Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Gulf Shore Care Center during CMS and state inspections, most recent first.
Inaccurate PASARR screenings were found for several residents because the documented mental health diagnoses and behaviors were not reflected on the Level I screens. Residents had diagnoses such as PTSD, bipolar disorder, psychotic disorder, depression, anxiety, dementia, and suicidal ideations, yet the PASARRs left MI sections blank, omitted psychotic disorder, or marked no for intensive psychiatric treatment and dangerous behaviors despite observed aggression, behavioral symptoms, and a hospitalization for suicidal ideations. The DON and SSD acknowledged the PASARRs were not correct.
Failure to document ordered care, hospice communication, and resident positioning. A resident was observed leaning off-center in a wheelchair despite a care plan for repositioning, a hospice resident lacked current hospice notes in the chart, and multiple residents had missing MAR/TAR documentation for ordered meds, behavior monitoring, tube feeds, wound-related care, and dialysis-day medication administration. The DON and staff acknowledged gaps in documentation and, in one case, that medications were not given as ordered.
Untimely incontinence care and missing documentation affected a cognitively intact resident with MS, MDD, gastroparesis, and constipation. The resident reported waiting over an hour for bowel incontinence care on recurring Thursday and Friday shifts, said the same aides were repeatedly not timely, and described anxiety about those shifts. Record review showed many shifts with no bowel task documentation, while the LCNA, RN, and DON stated care should be provided at least every 2 hours/as needed and documented each shift, including refusals or when no care was needed.
Call Light Not Within Reach: A resident with severe cognitive impairment and multiple diagnoses, including dementia, aphasia, and repeated falls, was observed on multiple occasions with the call light hanging out of reach, on the floor, or behind the bed rail. The resident was seen in a hospital gown, unable to reach the call light, and stated pain and difficulty sitting up or moving. Staff and the DON acknowledged that call lights should be within reach and checked during routine rounds, and the ADON later moved the call light to the other side of the bed.
MDS PASRR coding was inaccurate for two residents when Section A1500 was marked “no” despite diagnoses including major depressive disorder, PTSD, anxiety, psychotic disorder, and dementia-related conditions that indicated Level II PASRR consideration. The MDSD stated she completed one assessment and missed the need to code the other resident as “yes” based on the diagnoses, while the DON stated assessments are expected to be completed accurately.
Inadequate supervision during smoking time: A resident with dementia, psychotic disorder, anxiety, depression, and elopement risk was assessed to smoke only with supervision, with the care plan directing staff to accompany him to the designated smoking area. However, staff were observed supervising from inside the facility while the resident smoked outside, and on another occasion a CNA briefly left the resident outside alone while retrieving something from the smoking cart. The DON and NHA stated supervision could be provided from inside or outside during smoking times.
A resident with metabolic encephalopathy, anxiety, acute and chronic respiratory failure, and OSA did not receive ordered Modafinil because the facility repeatedly awaited a script and pharmacy delivery. Nursing notes documented the medication order as pending, and the resident was noted to be lethargic and hard to arouse with altered LOC. The RN/UM stated the resident missed several days of the medication, and the MD said it was not acceptable that the resident went without it.
An observation found narcotics stored in an unlocked box in a refrigerator, an opened Symbicort inhaler that was used but not dated, and an opened box of thickened liquids kept in a medication cart instead of refrigerated as directed. Staff and the DON stated the narcotics should have been locked, the inhaler should have had an opened date, and the thickened liquids did not belong in the cart and were expired.
