Inspection Report Summary
The most recent inspection on February 27, 2025, found deficiencies related to four nursing aides not obtaining required certification within the mandated timeframe. Earlier inspections showed multiple deficiencies involving resident care, medication security, respiratory equipment storage, and dining services. Prior reports cited issues with maintaining confidentiality, incomplete assessments, and inadequate trauma-informed care plans, as well as unsecured medications and insufficient kitchen staffing. Complaint investigations were not listed in the available reports. The pattern of deficiencies suggests ongoing challenges in staff certification and various aspects of resident care and medication management without a clear trend of improvement or worsening.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
13% better than Florida average
Florida average: 4.6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Deficiencies: 1
Date: Feb 27, 2025
Visit Reason
The inspection was conducted to assess compliance with certification requirements for nursing aides, specifically to ensure that nursing aides who have worked more than four months are appropriately certified.
Findings
The facility failed to ensure that four nursing aides employed for over four months obtained certified nursing assistant certification within the required timeframe. Interviews with facility leadership confirmed the aides were not certified as required by state regulations.
Deficiencies (1)
Failure to ensure appropriate certification for Nursing Aides within four months of hire for four staff members.
Report Facts
Number of nursing aides uncertified beyond 4 months: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Nursing Aide | Not certified within four months of hire |
| Staff B | Nursing Aide | Not certified within four months of hire |
| Staff C | Nursing Aide | Not certified within four months of hire |
| Staff D | Nursing Aide | Not certified within four months of hire |
| Human Resources Director | Provided documentation and confirmed uncertified nursing aides | |
| Director of Nurses | DON | Unaware of uncertified nursing aides |
| Nursing Home Administrator | NHA | Unaware of uncertified nursing aides working beyond allowed period |
Inspection Report
Routine
Deficiencies: 7
Date: Jun 20, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication management, confidentiality, and other facility operations.
Findings
The facility was found deficient in multiple areas including failure to ensure residents received dignified dining experiences, confidentiality breaches of medical records, incomplete PASARR screenings, inadequate monitoring of wound care and positioning devices, improper storage and handling of respiratory equipment, incomplete tracheostomy care orders, failure to identify PTSD triggers and develop trauma-informed care plans, and unsecured medications accessible to residents and unauthorized persons.
Deficiencies (7)
Failure to ensure residents received a dignified dining experience, including assistance with meal setup and timely feeding for dependent residents.
Failure to maintain confidentiality of resident medical records and medication cart computer screens, including leaving PHI visible and unsecured.
Failure to complete required PASARR screenings and assessments for residents with qualifying mental health diagnoses.
Failure to monitor and maintain negative pressure wound therapy and to order and monitor positioning devices for residents.
Failure to ensure respiratory equipment was stored appropriately and tracheostomy care and suctioning were provided according to standards.
Failure to identify resident-specific PTSD triggers and develop individualized trauma-informed care plans to prevent re-traumatization.
Failure to ensure medications were stored securely and inaccessible to unauthorized persons, including unlocked medication carts and unsecured medications at bedside.
Report Facts
Residents observed for assisted dining: 7
Residents with failed PASARR screening: 5
Residents sampled for positioning devices: 2
Residents sampled for respiratory equipment storage: 3
Residents sampled with tracheostomy tube: 1
Residents reviewed with PTSD diagnosis: 2
Residents sampled with unsecured medications: 4
Medication carts observed unlocked: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff R | Registered Nurse (RN) | Interviewed regarding Resident #6's meal assistance and confidentiality practices. |
| Staff S | Registered Nurse (RN) / Licensed Practical Nurse (LPN) | Interviewed regarding meal assistance delays and confidentiality breaches. |
| Staff D | Licensed Practical Nurse (LPN) / Unit Manager | Interviewed regarding meal assistance delays, confidentiality breaches, respiratory equipment storage, and medication security. |
| Staff A | Certified Nursing Assistant (CNA) | Interviewed regarding feeding assistance and restorative nursing responsibilities. |
| Staff J | Licensed Practical Nurse (LPN) | Interviewed regarding Resident #50's splint care and Resident #59's tracheostomy care. |
| Staff P | Licensed Practical Nurse (LPN) | Interviewed regarding respiratory equipment storage and medication security. |
| Staff B | Licensed Practical Nurse (LPN) | Interviewed regarding Resident #32's PTSD and medication security. |
| Staff C | Social Services Director (SSD) | Interviewed regarding Resident #32's PTSD and trauma-informed care. |
| Staff L | Certified Occupational Therapist Assistant (COTA), Director of Rehabilitation (DOR) | Interviewed regarding Resident #47's positioning device and restorative nursing program. |
| Staff M | Registered Nurse (RN) | Interviewed regarding restorative nursing splint application. |
| Staff N | Certified Nursing Assistant (CNA) | Interviewed regarding splint responsibilities for Resident #88. |
| Staff Q | Registered Nurse (RN) / Infection Preventionist | Interviewed regarding respiratory equipment cleaning and storage. |
| Director of Nursing (DON) | Director of Nursing | Interviewed multiple times regarding deficiencies in meal assistance, confidentiality, PASARR, wound care, respiratory care, PTSD care, and medication security. |
| Regional Nurse Consultant (RNC) | Regional Nurse Consultant | Interviewed regarding medication security and PASARR screening. |
| Assistant Director of Nursing (ADON) | Assistant Director of Nursing | Interviewed regarding medication security and respiratory equipment storage. |
Inspection Report
Routine
Census: 33
Deficiencies: 6
Date: Apr 7, 2022
Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulatory requirements related to medication administration, respiratory care, psychotropic medication monitoring, medication storage, food and nutrition services, and resident care.
