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 Ybor City Center For Rehabilitation And Healing during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of dementia repeatedly complained of left wrist and arm pain and developed swelling and an abnormal arm position over several weeks. An LPN initially notified an ARNP, who ordered a hand/wrist X‑ray and PRN Tylenol; the X‑ray was negative, and the resident’s representative was told the results were clear. A PTA later reported ongoing wrist pain to nursing, and Pain Management documented significant pain with movement and ordered routine Tylenol and topical gel, but no further nursing assessments were documented. During a routine visit, the ARNP did not document a focused assessment of the left upper extremity. The resident’s representative observed worsening swelling and severe pain with minimal touch, made multiple unsuccessful attempts to reach the DON by phone, and ultimately insisted in person that the resident be sent to the hospital. After the Medical Director noted over four weeks of arm swelling and pain and inability to perform range of motion, the resident was transferred to the emergency room, where a longstanding left shoulder dislocation was diagnosed.
A resident with severe frailty, contractures, and multiple comorbidities was admitted for respite care and assessed as high risk for pressure wounds. Despite physician recommendations for frequent repositioning, use of positioning supports, and pressure-relieving devices, these interventions were not included in the care plan or consistently provided. The resident developed multiple new pressure wounds, leading to severe infection and subsequent amputation, with staff confirming that key preventive measures were not implemented.
The facility did not maintain an effective pest control program, as live roaches and flies were observed in two rooms across different halls. Staff reported frequent pest sightings but failed to consistently document them in pest sighting logbooks, and unapproved pesticide sprays were used inside the building. Personal items were exposed to chemicals, and food trays were left in resident rooms, contributing to the pest problem. The facility's pest control policy was not consistently followed, and grievances about pests remained unresolved.
A resident with severe cognitive impairment and expressive aphasia was repeatedly administered medication against her will by an LPN, who held the resident's nose and mouth closed after she refused and spit out the medication multiple times. The incident was witnessed by two CNAs, and the resident verbally expressed refusal throughout the event. Facility policy and leadership confirmed that residents have the right to refuse medications, which was not honored in this case.
A resident with severe cognitive impairment and dementia was subjected to physical force by an LPN during medication administration after repeatedly refusing to take her medication. The LPN held the resident's nose and mouth closed while using a syringe to administer the medication, despite the resident's verbal refusals and care plan instructions to respect refusals and use redirection. The incident was witnessed by two CNAs and later reported to the DON, with the LPN admitting to the action.
Medications, including prescription and OTC drugs, were found unsecured in unlocked cabinets, a medication refrigerator, and a treatment cart on two units. These storage areas were accessible to residents, visitors, or unlicensed staff, and staff interviews confirmed that medications should have been locked at all times according to facility policy.
The facility failed to provide adequate ADL care, including showering and incontinence care, for several residents. One resident with multiple health issues received insufficient showers and incontinence care documentation. Another resident, admitted for knee replacement rehab, lacked documentation for toilet use assistance. A third resident with cognitive impairments missed scheduled baths, with inadequate documentation of care. Staff interviews confirmed these deficiencies, indicating systemic issues in care plan execution and documentation.
The facility failed to ensure that four residents had access to the call light system. Observations showed that call lights were placed out of reach for these residents, with confirmation from an LPN and the DON. The residents had varying levels of cognitive and physical impairments, and the facility's CNA job description required prompt response to call lights, which was not met.
A resident admitted with multiple health issues did not receive timely physical and occupational therapy services due to the absence of the Director of Rehabilitation, who failed to arrange adequate coverage. The delay in therapy initiation was not communicated to the Director of Nursing or the Nursing Home Administrator, leading to a significant oversight in care.
A facility failed to maintain accurate medical records for a resident, leading to a deficiency. The resident's admission records contained incorrect language documentation, and there was incomplete documentation for ADLs and nursing progress notes. The discharge Against Medical Advice (AMA) lacked sufficient details. Interviews revealed staff were unaware of specific medications given and reasons for the AMA discharge, and the facility lacked a skilled nursing policy.
