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 Bayshore Pointe Nursing And Rehab Center during CMS and state inspections, most recent first.
Two residents in a shared room were subjected to continuous video surveillance installed by one resident’s family without documented consent from the cognitively intact roommate and without any care plan addressing camera use or privacy protections, despite a facility policy requiring roommate authorization before camera installation. Staff and leadership acknowledged the camera had been in place for months, that the family monitored the resident remotely, and that they could not confirm the camera’s field of view or whether the roommate was being recorded or overheard. In a separate incident, a dependent, incontinent resident repeatedly requested toileting assistance, called the Receptionist twice, and ultimately soiled herself after waiting an extended period while CNAs and RNs were aware of her request but did not provide timely assistance, contrary to the resident’s care plan and the facility’s dignity policy.
The facility failed to update PASRR assessments for several residents, omitting key diagnoses such as dementia, anxiety, and depression. This led to incomplete documentation and a lack of necessary Level II evaluations. Interviews revealed ongoing audits and education efforts, but systemic issues persisted in maintaining accurate assessments.
A resident developed a facility-acquired pressure ulcer on the left heel, which was not identified or managed in a timely manner. The resident had a history of pressure ulcers and was admitted with an ulcer on the left buttock. Staff acknowledged lapses in care, including delayed skin checks and failure to arrange a vascular consult. The resident's wound culture returned positive, indicating an infection, but there were significant delays in addressing the wound and arranging necessary consultations.
The facility failed to administer enteral nutrition as ordered for three residents with gastrostomy tubes. A resident was observed without nutrition being administered, with staff acknowledging the oversight. Another resident experienced delays in enteral feeding, and a third resident had discrepancies between hospital recommendations and facility orders, leading to inadequate nutrition.
The facility failed to properly manage enteral nutrition and medication administration for two residents. One resident was observed without prescribed nutrition and orthotic devices, with inconsistent documentation of nutrition administration. Another resident's enteral feeding orders did not align with hospital recommendations, and there was a lack of documentation. Additionally, a medication was documented as given but was not administered, highlighting issues in documentation and communication.
The facility failed to ensure proper food storage, handling, and cleanliness in its kitchen. Observations revealed condensation droplets falling onto clean items, improperly labeled food, and improper glove use by dietary aides. The CDM confirmed these issues, and the Director of Maintenance noted that the air conditioning unit might be causing the condensation.
The facility failed to maintain effective infection control, with staff not using PPE for residents on contact precautions, and not offering hand hygiene before meals. A resident awaiting C. diff results was not placed in appropriate isolation, and an LPN handled medication without gloves.
A facility failed to ensure a resident with limited ROM wore physician-ordered hand splints consistently. Observations showed the resident without splints, which were found in a personal belongings bag. Staff interviews revealed confusion over responsibility for applying the splints, and documentation was lacking in the MAR/TAR and CNA tasks. The resident, with severe cognitive impairment and multiple diagnoses, was on a Splint/Brace Nursing Restorative Program, but the facility had no policy for splints/braces or a restorative program.
A facility failed to document post-dialysis assessments for a resident with chronic kidney disease and cardiomyopathy. Despite the care plan requiring monitoring of the dialysis access site and vital signs, the necessary documentation was missing from the resident's electronic chart for several months. The Director of Nursing confirmed the lack of documentation, highlighting a deficiency in following the facility's protocols.
The facility failed to securely store medications, resulting in loose tablets found on the floor and unsecured medications at a resident's bedside. An LPN identified the tablets as medications that should have been crushed, and the DON confirmed that medications should not be left unsecured. Facility policies require secure storage and physician orders for self-administration, which were not followed.
A resident with severe cognitive impairment and multiple diagnoses, including a UTI, had a positive lab result for Escherichia Coli and Enterococcus Faecalis that was not promptly communicated to the physician. Observations showed improper catheter positioning, and staff interviews revealed a lack of timely notification of lab results. The resident was started on Keflex, which would not cover the detected organisms, and the facility lacked policies for lab collection and reporting.
A resident with missing teeth and difficulty eating did not receive necessary dental services despite requests. The resident, undergoing chemotherapy, was at risk for oral health issues. Interviews revealed a lack of documentation and follow-up on dental care, contrary to facility policy.
The facility failed to maintain sanitary conditions in two resident rooms, with observations of stains, debris, and insects. Communication barriers and lack of awareness among staff contributed to the ongoing issues, despite a policy requiring daily cleaning. The Nursing Home Administrator cited resident non-compliance and recent repairs as factors, but the unsanitary conditions persisted over multiple days.
