Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Bay Pointe Nursing Pavilion during CMS and state inspections, most recent first.
Surveyors found that nurses failed to consistently complete and sign Controlled Substance Key Exchange Audit (CSKEA) forms at shift change on multiple halls, with some forms left blank, others signed late, and some pre‑signed for future shifts, resulting in numerous missing signatures and undocumented card counts in the March logs. On one cart, an LPN reported fewer controlled medication cards than were actually present and admitted not adding a newly received card to the log, while on two carts surveyors observed multiple controlled medication bubble packs that were punctured, torn, or taped, even though facility policy and leadership required intact packaging and proper removal of damaged containers.
Surveyors identified that an LPN was storing an opened vial of Ativan 20 mg/10 ml on a medication cart without an open or expiration date and without volume markings, despite the outer bag indicating it should be refrigerated. The LPN relied on a declining inventory sheet to determine the remaining volume, was unsure how long the vial had been in the cart, and did not confirm its required refrigeration. The facility pharmacist later stated the medication was dispensed as a one-time dose that should not still be in use and must be refrigerated, and the DON acknowledged it should have been wasted long ago. Review of the facility’s controlled medication storage policy showed that refrigerated controlled drugs must be kept in a separately locked box in the refrigerator and that outdated or discontinued medications must be promptly removed and securely stored for destruction, which was not followed in this case.
The facility experienced staffing shortages, leading to delayed call light responses and unmet resident needs. Residents reported waiting up to an hour for assistance, particularly during nights and weekends. Staff confirmed the impact of call-outs and insufficient replacements on their ability to complete tasks. Despite call light audits and a QAPI initiative, the facility lacked policies on timely call light response and staffing.
A resident with ESRD missed a dialysis appointment and was late to another due to transportation issues. The facility lacked physician orders for hemodialysis at admission and did not confirm dialysis appointments and transportation. Staff interviews revealed unreliable transportation and no emergency plan. The facility's dialysis management policy was not followed, with incomplete documentation and lack of daily assessment of the shunt site.
Incomplete Controlled Substance Documentation and Compromised Packaging
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate shift‑to‑shift controlled substance logs and to ensure the integrity of controlled medication packaging across multiple medication carts. Surveyors observed that on several halls the Controlled Substance Key Exchange Audit (CSKEA) forms were either blank or missing required signatures from the off‑going and oncoming nurses, despite counts having been performed. On the 400 Hall even cart and 300 Hall cart, the nurse assigned had not signed the CSKEA forms until prompted during the survey. On the 400 Hall odd and 500 Hall carts, another nurse had pre‑signed the CSKEA form for a future shift instead of signing at the end of her own shift. On the 100 Hall odd and 200 Hall carts, the CSKEA forms were not signed at the beginning of the shift, with the nurse stating the count had been interrupted by a resident emergency. Further review of the 100, 300, 500, and 600 Hall controlled substance logs for March 2026 showed numerous missing signatures and missing documentation of total card counts, with missing signature rates ranging from 18.3% to 38.8% and missing card count documentation up to 17.9%. These omissions occurred despite facility policy requiring a controlled medication accountability record and dual nurse verification at each shift change, including signatures from both off‑going and oncoming nurses and documentation of the total number of controlled medication cards. The DON, unit manager, medical director, and consultant pharmacist all confirmed that accurate counts, proper documentation, and adherence to the established system of records are expected and required by facility policy and applicable regulations. In addition to documentation failures, surveyors observed issues with the physical integrity and accounting of controlled medication bubble packs. On the 600 Hall cart, the assigned nurse reported 40 controlled medication cards, but 41 cards were present, and she acknowledged receiving a new controlled medication card the previous day that she had not added to the log. On the 100 Hall even and 600 Hall carts, multiple bubble packs were punctured, torn, or taped, yet the nurse stated she checked for tampering during narcotic counts and did not consider these packs to be tampered with because the pills were still present. This practice conflicted with facility policy and statements from the DON, unit manager, and pharmacist, which specified that medications in containers that are cracked, soiled, without secure closures, or otherwise not intact should be removed from stock and handled according to established procedures for controlled substances.
