included: On 4/5/2022 at 9:20 a.m. the kitchen was toured with Staff A, Kitchen Manager. During the tour, Staff A pointed out he had two dietary aides, Staff E and Staff Y, in the kitchen as well as himself, a total of three dietary staff members. He confirmed there were one hundred and fourteen residents in the building as of 4/5/2022. […]

• No harm, potential for more than minimal, patternF728Feb 27, 2025

  Based 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. Findings included: On 02/27/2025 at 9: 00 a.m., the Human Resources Director brought documentation of the nursing aides hired by the facility to the conference room. Review of the documentation revealed four nursing aides had been working for the facility over four months without obtaining certified nursing assistant certification: Staff A, Nursing Aide was hired on 6/18/2024. Staff B, Nursing Aide was hired on 9/24/2024. Staff C, Nursing Aide was hired on 9/24/2024. Staff D, Nursing Aide was hired on 10/22/2024. During an interview on 2/27/2025 at 1:40 p.m. […]