Failure to Protect Resident Privacy With In-Room Video and Delay in Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to protect residents’ dignity and privacy related to unauthorized video recording in a shared room and failure to provide timely incontinence care. During a tour, surveyors observed a notice on a resident room door stating the area was under 24-hour video surveillance. A private caregiver reported that the family of one resident had installed a camera to monitor that resident’s care 24 hours a day, with the camera positioned toward that resident’s bed and not intended for the roommate. Record review showed that the cognitively intact roommate had no signed consent to be in a room under continuous video surveillance, and neither resident had a care plan addressing the camera’s operation or measures to protect privacy. The roommate later stated she did not know if the camera was recording her, expressed concern about being seen when walking to the bathroom, and confirmed no one had discussed the surveillance with her or obtained her consent. Interviews with staff and administration confirmed that the camera had been in place for a couple of months, that the family monitored the resident from home, and that facility staff did not know how many family members had access to the surveillance or the camera’s field of view. The weekend RN supervisor stated she did not know how wide the camera view was and believed it recorded visual only, with no audio, but could not confirm whether the other resident’s care was captured. The Nursing Home Administrator acknowledged that the roommate’s consent had been missed, that previous roommates had signed consents, and that there was no documentation of consent for the current roommate. The Administrator also stated she could not guarantee that the roommate was not recorded and could not confirm whether the family ever activated audio, despite an agreement that the camera would be video-only. Review of the facility’s policy on video monitoring showed that roommate consent is required before installation of a camera in a shared room, and that if consent is refused, the facility should attempt to accommodate the resident requesting the camera by room changes, subject to availability. The deficiency also includes failure to provide timely toileting and incontinence care to another resident who was dependent on staff for toileting and hygiene. This resident, with a diagnosis of metabolic encephalopathy and care plans indicating incontinence of bowel and bladder and dependence for toilet use, was heard calling out for help and was observed emotionally agitated and angry. She reported that she had been waiting to be toileted, that two staff members had responded and told her to wait, and that she had been waiting for about two hours, particularly noting that on weekends call lights were not answered and she had resorted to calling the Receptionist twice. A nurse confirmed the resident had requested to use the bathroom about 30 minutes earlier and that she had informed a CNA, assuming care had been provided. A CNA later acknowledged that the resident had requested toileting 30–45 minutes earlier, that she was busy with other residents, and that another CNA was also busy. When a CNA finally responded after surveyor intervention, the resident was heard crying out that she had waited too long and was now soiled, which she stated she did not want. The CNA apologized and stated she had 25 patients and had been caring for others. Another RN on the hallway stated that CNAs were expected to respond right away, that he would normally help if notified, and that the resident should not have waited that long to be toileted; he reported he had not been informed of the need. The weekend RN supervisor reported hearing from the Receptionist that the resident had called downstairs twice for help with toileting and had been waiting about 20 minutes, and stated that CNAs and nurses should have responded and that it was not acceptable for the resident to wait and end up soiling herself. The Receptionist confirmed receiving two calls from the resident seeking toileting assistance, paging the nurse each time, and then receiving another call close to an hour later indicating no one had come. The facility’s dignity and personal privacy policy states that care is to be provided in a manner that respects and enhances each resident’s dignity and includes assisting residents with grooming and personal care, which was not followed in this instance.
Deficiencies in PASRR Documentation for Residents
Penalty
Summary
The facility failed to ensure that Preadmission Screening and Resident Review (PASRR) assessments were updated to include current diagnoses for eight residents. This deficiency was identified through observations, interviews, and record reviews. For instance, Resident #28, who was admitted with Alzheimer's disease and other mental health conditions, had a Level I PASRR that incorrectly indicated no need for a Level II evaluation despite having a primary diagnosis of dementia. Similarly, Resident #1's PASRR did not reflect the primary diagnosis of dementia, which necessitated a Level II evaluation. The report also highlights that Resident #46's PASRR did not include a diagnosis of Pseudobulbar Affect, a mental disorder, despite being identified in the resident's Quarterly Minimum Data Set (MDS). Resident #33's PASRR omitted the diagnosis of anxiety, and Resident #57's PASRR failed to recognize the need for a Level II evaluation despite the presence of non-Alzheimer's dementia, anxiety, and depression. These omissions indicate a pattern of incomplete or outdated PASRR documentation. Further deficiencies were noted with Resident #47, whose PASRR lacked documentation of depression, and Resident #40, whose PASRR did not reflect a diagnosis of adjustment disorder with mixed anxiety and depressed mood. Resident #506's PASRR failed to include bipolar disorder, despite active physician orders for psychotropic medications. Interviews with the Director of Nursing and the Regional RN revealed ongoing audits and education efforts, but the PASRRs remained incomplete, indicating a systemic issue in updating and maintaining accurate resident assessments.