Failure to Timely Assess and Escalate Care for Persistent Upper Extremity Pain and Swelling
Penalty
Summary
The deficiency involves the facility’s failure to timely and adequately address a resident’s ongoing left upper extremity pain and swelling despite multiple reports and observable changes in condition. The resident was admitted with dementia, severe cognitive impairment (BIMS score of 6), muscle weakness, and chronic kidney disease. On 1/7/2026, nursing documented that the resident was yelling that her hand hurt, and an ARNP was notified, who ordered an X‑ray of the hand/wrist and PRN Tylenol. The X‑ray on 1/7/2026 showed no fracture, anatomic alignment, and no soft tissue swelling. The resident’s RR was informed that the X‑ray was clear. A change in condition report was completed that same day for hand pain, but no further documented nursing assessment of the left upper extremity followed after this initial workup. On 1/9/2026, a PTA performing a quarterly therapy screen noted that the resident complained of left wrist pain and resisted giving her hand when positioned on her side. The PTA reported these concerns to the unit nurse and documented them on a communication form, but the medical record contained no subsequent nursing assessment by an LPN in response to this report. Pain Management evaluated the resident starting 1/17/2026 for left wrist pain and swelling and ordered routine Tylenol and a topical gel. The Pain Management provider later stated he did not perform range of motion because the resident was in too much pain when her wrist was moved and that he relied on nursing to report further pain, which they did not. The ARNP saw the resident again on 2/3/2026 for a routine visit and acknowledged being aware of prior pain and discomfort in the left hand and wrist, but her progress note contained no documented range of motion or focused assessment of the left hand, wrist, or shoulder; she later stated she did not know why she failed to document her assessment. During this period, the resident’s RR observed progressive changes. After being told the initial X‑ray was clear, he visited about a week later and noticed swelling of the arm and an abnormal hanging position of the hand. When he lightly touched the arm above the wrist, the resident screamed in pain. He reported this to nursing and made multiple phone calls requesting to speak with the DON about the plan of care but did not receive a return call. Eventually, he went to the facility, located the DON, and showed her the resident’s arm; when the DON and physician touched the arm, the resident again screamed in pain. The RR insisted on hospital transfer, while the DON initially suggested trying other in‑house measures. A nursing note dated 2/10/2026 documented that the RR requested emergency room evaluation for left hand/wrist edema and pain and a provider change. The Medical Director examined the resident that day, noting left arm swelling and pain present for over four weeks, the resident’s refusal to allow range of motion, and the inability to fully examine the axilla. He agreed with the RR to send the resident to the emergency room for immediate imaging. At the hospital, the resident was found to have a left shoulder dislocation that could not be reduced, and the hospital physician documented that the shoulder appeared to have been dislocated for a long time. The facility’s change‑in‑condition policy required prompt notification and documentation of changes in condition, but the facility was unable to provide an assessment change‑in‑condition policy beyond the general notification policy, and the record lacked timely, thorough nursing assessments in response to repeated reports of pain and swelling. Additional staff interviews corroborated that the resident repeatedly voiced pain without corresponding documented follow‑up assessments. A CNA recalled hearing the resident yelling in pain while passing meal trays and reported this to the nurse, after which she only heard that an X‑ray had been done. An LPN stated that about a month before the hospital transfer, a CNA reported the resident’s hand pain; she observed some swelling, notified the ARNP, and obtained the initial X‑ray and PRN Tylenol, but she did not describe any further systematic reassessment after the negative X‑ray. The DON stated that her expectation was that when another discipline reported a change in condition, the nurse should notify the physician and family and complete a change‑in‑condition note, with follow‑up documentation that the physician and family were made aware. She also stated that 2/10/2026 was the first time she personally assessed the resident and observed that the resident was in pain and unable to move her arm. The combination of repeated complaints of pain, observed swelling and abnormal arm positioning, lack of documented follow‑up assessments after therapy and Pain Management reports, and delayed escalation to hospital evaluation led to the discovery of a longstanding left shoulder dislocation. The facility’s own documentation and staff statements show that, despite multiple indicators of a persistent and worsening problem with the resident’s left upper extremity, there was no timely, comprehensive reassessment or escalation of diagnostic evaluation beyond the initial negative hand/wrist X‑ray and symptomatic treatment with Tylenol and topical gel. The ARNP’s lack of documented assessment of the left upper extremity during the 2/3/2026 visit, the absence of nursing assessments following therapy’s 1/9/2026 report of continued wrist pain, and the failure of the DON to respond to multiple calls from the RR about the resident’s condition all contributed to the delay in identifying the true source of the resident’s pain. Ultimately, the resident’s RR’s insistence on hospital transfer prompted the emergency room evaluation that revealed the left shoulder dislocation, which the hospital physician believed had been present for at least a month.