Inaccurate PASARR screenings for multiple residents
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was inaccurate for multiple residents because the facility did not ensure the screening information matched the residents’ documented diagnoses and clinical status. Resident #78 was admitted with diagnoses including PTSD, major depressive disorder, alcohol abuse, and generalized anxiety disorder, but the PASARR dated 02/20/2026 left the MI section blank and marked no mental illness, no provisional admission, and no need for a Level II evaluation. Resident #5 was admitted with diagnoses including epilepsy, generalized anxiety disorder, brief psychotic disorder, Parkinson’s disease, persistent mood disorder, and recurrent major depressive disorder, yet the PASARR dated 02/20/2026 also left MI blank and marked no mental illness and no Level II evaluation required. Resident #77 was admitted with diagnoses including major depressive disorder, generalized anxiety disorder, brief psychotic disorder, and unspecified dementia, but the Level I PASARR dated 02/25/2026 did not list the psychotic disorder. The admission MDS documented anxiety disorder, depression, and psychotic disorder. During interview, the DON and SSD stated the PASARR should have been updated to reflect the current diagnoses and that a new Level I should have been completed for the psychotic disorder. Resident #2 had diagnoses including brief psychotic disorder, bipolar disorder, major depressive disorder, and generalized anxiety disorder, and the Level I PASARR dated 10/6/2025 marked bipolar disorder but indicated no intensive psychiatric treatment and no dangerous behaviors. However, surveyors observed the resident speaking loudly, using aggressive language, and slapping and pushing a CNA, and staff reported ongoing pushing, slapping, yelling, and throwing things. Progress notes documented behavioral symptoms and a PCP response recommending psychiatric treatment and transport to the hospital. Resident #8 had diagnoses including suicidal ideations, bipolar disorder, major depressive disorder, anxiety disorder, primary insomnia, and unspecified dementia, but the PASARR dated 8/29/2025 did not reflect the later hospitalization for suicidal ideations. Progress notes and staff interviews indicated the resident had a brief hospitalization for suicidal ideations, and the DON stated the PASARR was not correct and should have been updated after the hospitalization.
Failure to document ordered care, hospice communication, and resident positioning
Penalty
Summary
The facility failed to ensure residents received care and treatment in accordance with professional standards of practice, the comprehensive care plan, and resident choice. One resident was observed twice sitting in a wheelchair with the torso shifted off center, first toward the left and later toward the right. The resident had diagnoses including unspecified dementia with behavioral disturbance, major depressive disorder, tachycardia, pseudobulbar affect, and vitamin deficiency, and the MDS showed substantial to maximal assistance was required for most ADLs. The care plan directed staff to turn and reposition as needed and shift weight to enhance circulation, and the DON stated staff should reposition residents when they are leaning or not properly sitting in their wheelchair. For another resident receiving hospice services, the facility did not have current hospice documentation in the chart at the time of review. The DON stated the only hospice note available was from December and that no further notes were in the chart, with additional notes being faxed later. The facility policy required communication with the hospice provider and documentation of such communication to ensure resident needs were addressed. The resident’s record showed diagnoses including unspecified dementia, major depressive disorder, anxiety disorders, cirrhosis cutis, and traumatic subarachnoid hemorrhage without loss of consciousness, and the MDS indicated stage four pressure ulcers. The facility also failed to document multiple physician-ordered services and medications for three residents. For one resident with epilepsy, Parkinson’s disease, psychotic disorder, mood disorder, and major depressive disorder, the MAR/TAR lacked documentation for behavior monitoring, medications administered via PEG tube, vital signs, enteral feed orders, and tube flushes on multiple dates in February and March 2026. For another resident with encephalopathy, cerebral infarction sequelae, aphasia, Parkinson’s disease, dementia, and depression, the MAR showed missing adverse effect monitoring for pimavanserin and multiple entries coded as “9=Other/See Nurse’s notes,” while progress notes contained repeated medication-related entries and the DON stated she did not have an explanation for the charting. For a third resident with COPD, diabetes, pulmonary fibrosis, renal dialysis dependence, heart failure, cardiomyopathy, and hypertension, the MAR showed no documentation for several ordered medications on dialysis days, and staff stated medications should be given before dialysis and after return, with the DON stating the resident did not receive medications as ordered.