Failure to Timely Identify and Manage Pressure Ulcer
Penalty
Summary
The facility failed to ensure timely identification and management of a facility-acquired pressure ulcer for Resident #67. The resident was observed with a dressing on his left foot, and it was noted that the wound had a foul smell, indicating a possible infection. Despite an order for a wound culture, the results were pending, and there was a delay in addressing the wound's condition. The resident had a history of pressure ulcers and was admitted with a pressure ulcer on the left buttock. However, a new pressure ulcer developed on the left heel, which was not promptly identified or managed. The facility's staff, including the RN/Unit Manager and the Director of Nursing, acknowledged lapses in the resident's care. The RN/Unit Manager noted that the resident's skin checks were not conducted weekly as required, with the last documented check being vague and not comprehensive. Additionally, the resident's refusal to get out of bed was not adequately addressed, contributing to the development of the heel ulcer. The wound therapy physician had recommended a vascular surgery referral, but this was not arranged in a timely manner due to procedural delays and miscommunication regarding the appropriate consult. The Director of Nursing confirmed that the time frame between skin checks exceeded the required seven days and acknowledged the oversight in arranging the vascular consult. The facility did not provide a policy or procedure for skin checks or assessments, which may have contributed to the deficiency. The resident's wound culture eventually returned positive, necessitating antibiotic treatment, but the delay in addressing the wound and arranging necessary consultations highlighted significant gaps in the facility's wound care management.
Failure to Administer Enteral Nutrition as Ordered
Penalty
Summary
The facility failed to provide enteral nutrition per physician orders for three residents with gastrostomy tubes. Resident #52 was observed multiple times without enteral nutrition being administered as ordered. The MAR lacked documentation of whether the nutrition was stopped or started at the correct times. Staff interviews revealed inconsistencies in the administration of the enteral feed, with reports of the nutrition being disconnected and reconnected without proper documentation or adherence to the physician's orders. The resident's care plan indicated a need for a feeding tube due to dysphagia and severe protein malnutrition, yet the enteral feeding regimen was not meeting the resident's nutritional needs. Resident #101 was observed without enteral feedings being administered as per the physician's orders. The resident's enteral feeding was delayed, and staff acknowledged the delay but did not take immediate corrective action. The resident's care plan included specific orders for enteral feeding, which were not followed, leading to a lack of nutrition being provided at the scheduled times. Resident #14 was found with feces on his face, arms, and bed linens, and without enteral nutrition being administered as ordered. The resident's care plan included a PEG tube for dysphagia, but there was a discrepancy between the hospital's recommended enteral feeding regimen and the facility's orders. Staff interviews revealed a lack of communication and documentation regarding the enteral feeding orders, leading to the resident not receiving the appropriate nutrition as prescribed.
Deficiencies in Enteral Nutrition and Medication Administration
Penalty
Summary
The facility failed to ensure proper administration of enteral nutrition and application of orthotic devices for two residents, leading to deficiencies in their care. Resident #52 was observed multiple times without the prescribed enteral nutrition running and without wearing the required left hand grip splint. The Medication Administration Record (MAR) showed inconsistencies in the documentation of enteral nutrition administration, with no clear record of when the nutrition was started or stopped. Additionally, the resident's head of bed was not elevated as required during feeding, and there was a lack of documentation regarding the application of the splint. Resident #14 was found with feces on his face, arms, and bed linens, and initially, there was no enteral nutrition formula hanging. The resident's care plan and progress notes did not align with the hospital's recommendations for enteral feeding, and there was no documentation of the recommended rate for the enteral feed. Staff interviews revealed a lack of communication and documentation regarding changes to the resident's enteral feeding orders upon return from the hospital. Furthermore, during a medication administration observation for Resident #52, it was noted that Amlodipine 5 mg was documented as given but was not witnessed during the administration. The LPN involved later admitted to not administering the medication and stated that it was charted under her name by mistake. This incident highlights a lack of proper documentation and communication among staff, contributing to the deficiencies in resident care.