Findings
The facility was found deficient in multiple areas including failure to properly assess and monitor a resident for self-administration of eye drop medications, improper storage of respiratory equipment for multiple residents, lack of behavior monitoring for a resident on psychotropic medications, unsecured medications and medication carts, inadequate kitchen staffing resulting in delayed meal delivery, and failure to honor resident food preferences.
Deficiencies (6)
Failed to ensure one resident (#62) was properly assessed and monitored for self-administration of eye drop medications.
Did not ensure respiratory equipment was stored appropriately for nine residents receiving respiratory care.
Failed to ensure behavior monitoring was in place for one resident (#59) on psychotropic medications.
Did not ensure medications were inaccessible to unauthorized staff, residents, and visitors for one resident (#70) and one medication cart was left unlocked.
Failed to ensure adequate kitchen staffing to provide timely meals to residents.
Failed to ensure food preferences and meal choices were honored for one resident (#94) who repeatedly received eggs despite disliking them.
Report Facts
Residents affected: 33
Residents affected: 9
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents receiving respiratory care: 15
Residents receiving meal trays: 109
Total residents in building: 114
Meal service delay: 66
Meal service delay: 66
Meal service delay: 71
Meal service delay: 30
Meal service delay: 69
Meal service delay: 35
Meal service delay: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff S | Unit Manager | Interviewed regarding medication administration supervision and respiratory equipment storage |
| Staff X | Licensed Practical Nurse (LPN) | Interviewed regarding medication administration supervision |
| Staff V | Licensed Practical Nurse (LPN) | Interviewed regarding medication administration and medication cart security |
| Staff O | Licensed Practical Nurse (LPN) | Interviewed regarding behavior monitoring for psychotropic medication |
| Staff R | Licensed Practical Nurse (LPN) | Interviewed regarding respiratory equipment storage and medication administration |
| Staff Q | Licensed Practical Nurse (LPN) | Interviewed regarding respiratory equipment storage |
| Staff U | Licensed Practical Nurse (LPN) | Interviewed regarding respiratory equipment storage |
| Staff A | Kitchen Manager | Interviewed regarding kitchen staffing, meal service delays, and food preference tracking |
| Staff E | Dietary Aide | Interviewed regarding kitchen staffing and meal service |
| Staff Y | Dietary Aide | Interviewed regarding kitchen staffing and meal service |
| Staff Z | Dietary Aide | Observed working in kitchen during meal service |
| Staff F | Licensed Practical Nurse (LPN) | Interviewed regarding meal service delays and resident food preferences |
| Staff K | Certified Nursing Assistant (CNA) | Interviewed regarding meal service delays and resident food preferences |
| Staff M | Certified Nursing Assistant (CNA) | Interviewed regarding meal service delays |
| Staff I | Certified Nursing Assistant (CNA) | Interviewed regarding resident food preferences |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding medication administration supervision, respiratory equipment storage, psychotropic medication monitoring, and food preferences |
| Interim Certified Dietary Manager | Dietary Manager | Interviewed regarding food preferences and tray slip updates |
| Regional Dietary Manager | Dietary Manager | Interviewed regarding kitchen staffing and meal service |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Nov 6, 2020
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, medication storage, and facility operations at Manatee Springs Rehabilitation and Nursing Center.
Findings
The facility failed to ensure ordered splinting interventions were implemented for two residents, resulting in minimal harm or potential for harm. Additionally, the facility did not properly secure controlled substances in medication storage, specifically lorazepam was not stored in a locked, permanently affixed compartment as required.
Deficiencies (2)
Failure to provide appropriate care to maintain or improve range of motion by ensuring ordered splinting interventions were in place for two residents.
Failure to ensure controlled substances were stored in locked, separately locked compartments; lorazepam was unsecured in a medication storage room refrigerator.
Report Facts
Residents affected: 2
Residents affected: 1
Medication vials: 2
Medication vials: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Certified Nursing Assistant (CNA) | Interviewed regarding absence of splint on Resident #161 |
| Staff J | Certified Nursing Assistant (CNA) | Interviewed regarding absence of splints on Resident #23 |
| Staff H | Restorative CNA | Interviewed confirming splinting responsibility lies with floor nursing staff |
| Staff I | Licensed Practical Nurse (LPN) | In charge of restorative nursing program; confirmed issues with splint orders and referrals |
| Staff K | Occupational Therapist (OT) | Treating therapist for Resident #23; admitted failure to complete restorative nursing referral |
| Staff L | Registered Nurse (RN) | MDS Coordinator interviewed about splinting process |
| Staff M | Licensed Practical Nurse (LPN) | MDS Coordinator interviewed about splinting process |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding splinting process and medication storage deficiencies |
| Staff A | Registered Nurse (RN), Unit Manager | Observed unsecured controlled substances in medication storage |
| Staff B | Licensed Practical Nurse (LPN) | Interviewed about medication storage practices |
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