Untimely Incontinence Care and Missing Documentation
Penalty
Summary
The facility failed to ensure Resident #13’s right to be treated with dignity was honored when incontinence care was not provided in a timely manner and documentation of care was missing on multiple shifts. Resident #13 was admitted with diagnoses including progressive multiple sclerosis, major depressive disorder, insomnia, gastroparesis, and constipation, and had a BIMS score of 15 out of 15, indicating cognitive intactness. The resident reported that for at least the prior two weeks, she had to sit in her own bowel movement for over an hour waiting for care on Thursdays and Fridays, and stated that the same aides on both shifts were repeatedly not timely with incontinence care. During interview, Resident #13 stated she became upset when she had to wait so long and said she only used her call light when she had a bowel movement. She described that an aide would come, turn off the call light, say they would be right back, and then take over an hour to return and provide care. On a later interview, the resident stated she was nervous about the upcoming Thursday and Friday shifts and had anxiety about not being cared for timely if she needed to use the bathroom. She also stated she hoped things would improve while the State was at the facility. Record review showed no documentation of refusals for incontinent care or behaviors related to rejection of care in the progress notes, and the care plan directed staff to encourage the resident to voice concerns and provide reassurance. The bowel task record showed numerous Thursday and Friday shifts with no care documented across several months, including multiple day and evening shifts and one overnight shift. Staff interviews confirmed that residents should be checked or changed at least every two hours and as needed, and that every episode of incontinence care should be documented, including refusals or when care was not needed. The DON stated the resident’s care plan and bowel/bladder documentation should be followed, that the situation was not the facility’s expectation, and that the resident had the right to receive incontinent care when needed.
Call Light Not Within Reach
Penalty
Summary
The facility failed to ensure a call light was within reach for one resident. During observations on 3/23/2026, 3/24/2026, and 3/25/2026, Resident #127 was seen in bed or seated in a wheelchair with the call light hanging on the left side of the bed, on the floor under the left side of the bed, or hanging behind the resident from the bed rail, all out of reach. During these observations, the resident stated pain, pointed to the neck and wrist, and said, "I have told many people, and they have not done anything," "I cannot walk or move and my pants are dirty," and "I want to sit up, I cannot sit up, can you help me sit up?" The resident was observed wearing a hospital gown during two of the observations and was unable to reach the call light. Resident #127's record showed an admission date of 7/21/2025 and a re-entry date of 3/11/2026. Diagnoses included encephalopathy, acute respiratory failure with hypoxia, unspecified dementia with other behavioral disturbance, brief psychotic disorder, other specified persistent mood disorders, aphasia, repeated falls, primary osteoarthritis, and other seizures. The admission MDS showed a BIMS score of 6 out of 15, indicating severe cognitive impairment. Functional status showed dependence for toileting hygiene and lower body dressing, and partial/moderate assistance needed for bed mobility, transfers, and toileting transfers. Staff interviews confirmed that call lights should be within reach and checked during routine rounds, and the ADON stated the call light was not within reach before moving it to the right side of the bed.
MDS PASRR Coding Inaccurately Completed for Two Residents
Penalty
Summary
The facility failed to ensure the comprehensive MDS was accurately coded for two sampled residents. Resident #6 was admitted with diagnoses including recurrent moderate major depressive disorder, unspecified PTSD, and unspecified personality disorder. His MDS with an ARD of 12/1/2026 showed Section A1500 PASRR coded as “no” for whether the resident was currently considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition, even though the record indicated he should have been considered for a Level II PASRR because of his mental illness diagnoses. Resident #77 was admitted with diagnoses including recurrent moderate major depressive disorder, generalized anxiety disorder, unspecified brief psychotic disorder, and unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. His MDS with an ARD of 03/02/2026 also showed Section A1500 PASRR coded as “no,” despite the record indicating he should have been considered for a Level II PASRR due to his serious mental illness. During interview, the MDS Director stated she completed Resident #6’s initial assessment and marked “no” because the PASRR did not show a mental illness supporting Level II, and she stated she did not recognize that Resident #77 should have been coded “yes” based on his diagnoses. The DON stated her expectation was that resident assessments be completed accurately.