Improper Storage and Labeling of Controlled Ativan Vial on Medication Cart
Penalty
Summary
The deficiency involves failure to store and label medications in accordance with professional standards and facility policy. During an observation and narcotic count verification of the 600 Hall medication cart with an LPN, surveyors found an opened, undated vial of Ativan 20 mg/10 ml in the controlled medication drawer. The vial was in a clear plastic bag labeled with the resident’s name, an issue date of 9/24/25, medication strength, and instructions to keep it refrigerated, but the vial itself lacked an open date or expiration date and had no markings to verify the remaining volume. The LPN stated she knew there were 9.75 ml remaining based on the controlled drug declining inventory sheet, which showed that 0.25 ml had been administered on 12/19 at 9:00 a.m., but she did not know how long the medication had been stored in the drawer and did not respond when asked if it should be refrigerated. The LPN also stated the medication label should list the expiration date. In a telephone interview, the facility’s pharmacy services pharmacist confirmed the Ativan prescription was filled on 9/24/25, stated she would not expect the vial to still be in use, and clarified it was intended as a one-time dose that must be stored in the refrigerator. In a separate interview, the DON stated the vial should have been wasted a long time ago. Review of the facility’s “Controlled Medication Storage” policy dated 1/26 showed that controlled medications requiring refrigeration must be stored in a separately locked, permanently affixed box within the refrigerator, and that outdated, contaminated, discontinued, or deteriorated medications, or those in compromised containers, must be immediately removed from stock and disposed of according to procedure, with medications awaiting destruction stored securely and logged separately from active orders. The observed handling and storage of the Ativan vial did not comply with these policy requirements.
Staffing Shortages Lead to Delayed Call Light Responses
Penalty
Summary
The facility failed to ensure sufficient staffing to meet the needs of residents, as evidenced by multiple resident interviews and staff statements. Residents reported untimely responses to call lights, with some waiting up to an hour for assistance, particularly during nights and weekends. Resident interviews revealed that staff sometimes discouraged the use of call lights, and residents felt staff were irritated when responding. Additionally, grievances related to call light response times were unresolved, and resident council meetings frequently raised concerns about delayed responses, although these were not documented in the meeting minutes. Staff interviews corroborated the residents' experiences, with CNAs and LPNs acknowledging staffing shortages and the impact on their ability to complete tasks. Staff reported that call-outs and insufficient replacements led to incomplete shower schedules and tasks rolling over to the next shift. The facility's staffing coordinator confirmed that staffing was based on acuity and census, but could not confirm if tasks were left incomplete due to lack of replacement staff. Observations during facility tours showed call lights going unanswered, and staff, including the Director of Nursing and Nursing Home Administrator, stepping in to assist residents when CNAs were unavailable. The facility's administration was aware of the call light response issues, as evidenced by the initiation of call light audits and a Quality Assurance and Performance Improvement (QAPI) initiative. However, the Nursing Home Administrator could not confirm the success of these measures. Despite the presence of a concierge program conducting ongoing audits, the facility lacked policies related to timely call light response and staffing, which were requested but not provided. The deficiency highlights a systemic issue with staffing levels and response times, impacting the quality of care provided to residents.
Failure to Ensure Hemodialysis Care per Physician Orders
Penalty
Summary
The facility failed to ensure Hemodialysis (HD) care was provided per physician orders for a resident with End Stage Renal Disease (ESRD) who required dialysis. The resident missed a dialysis appointment on one occasion and was late on another due to transportation issues. The facility did not have physician orders for hemodialysis at the time of the resident's admission, and there was a lack of documentation confirming the dialysis appointments and transportation arrangements prior to the resident's admission. Interviews with staff revealed that the transportation company was unreliable, and the facility did not have an emergency plan or vehicle to transport residents to dialysis appointments. The Director of Nursing (DON) acknowledged that the hospital typically sets up the first dialysis appointment, but in this case, it was not done. The resident had a shortened chair time for one dialysis session due to scheduling issues, and on another occasion, the resident was transferred to the hospital for dialysis after the transportation company failed to show up. The facility's policy on dialysis management was not followed, as evidenced by incomplete documentation in the dialysis communication books and a lack of daily assessment and documentation of the shunt or access site. The DON admitted that the weekend supervisor did not confirm the dialysis appointments and transportation, and there was no evidence of such confirmation. The facility had a contingency plan involving other transportation companies, but it was not utilized in this case.
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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 Saint Petersburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pinellas Point Nursing And Rehab Center | 0.9 mi | ★★★★★ | 0 | 0 |
| Addington Place At College Harbor | 1.2 mi | ★★★★★ | 0 | 0 |
| Alpine Health And Rehabilitation Center | 1.4 mi | ★★★★★ | 18 | 0 |
| South Heritage Health & Rehabilitation Center | 2.3 mi | ★★★★★ | 9 | 0 |
| Westminster Suncoast | 2.4 mi | ★★★★★ | 5 | 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.