Failure to Implement Pressure Injury Prevention Measures for High-Risk Resident
Penalty
Summary
A resident with a history of Alzheimer's disease, dementia, prior CVA with right-sided contractures, right lower extremity osteomyelitis, and multiple comorbidities was admitted for respite care. Upon admission, the resident was assessed as being at high risk for pressure wounds due to severe frailty, immobility, and peripheral vascular disease. Physician recommendations included frequent turning and repositioning, use of positioning supports such as wedges and heel protectors, pressure redistributing mattress, and daily wound care. However, these recommendations were not transcribed into the resident's care plan or implemented in daily care routines. During the resident's stay, the baseline plan of care only included general interventions such as daily skin inspection, moisturizing, and encouraging nutrition, but omitted specific physician-ordered interventions for pressure injury prevention. Staff interviews and record reviews revealed that the resident was not provided with an air mattress, heel boots, or adequate offloading supports, despite these items being available in facility supply. Documentation in the Treatment Administration Record showed completion of some skin care interventions, but there was no evidence of regular turning, repositioning, or use of pressure-relieving devices as ordered. The wound care nurse and DON were unaware of the resident's deteriorating skin condition until notified by the resident's representative. The deficiency was identified when the resident's representative discovered multiple new pressure wounds on the resident's right foot, heel, and knee, which were not present prior to admission. The wounds were severe enough to require emergency transfer to the hospital, where the resident was diagnosed with severe sepsis and ultimately underwent a right foot amputation. Facility staff confirmed that the required interventions for pressure injury prevention were not consistently implemented, and the care plan did not reflect the physician's recommendations for high-risk skin care management.
Failure to Implement Effective Pest Control Program
Penalty
Summary
The facility failed to implement an effective pest control program, as evidenced by the presence of live roaches in two resident rooms located in separate halls. Observations revealed several roaches behind a nightstand and under an armoire/closet in one room, as well as flies and a food tray left on a resident's bed in another. Staff interviews confirmed ongoing sightings of roaches in these areas, with staff reporting that pests persist despite regular exterminator visits. Staff also indicated that they often notify maintenance verbally but do not document pest sightings in the designated logbooks, contrary to facility policy. Additionally, staff were observed using unapproved pesticide sprays inside the facility, and personal resident items were exposed to these chemicals during attempts to control pests. A review of pest sighting logbooks showed inconsistent and incomplete documentation, with exterminator invoices noting a lack of reported activity and requesting improved use of the logbooks. The facility's policy requires staff to report and document pest sightings, use only approved pest control measures, and remove residents from affected areas until control measures are implemented. However, interviews with staff and the NHA revealed that these procedures were not consistently followed, and grievances regarding pest issues remained unresolved at the time of the survey.