Inadequate supervision during smoking time
Penalty
Summary
The facility failed to ensure appropriate supervision during smoking time for one resident who was assessed as able to smoke only with supervision. The resident had diagnoses including major depressive disorder, generalized anxiety disorder, brief psychotic disorder, unspecified dementia, and an elopement risk evaluation score of 14 indicating risk for elopement. The resident’s care plan directed staff to accompany him to designated smoking areas and provide supervision, and his physician order included an electronic monitoring device with daily shift checks for function. During observations, the resident was seen outside smoking with a smoke apron on while a staff member sat inside the facility behind a table with a cart next to the table. A CNA stated she was the smoking aide and that she always sat inside the facility when supervising smoking times. On another observation, a CNA assisted the resident with cigarettes outside, then returned inside to get something from the smoking cart while the resident remained outside smoking, before later returning outside to supervise him. The CNA stated she had to remain outside with the resident while he smoked because his hands shook and he required supervision. The DON and NHA stated that supervision could be provided from inside or outside the facility during smoking times.
Failure to Obtain Ordered Modafinil
Penalty
Summary
The facility failed to ensure that Resident #27 received Modafinil as ordered. Resident #27 was admitted with diagnoses including metabolic encephalopathy, generalized anxiety disorder, acute and chronic respiratory failure, and obstructive sleep apnea. During observation, the resident was found in bed with the bed at a 90-degree angle and a pillow under his legs to keep his feet offloaded; he stated he felt weak and had not been out of bed or participated in therapy. Later the same day, he was observed sitting up in bed eating lunch and visiting with his wife. Record review showed multiple nursing progress notes documenting Modafinil 200 mg twice daily for obesity or obstructive sleep apnea, with repeated notes that the order was awaiting a script or pharmacy delivery. A change in condition note dated 03/14/2026 stated the resident was lethargic and hard to arouse with altered level of consciousness. Staff C, RN/UM stated the hospital did not send a script when the resident was admitted, the facility contacted the ARNP and primary provider for the medication, and the resident missed a total of three days of Modafinil. Staff C stated it was not acceptable that the resident went 5 days without the medication. The Medical Director stated it was not acceptable that the resident did not receive the medication for the days missed and said he could have filled the script if contacted.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Drugs and biologicals were not stored and labeled in accordance with accepted professional principles. During an observation of the East side medication storage room, several narcotics were found stored in an unlocked box in the refrigerator labeled “B Box.” Staff stated the narcotics should have been locked, that he did not have a key for the lock, and that he was responsible for keeping the narcotics locked. The DON also stated the narcotic box in the refrigerator should have been locked, and staff did not know how long it had been left unlocked. During an observation of the East Hall 200 medication cart, an opened Symbicort inhaler was found used and undated, and an opened box of thickened liquids dated 2/22/2026 was found in the third drawer of the cart even though the box directions stated it should be refrigerated prior to serving and kept up to 7 days under refrigeration after opening. Staff stated the inhaler should have been labeled with the opened date and did not know when it was opened. Staff also stated the thickened liquids should have been stored in the refrigerator and did not belong in the medication cart. The DON stated the thickened liquids were not supposed to be stored in the medication cart and should have been discarded, and that all medications were expected to be labeled with the date opened and expiration date.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 326 citations issued within 25 miles in the last 12 months — including the 23 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Pinellas Park
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pinellas Park Fl Opco, Llc | 2.1 mi | ★★★★★ | 4 | 3 |
| Palm Garden Of Largo | 2.1 mi | ★★★★★ | 2 | 0 |
| Aviata At Seminole | 2.2 mi | ★★★★★ | 6 | 0 |
| Aviata At Bryan Dairy | 2.4 mi | ★★★★★ | 4 | 4 |
| Vivo Healthcare Gateway | 2.6 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Gulf Shore Care Center.
100% money-back within 48 hours.
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.