Below 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 Brighton Bay Center For Rehabilitation And Healing during CMS and state inspections, most recent first.
Three residents with surgical wounds did not have their wounds properly assessed or measured according to physician orders and facility policy. Documentation was inconsistent or missing, and staff interviews revealed a misunderstanding about the need to measure surgical wounds. The DON confirmed gaps in wound assessment and the absence of required baseline care plans.
The facility failed to maintain a safe and homelike environment in 13 resident rooms, with issues such as holes in walls, loose toilet seats, and water-damaged ceilings. Unlabeled personal items like razors were also found, posing potential safety risks. The Nursing Home Administrator and Maintenance Director were aware of some issues but had not addressed all deficiencies.
The facility failed to ensure accurate and updated PASRR assessments for three residents with mental health diagnoses. A resident with dementia, anxiety, and major depressive disorder, another with bipolar disorder and depression, and a third with depression and schizoaffective disorder had PASRR screens that did not reflect their mental health conditions. The DON acknowledged the issue, and the facility's policy on reevaluation was not followed.
The facility failed to implement effective infection control practices, including improper use of PPE by an LPN in a contact precaution room, inadequate handling of a catheter bag, and lack of hand hygiene by staff during meal service and resident care. These deficiencies were observed despite clear policies and training on infection prevention.
A facility failed to conduct a PASARR Level II assessment for a resident with a new diagnosis of schizoaffective disorder. The resident had multiple mental health diagnoses, but the PASARR completed only identified anxiety disorder. The Director of Nursing confirmed that no PASARRs were submitted for a Level II review.
A facility's medication error rate exceeded the acceptable threshold, with errors observed in three residents. An RN failed to administer Lisinopril to a resident without documented vital signs, an LPN applied a Lidoderm patch to the wrong location, and another RN did not administer Arthritis Pain Reliever Gel due to unavailability, failing to notify the doctor of the missed dose.
Two residents received meals that did not align with their dietary preferences and restrictions, leading to deficiencies in meal service. One resident, with restrictions against red meat and pork, was served these items, while another, with restrictions against eggs, received them regularly. Staff interviews revealed a failure to adhere to the process of matching meal tickets with the food served.
A resident was observed with an undated dressing on their right elbow, lacking proper assessment and physician orders. An LPN confirmed the need for a dated dressing and physician order, but the medical record showed no assessment or treatment order. The DON was unaware of the injury, and the facility's wound care policy was not followed, leading to the deficiency.
A facility failed to conduct scheduled laboratory tests for a resident with chronic conditions, missing tests in May 2023 and May 2024, and performing an incomplete test in September 2023. The DON cited timing issues with the lab vendor as a contributing factor. The facility did not follow its policy for obtaining and reviewing lab results, leading to a deficiency in providing timely laboratory services.
Failure to Assess and Measure Surgical Wounds as Ordered
Penalty
Summary
The facility failed to ensure that surgical wounds were properly assessed and measured for three residents, as required by physician orders and facility policy. For one resident with a history of rhabdomyolysis, open wound on the right hip, and other significant comorbidities, documentation showed inconsistent and missing wound measurements. Although initial wound sizes were recorded, subsequent weekly wound observation tools lacked measurements, and there were gaps in assessment documentation. The care plan specifically required weekly documentation of wound measurements, but this was not consistently followed. Interviews with staff and the DON confirmed that wound measurements were not performed as required, and that there was a misconception among staff that surgical wounds did not need to be measured. Another resident with diagnoses including sepsis, cellulitis, and a diabetic foot ulcer had physician orders for daily wound care to a surgical incision on the left foot. However, the skin evaluation and progress notes lacked wound measurements and descriptions. The DON acknowledged that the required wound observations and measurements were missing and that there was no baseline care plan documented in the assessment section of the medical record. The absence of wound measurements and descriptions was confirmed during interviews and record review. A third resident with multiple surgical incisions and complex medical history also did not have wound measurements or descriptions documented upon admission or in subsequent evaluations. The skin evaluation and nursing admission screening noted the presence of wounds but failed to provide objective data such as size or description. The DON verified that wound evaluations should have been completed using the appropriate tool and that baseline care plans were not present in the medical record. Facility policies required thorough documentation of wound assessments and baseline care plans within 48 hours of admission, but these requirements were not met for the residents involved.