Failure to Honor Resident's Right to Refuse Medication
Penalty
Summary
A resident with severe cognitive impairment, vascular dementia, psychosis, and major depressive disorder was observed to have her right to refuse medication violated. The resident's care plan acknowledged her history of refusing medications and outlined interventions such as explaining procedures, allowing time for adjustment, and leaving and returning later if care was resisted. Despite these interventions, staff did not honor the resident's repeated verbal refusals of medication. On the day of the incident, the resident was being assisted by two CNAs when an LPN attempted to administer her medication. The resident spit out the medication twice when offered on a spoon. The LPN then left the room, returned with a syringe, and administered the medication by holding the resident's nose and mouth closed until she swallowed, despite the resident verbally expressing refusal. Both CNAs present witnessed the event and reported that the resident was saying, "I don't want it, I don't want it," during the process. The LPN admitted to using this method to ensure the resident took her medication, stating it was not done maliciously and referencing the resident's history of being combative when not medicated. The facility's policy and the Director of Nursing confirmed that residents have the right to refuse medications and that such rights must be honored, especially for those with cognitive impairments. The incident was also documented in a psychiatric note, which confirmed the nurse's actions and the resident's difficulty with communication due to expressive aphasia.
Resident's Rights Violated During Medication Administration
Penalty
Summary
A resident with severe cognitive impairment, vascular dementia, psychosis, and major depressive disorder was observed to have her rights violated when a nurse used physical force to administer medication. The resident, who had a history of being resistive to care and difficulty communicating due to expressive aphasia, repeatedly refused her medication by spitting it out. Despite this, the nurse attempted to administer the medication multiple times, ultimately resorting to holding the resident's nose and mouth closed while using a syringe to force the medication into her mouth. Multiple staff members witnessed the incident and reported that the resident verbally expressed her refusal by saying, "I don't want it, I don't want it." The nurse admitted to the action, stating that she did not act maliciously and referenced using a similar method with her own children. The incident was documented in a psychiatric note, which confirmed the nurse's admission and the resident's ongoing difficulty with communication and resistance to care. The facility's policy prohibits all forms of abuse, including physical abuse, and requires immediate reporting of any alleged violations. The actions taken by the nurse were inconsistent with the resident's care plan, which emphasized respecting refusals, using redirection, and allowing time for the resident to adjust. The incident was not immediately reported by the witnessing CNAs, but was later brought to the attention of the Director of Nursing, who confirmed that the resident's right to refuse medication should have been honored.
Failure to Secure Medication Storage Areas
Penalty
Summary
Medications, including prescription and over-the-counter (OTC) drugs, were observed to be improperly stored and unsecured on two units within the facility. On the 400-unit, the nurses' station door was left open with no staff present, and both the medication refrigerator and cabinets containing OTC medications were unlocked and accessible. These conditions persisted during multiple observations throughout the day, with photographic evidence obtained. On the 300-unit, a treatment cart containing prescription medications and wound care supplies was left unlocked and unattended in a resident common area. Staff interviews confirmed that the medication storage areas should have been locked at all times and accessible only to authorized personnel. An LPN acknowledged that the refrigerator and cabinet should have been secured but had not yet been locked. The DON stated that it was her expectation that all medication storage areas, including treatment and medication carts, remain locked when not in use. Facility policy also requires all medications, except for emergency drug kits, to be stored in locked areas accessible only to authorized staff.