Deficiencies in Food Storage and Handling Practices
Penalty
Summary
The facility failed to ensure proper food storage, handling, and cleanliness in its kitchen, leading to several deficiencies. During a kitchen tour, it was observed that a vent had condensation droplets falling onto clean kitchen items, which the Certified Dietary Manager (CDM) confirmed were clean. Additionally, a jar of pickles in one refrigerator was found without an expiration date, and other beverages were improperly labeled or not labeled at all. The CDM acknowledged that these items should have been labeled and dated according to the facility's policy. Further observations revealed improper glove use by dietary aides. One aide wore the same gloves while touching various surfaces, including her face and personal items, before preparing resident lunch trays. Another aide used his cellphone and then handled utensils and trays without performing hand hygiene. The CDM confirmed that cellphones should not be used in the kitchen and that disciplinary action would be taken if staff were caught using them. The Director of Maintenance mentioned that the air conditioning unit, which was two years old, might be causing the condensation due to temperature differences, and an air conditioning company was scheduled to address the issue.
Infection Control Deficiencies in PPE Use and Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by several observations and interviews. Staff were observed not donning personal protective equipment (PPE) before entering the rooms of residents with contact precaution signage. Specifically, a Social Services Assistant entered a resident's room, who was on contact precautions due to a history of VRE/ESBL, without wearing the required PPE. This was despite the clear signage indicating the need for gloves and a gown prior to entry. The Social Services Assistant confirmed the oversight during an interview. Additionally, the facility did not offer hand hygiene to residents prior to lunch service on two separate days in the main dining areas on the second and third floors. Observations showed that residents were served meals without being offered the opportunity to clean their hands, which is a basic infection control practice. This lapse was noted during multiple meal services, indicating a systemic issue in the facility's infection control practices. The facility also failed to ensure appropriate contact isolation for a resident awaiting Clostridium difficile (C. diff) test results. Although the resident had an order for C. diff testing due to loose stools, the necessary contact isolation precautions were not implemented while awaiting the test results. The Director of Infection and Control acknowledged that the resident had some loose stools documented, which should have warranted proper signage for contact isolation until the results were reported. Furthermore, during medication administration, a Licensed Practical Nurse was observed using ungloved fingers to handle medication, further highlighting lapses in infection control practices.
Failure to Apply Physician-Ordered Orthotic Devices
Penalty
Summary
The facility failed to provide appropriate assistance for a resident with limited range of motion (ROM) concerning the application of physician-ordered orthotic devices. Observations revealed that the resident was not wearing the prescribed hand splints on multiple occasions, and the splints were found in a personal belongings bag on the bedside dresser. Interviews with staff, including a Licensed Practical Nurse (LPN), a Certified Nursing Assistant (CNA), and a Restorative Nursing Assistant (RNA), indicated a lack of clarity and responsibility regarding who was supposed to apply the splints. The Director of Rehab confirmed that the resident had a left grip splint, which was supposed to be worn at all times as tolerated, but there was no documentation in the Medication and Treatment Administration Records (MAR/TAR) or CNA tasks to confirm the application of the splint. The resident, who was admitted with severe cognitive impairment and multiple diagnoses including hemiplegia and hemiparesis, was supposed to be on a Splint/Brace Nursing Restorative Program. The care plan required the resident to wear a left hand grip splint at all times as tolerated, with removal for skin checks and hygiene. However, there was no physician order for the observed right hand splint, and the facility lacked a policy for splints/braces or a restorative program. The Director of Nursing (DON) stated that both restorative staff and CNAs were responsible for applying the splints, but the tasks were not clearly documented in the Plan of Care (POC).
Failure to Document Post-Dialysis Assessments
Penalty
Summary
The facility failed to ensure a post-dialysis assessment was completed for a resident who required such services. On a specific date, a certified nursing assistant (CNA) reported that a resident had returned from dialysis and post-vital signs were taken, but the necessary post-dialysis assessment was not documented in the resident's electronic chart. The Registered Nurse/Unit Manager (RN/UM) confirmed that post-dialysis assessments, including vital signs and dialysis access assessments, are supposed to be documented in the electronic chart. However, a review of the resident's medical record revealed that post-dialysis assessments were not consistently documented from July through early September, except for one entry in March. The resident involved had a history of cardiomyopathy, chronic kidney disease stage IV, and was dependent on renal dialysis. The resident's care plan included specific interventions to observe the dialysis access site and monitor for signs of complications. Despite these requirements, the facility's policy on dialysis was found to be lacking in guidance regarding post-dialysis assessments. The Director of Nursing acknowledged that the post-dialysis assessments were not well-documented, indicating a deficiency in the facility's adherence to its own protocols and the resident's care plan.