Failure to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe and homelike environment in 13 out of 74 resident rooms. Observations revealed various maintenance issues, including holes in walls, loose toilet seats, and water damage in ceilings. Additionally, some rooms had unlabeled personal items, such as razors, which could pose safety risks. These deficiencies were noted during multiple facility tours over several days. Interviews with the Nursing Home Administrator and Maintenance Director indicated that they were aware of some issues, such as holes caused by door handles and bed rubbing, and were in the process of ordering materials to address these problems. However, they were unaware of the ceiling damage, which they attributed to hurricane curtains. The facility's policies on maintaining a homelike environment and providing maintenance services were not effectively implemented, as evidenced by the numerous unresolved maintenance issues.
Inaccurate PASRR Assessments for Residents
Penalty
Summary
The facility failed to ensure that Preadmission Screening and Resident Review (PASRR) assessments were accurate and updated for three residents. Resident #29 was admitted with diagnoses including unspecified dementia, anxiety, and major depressive disorder, but their Level I PASRR did not reflect any mental illness or suspected mental illness. The Director of Nursing acknowledged that PASRRs had not been conducted properly in the facility. Resident #28 was admitted with diagnoses of bipolar disorder, depression, and panic disorder, yet their PASRR screen also failed to indicate any mental illness or suspected mental illness. Similarly, Resident #77, who had diagnoses of depression, generalized anxiety disorder, and bipolar disorder, with an added diagnosis of schizoaffective disorder, had a PASRR screen that did not reflect these conditions. The facility's policy requires reevaluation of residents when there is a change in their mental or physical condition, but this was not adhered to in these cases.
Infection Control Deficiencies in PPE Use, Catheter Handling, and Hand Hygiene
Penalty
Summary
The facility failed to implement an effective infection control program in several instances. In one case, a Licensed Practical Nurse (LPN) was observed entering a resident's room, which was under contact precautions, without donning the required personal protective equipment (PPE) such as a gown and face mask. The LPN only wore gloves and did not perform hand hygiene before or after resident contact, nor after removing the gloves. This occurred despite clear signage indicating the need for PPE and hand hygiene. The resident in question was being treated for an infection requiring contact isolation precautions, including MRSA bacteremia. Another deficiency was noted in the handling of an indwelling catheter bag for a resident. The catheter bag and tubing were observed hanging in the bathroom, which was shared with another resident, and had a faint urine odor. The catheter bag appeared to have been used and was not properly stored or disposed of, posing a risk of infection. The Unit Manager confirmed that the resident was not responsible for catheter care and that the improper storage of the catheter bag was not in line with infection control practices. Additionally, during a meal service observation, the Admissions Director was seen handling meal trays and assisting residents without performing hand hygiene between tasks and resident interactions. This included touching residents and their utensils without sanitizing hands, which is against the facility's hand hygiene policy. Furthermore, a Registered Nurse was observed failing to perform hand hygiene and sanitize reusable equipment after taking a resident's blood pressure, further indicating lapses in infection control practices.
Failure to Complete PASARR Level II for New Mental Health Diagnosis
Penalty
Summary
The facility failed to complete the Preadmission Screening and Resident Review (PASARR) Level II for a resident who had a new qualifying mental health diagnosis. The resident was admitted with multiple diagnoses, including schizoaffective disorder, anxiety disorders, unspecified dementia with agitation, and PTSD. However, the PASARR completed prior to admission only identified anxiety disorder as a mental illness. A new diagnosis of schizoaffective disorder was made, but the facility did not conduct a PASARR Level II assessment for this condition. During an interview, the Director of Nursing confirmed that no PASARRs were submitted for a Level II review.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in an observed error rate of 8.33% during a survey. Three medication errors were identified among four residents observed. For Resident #90, a Registered Nurse (RN) did not administer Lisinopril as prescribed, citing low blood pressure as the reason for holding the medication. However, there were no documented vital signs to support this decision, and the facility's policy requires parameters for holding medication and notifying the doctor, which was not done. Resident #27 received a Lidoderm patch applied to the incorrect location by a Licensed Practical Nurse (LPN), who placed it on the left upper arm instead of the right shoulder as ordered. Additionally, Resident #38 did not receive their prescribed Arthritis Pain Reliever Gel due to the RN being unable to locate the medication. The RN did not notify the doctor of the missed dose, contrary to facility policy. These errors highlight a failure to adhere to medication administration protocols, including verifying the right resident, medication, dosage, time, and method of administration.