Deficiencies in ADL Care and Documentation
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADLs) care, specifically in showering and incontinence care, for several residents. Resident #2, who had multiple health issues including acute respiratory failure, COPD, and muscle weakness, required assistance with toileting and showering. Despite care plans indicating the need for regular showers and incontinence checks, documentation showed that Resident #2 received only two showers in October 2024 and had significant gaps in incontinence care documentation. Interviews with staff confirmed the lack of documentation and adherence to the care plan. Resident #3, admitted for rehabilitation after a knee replacement, also experienced deficiencies in care. The resident required assistance with transfers and toilet use, but documentation for bladder and bowel elimination was missing for several shifts. Interviews revealed that staff failed to document the resident's needs and care provided, despite the resident's requirement for assistance due to mobility issues. Resident #4, who had cognitive impairments and required total assistance with ADLs, was not bathed according to the facility's schedule. Documentation showed missed shower opportunities and inadequate recording of bathing activities. Staff interviews confirmed the lack of adherence to the bathing schedule and the absence of documentation for refusals or alternative care provided. These deficiencies highlight a systemic issue in the facility's documentation and execution of care plans for residents requiring assistance with daily living activities.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that four residents had access to the call light system, as observed during a survey. Resident #5 was found lying in bed with the call light pull string placed on a bedside dresser, out of reach, and obscured by boxes. Resident #6's call light was positioned behind and above the resident, making it inaccessible. Staff B, an LPN, confirmed that both residents could not reach their call lights. Resident #5 had a BIMS score indicating intact cognition, while Resident #6 had severe cognitive impairment. Further observations revealed that Resident #9's call light was on the floor, wrapped around the bed control cord, and Resident #10's call light was on a bedside dresser, out of reach. The Director of Nursing confirmed the inaccessibility of the call lights for these residents. Resident #9 had intact cognition, while Resident #10 was blind with intact cognition. The facility's job description for CNAs included the responsibility to ensure call lights are promptly answered, highlighting a failure in meeting this standard.
Failure to Provide Timely Therapy Services
Penalty
Summary
The facility failed to provide timely therapy services for a resident, identified as Resident #2, who was admitted with multiple diagnoses including acute respiratory failure with hypoxia, COPD, and muscle weakness. The resident required both physical and occupational therapy five times a week as per physician orders. However, there was a delay in initiating these therapy services, with physical therapy starting on 10/12/2024 and occupational therapy on 10/14/2024, despite the resident being admitted on 10/7/2024. The delay in therapy services was attributed to the absence of the Director of Rehabilitation (DOR), who was out ill and did not arrange for adequate coverage. The DOR admitted that the resident might have been missed and acknowledged that under Medicare guidelines, evaluations should occur within 48 hours. The DOR also mentioned that a therapist was available on 10/12/2024, but the resident was not on the schedule. The Director of Nursing (DON) and the Nursing Home Administrator (NHA) were also unaware of the lapse in therapy services. Interviews with facility staff revealed a lack of communication and planning to ensure continuity of care during the DOR's absence. The facility's policy required physician orders to be validated by therapists before initiating therapy services, but this process was not effectively managed. The failure to provide timely therapy services was a significant oversight, as the resident was at risk for various complications without the necessary therapeutic interventions.
Deficiency in Medical Record Maintenance and Communication
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident, leading to a deficiency in safeguarding resident-identifiable information. The resident was admitted following a hospital stay with several diagnoses, including an artificial knee joint and anxiety disorder. However, discrepancies were found in the resident's admission records, such as incorrect language documentation, which stated the resident spoke Spanish instead of English. Additionally, the continence evaluation was incomplete, and there was a lack of documentation for the resident's Activities of Daily Living (ADLs) during specific shifts. Furthermore, there were no nursing progress notes for a particular day, and the documentation regarding the resident's discharge Against Medical Advice (AMA) was insufficient, lacking details about communication with the physician or facility administration. Interviews with facility staff revealed further issues. The Director of Nursing (DON) admitted to working a shift without recalling specific medications given to the resident and was unaware of the reasons behind the resident's AMA discharge. The Nursing Home Administrator (NHA) and Social Services Director (SSD) confirmed the absence of necessary documentation and noted the transition of the Risk Manager position during the period in question. The facility lacked a skilled nursing policy, which contributed to the incomplete documentation and communication failures regarding the resident's care and discharge.
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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) |
|---|---|---|---|---|
| Elon Manor Nursing And Rehabilitation Center | 0.9 mi | ★★★★★ | 10 | 0 |
| Whispering Oaks | 1.9 mi | ★★★★★ | 11 | 0 |
| Rehabilitation And Healthcare Center Of Tampa | 2.7 mi | ★★★★★ | 1 | 0 |
| Aviata At The Bay | 2.8 mi | ★★★★★ | 3 | 2 |
| Canterbury Towers Inc | 4.1 mi | ★★★★★ | 0 | 0 |
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