Medication Storage and Administration Deficiencies
Penalty
Summary
The facility failed to ensure that medications were stored safely and securely, leading to several instances where medications were found on the floor and unsecured in resident rooms. During a facility tour, surveyors observed loose tablets on the floor in the rooms of four residents. A Licensed Practical Nurse (LPN) acknowledged the presence of these tablets and identified them as medications that should have been crushed for administration. The LPN admitted that the tablets might have been left from previous shifts and confirmed that medications should not be found on the floor. Additionally, unsecured medications were found on a resident's bedside furniture, including Neosporin and sore throat spray, which were not prescribed or authorized for self-administration. The resident was cognitively intact, but there was no care plan or physician's order allowing self-administration of these medications. The facility's policy requires an assessment and a physician's order for residents to self-administer medications, which was not followed in this case. Interviews with staff, including the Director of Nursing (DON), revealed that the facility's procedures for medication storage and administration were not adhered to. Staff members acknowledged that medications should not be left on the floor or at the bedside without proper authorization and storage. The facility's policies clearly state that medications must be securely stored and that residents require an evaluation and physician's order to self-administer medications, which were not implemented in these instances.
Failure to Notify Physician of Positive Lab Results
Penalty
Summary
The facility failed to promptly notify the physician of a positive lab result for an infection in a resident with severe cognitive impairment and multiple diagnoses, including acute kidney failure, bladder cancer, and a urinary tract infection. Observations revealed that the resident's catheter tubing was improperly positioned, with a portion touching the ground and containing rusty-colored sediment. Lab results from a urinalysis conducted on 9/05/2024 showed a positive culture for Escherichia Coli and Enterococcus Faecalis, but the physician was not informed of these results in a timely manner. Interviews with staff indicated that lab results are available in the electronic medical records, but the positive PCR results were not communicated to the physician. The Director of Nursing confirmed that the resident was started on Keflex based on the urinalysis, but this medication would not cover the organisms detected in the culture results. The facility did not provide policy and procedures for the collection and reporting of labs, contributing to the deficiency in care.
Failure to Provide Dental Services
Penalty
Summary
The facility failed to provide necessary dental services for a resident, identified as Resident #77, who was observed with missing teeth and expressed difficulty in eating due to the condition of her teeth. Despite her requests to see a dentist, there was no follow-up or documentation of dental services being provided. The resident was admitted with a primary diagnosis of malignant neoplasm of the endometrium and was at risk for oral/dental health problems due to her advanced age, cancer, and chemotherapy treatment. Her care plan included coordinating dental care, but there was no evidence of such coordination. Interviews with the Social Services Director and Assistant Social Services Director revealed that the resident had previously refused dental services due to undergoing chemotherapy, but there was no documentation of this refusal or any follow-up since September 2023. The facility's policy stated that residents should have access to dental services and that social services were responsible for coordinating these services. However, the resident's electronic medical record did not show any scheduled or refused dental appointments, indicating a lack of adherence to the facility's policy.
Failure to Maintain Sanitary Resident Rooms
Penalty
Summary
The facility failed to maintain a sanitary environment in two resident rooms, 203 and 207, located in Hall 200. Observations revealed brown and yellow stains on the walls and ceilings, a slimy yellow substance on the floor, and small flying insects in room 203. The privacy curtain was also stained, and the resident reported that the room had not been cleaned over the weekend. Room 207 had loose bathroom tiles and stained ceiling tiles, with a family member stating the room had been in this condition since the resident moved in. These issues persisted over multiple days, indicating a lack of regular cleaning and maintenance. Interviews with staff revealed communication barriers and a lack of awareness regarding the cleanliness issues. The Housekeeping Aide, Staff C, who did not speak English, was unaware of how long the stains had been present and stated she would notify her supervisor. The Housekeeping Manager acknowledged the stains and stated that rooms should be cleaned daily, but was unsure why the stains persisted. The Director of Maintenance was not aware of the issues and stated that work orders should be submitted for repairs. The Nursing Home Administrator attributed some of the cleanliness issues to resident non-compliance and acknowledged the need for repairs and painting. The facility's policy on daily room cleaning was not being followed, as evidenced by the ongoing unsanitary conditions.
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Illustrative
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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 Tampa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Canterbury Towers Inc | 1.2 mi | ★★★★★ | 0 | 0 |
| Vivo Healthcare Gandy | 1.4 mi | ★★★★★ | 6 | 1 |
| Ybor City Center For Rehabilitation And Healing | 5.2 mi | ★★★★★ | 3 | 0 |
| Rehabilitation And Healthcare Center Of Tampa | 6.1 mi | ★★★★★ | 1 | 0 |
| Elon Manor Nursing And Rehabilitation Center | 6.2 mi | ★★★★★ | 10 | 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.