Failure to Accommodate Resident Dietary Preferences
Penalty
Summary
The facility failed to provide meals that accommodated the dietary preferences and restrictions of two residents, leading to deficiencies in meal service. Resident #39, who had dietary restrictions against red meat and pork, was observed receiving meals that included these items on multiple occasions. Despite her deteriorating vision, which made it difficult for her to identify the food on her plate, she was served beef and pork instead of the specified alternatives on her meal ticket. The resident expressed concern about not receiving the appropriate protein intake due to these errors. Similarly, Resident #66, who had dietary restrictions against eggs, reported receiving eggs for breakfast regularly, contrary to her meal ticket instructions. On one occasion, she was served ground pork instead of the specified ground hot dog. Both residents had intact mental cognition, as indicated by their BIMS scores, and were able to articulate their concerns about the incorrect meals they received. Interviews with facility staff, including a CNA and the Food Services Director, revealed a lack of adherence to the process of matching meal tickets with the food served. The Food Services Director acknowledged the issue and confirmed that staff were not checking the meal tickets as required. The facility's policy on resident food preferences emphasized the importance of assessing and documenting individual preferences and ensuring that meals align with these preferences, which was not followed in these instances.
Failure to Obtain Wound Care Orders and Document Treatment
Penalty
Summary
The facility failed to assess and obtain wound care orders for a resident who was observed with a dressing on their right elbow. The dressing was undated and had a discolored area, indicating a lack of proper documentation and assessment. During an interview, a Licensed Practical Nurse (LPN) confirmed that the dressing should have been dated, a physician order should have been obtained, and an assessment of the area should have been conducted. However, a review of the resident's medical record revealed no assessment or treatment order for the injury, and the resident's responsible party had not been notified. The Director of Nursing (DON) was unaware of the resident's skin injury and stated that staff were expected to obtain a physician order and inform management when a skin issue was noted. The facility's wound care policy, dated October 2010, required a physician's order for wound care procedures and detailed documentation in the resident's medical record. This documentation should include wound care provided, assessment data, and any changes in the resident's condition, among other details. The lack of adherence to these procedures led to the deficiency identified in the report.
Failure to Conduct Scheduled Laboratory Tests
Penalty
Summary
The facility failed to ensure laboratory testing was conducted according to physician orders for a resident, leading to missed and incomplete tests. The resident, who had multiple diagnoses including chronic kidney disease and dementia, was supposed to have a Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), and Ammonia level tests every four months. However, the facility did not perform these tests as scheduled in May 2023 and May 2024, and the September 2023 test was incomplete as it lacked the Ammonia level. Additionally, there were no laboratory results provided for January 2024, despite the tests being recorded as drawn. The Director of Nursing (DON) explained that the night shift nurses were responsible for initiating lab requests, but there was a timing issue with the lab vendor's schedule, which contributed to the missed tests. The facility's policy required a systematic process for obtaining and reviewing lab results, but this was not followed, as evidenced by the lack of documentation and follow-up on the missing tests. The facility's failure to adhere to the physician's orders and its own policies resulted in a deficiency in providing timely and appropriate laboratory services for the resident.
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Illustrative
What surveyors actually found near you
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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.
Illustrative
A prioritized, do-first checklist
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Illustrative
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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) |
|---|---|---|---|---|
| Aventura At The Bay | 0.2 mi | — | 47 | 0 |
| Abbey Rehabilitation And Nursing Center | 2.1 mi | ★★★★★ | 16 | 0 |
| Vivo Healthcare St Petersburg | 2.2 mi | ★★★★★ | 0 | 0 |
| Vivo Healthcare Gateway | 3.2 mi | ★★★★★ | 1 | 0 |
| Laurellwood Post- Acute And Rehabilitation Center | 3.6 mi | ★★★★★ | 9 | 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.