Inspection visit
Inspection
3 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 3 deficiencies, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0677
Provide care and assistance to perform activities of daily living for any resident who is unable.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, interviews, and record review the facility failed to assist dependent residents with Activities of
Daily Living (ADL's) by 1) not providing showers as scheduled for two residents (#1 and #6) of three
residents sampled, and 2) not providing transfer assistance as requested for one resident (#7) out of three
residents sampled.
Residents Affected - Few
Findings Included:
1) A review of Resident #1's admission Record revealed she was admitted to the facility on [DATE] and
discharged on 2/8/2023 with a primary diagnosis of wedge compression fracture of unspecified lumbar
vertebra, subsequent encounter for fracture with routine healing. Further diagnoses included: collapsed
vertebra, syncope and collapse, history of falling, muscle weakness, unsteadiness on feet, unspecified
abnormalities of gait and mobility, repeated falls, fall on same level from slipping, tripping, and stumbling
with subsequent striking against object.
A review of the Minimum Data Set (MDS), dated [DATE], Section C: Cognitive Pattern revealed a Brief
Interview for Mental Status (BIMS) summary score of 15. A score of 15 indicates the resident was
cognitively intact. A review of Section G: Functional Status revealed help limited to one person for transfer.
Section GG: Self Care revealed shower bathe/self-performance: substantial/maximal assistance.
A review of Resident #1's Bathing documentation, dated January 2023 and February 2023, revealed
showers were scheduled on Tuesday/Thursday/Saturday on the 3-11 shift. The documentation review
reflected Resident #1 was provided showers on 1/12/23, 1/19/23, 1/21/23, 1/24/23, 1/26/23, 2/2/23, 2/4/23,
and 2/7/23. Resident #1 received eight of the fourteen scheduled showers during her stay at the facility.
On 7/10/2023 at 10:45 a.m. Resident #6 was receptive to an interview and smiled when approached. She
appeared comfortable sitting in her wheelchair with her right leg elevated on three pillows. A sign was
posted in the resident's room indicating her shower days were on Monday, Wednesday, and Friday. When
asked about the sign she stated, Those are the days the facility provides showers, she laughed out loud
and stated, I've never had three showers in one week. I get maybe one a week. She said she would be
happy with two showers a week. Her hair was oily in appearance. Resident #6 said, I need help with my
showers, my right leg doesn't work. It hasn't since I had a stroke, it's been like that for a few years now.
Resident #6 said her last shower was, last Wednesday, or maybe Monday. She stated The aide did not help
me. She stood behind the chair and talked on her phone the whole time. I need help I can't reach certain
areas. Resident #6 reached with her right arm to the left side of her torso, she stated, I can't reach that far.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 8
Event ID:
105650
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105650
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/11/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Bayshore Pointe Nursing and Rehab Center
3117 W Gandy Blvd
Tampa, FL 33611
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0677
Level of Harm - Minimal harm
or potential for actual harm
A review of Resident #6's admission Record revealed she was admitted to the facility on [DATE] with a
diagnoses including Hemiplegia and Hemiparesis following cerebral infarction affecting right dominant side,
localized swelling, mass and lump, lower limb bilateral.
A review of the MDS, dated [DATE] revealed a BIMS total score of 15, indicating intact cognition.
Residents Affected - Few
A review of the Resident #6's Bathing documentation, dated July 2023, revealed Showers/Bathing
scheduled on Monday-Wednesday-Friday, evening shift. The review of the documentation reflected
Resident #6 was provided showers on 7/5/23 and 7/8/23. There was no shower documented for 7/3/23.
On 7/11/2023 at 4:30 p.m. the Nursing Home Administrator (NHA) stated she was unaware showers were
not being performed as scheduled, she confirmed showers should be provided and documented as
planned for the resident.
2) Resident #7 is a [AGE] year-old male resident admitted to the facility on [DATE] from an acute care
hospital with diagnoses including but are not limited to, chronic kidney disease stage 3, dementia without
behavioral disturbances, weakness, cognitive communication deficit, and muscle weakness.
On 7/10/23 at 10:20 a.m. Resident #7 called out to the surveyor, Hey I need help in here! I need to get in
my bed, I've been sitting here a long time! The resident rolled his eyes and turned on his call light.
On 7/10/23 at 10:25 a.m. Resident #7's assigned Certified Nursing Assistant (CNA), Staff A, went into the
resident's room, turned off the call light and walked out of the room.
On 7/10/23 at 10:30 a.m. Resident #7 was reinterviewed, and he said, The girl came in, but she didn't say
anything to me. I want something to eat, and I want to get in bed! I'm older than you and everyone here and
I can't get any help around here!
An interview was conducted on 7/10/23 at 10:38 am. with Staff D, CNA she said, When I went into the room
for the call light, he [Resident #7] wanted to go back to bed but I just got him up and made his bed and I
think he is going to therapy, and I just came out of another room. The CNA was informed the resident
requested to get in bed again and wanted a snack. The CNA said He just had breakfast. I'm not sure if we
have any snacks. The CNA asked the Unit Manager if the resident could have a snack and she obtained the
snack and brought it to Resident #7 and immediately walked back out of his room.
On 7/10/23 at 10:41 a.m. Resident #7 was observed still sitting in his wheelchair next to his bed and eating
his snack.
On 7/10/23 at 10:56 a.m. Resident #7 was observed still sitting in his wheelchair next to his bed and he
yelled out Hey I need some help! Staff B, Registered Occupational Therapist (OTR) went into the resident's
room and put the resident's call light on and went to talk with the nurse.
On 7/10/23 at 10:58 a.m. Staff B, OTR checked back in with Resident #7 and said, I am still looking for your
CNA. The resident was yelling, I need to get back in bed! Staff B, OTR stated I'm not sure how you transfer
let me find out. Staff B, OTR called out to other staff from the resident's doorway. Staff B, OTR left the
resident's doorway and walked over to another staff member and was overheard talking to the other staff
member, I'm trying to find a CNA to transfer him.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105650
If continuation sheet
Page 2 of 8
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105650
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/11/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Bayshore Pointe Nursing and Rehab Center
3117 W Gandy Blvd
Tampa, FL 33611
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0677
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
On 7/10/23 at 11:07 a.m. Resident #7 was observed to be lying in his bed covered with a sheet watching
television.
An interview was conducted with Staff B, OTR on 7/10/23 at 11:07 a.m. she said [Staff C, CNA] helped
transfer [Resident #7] she's awesome. But I was asking around because [Resident #7] isn't my patient and I
wasn't sure how he transferred.
A review of Resident #7's admission Minimum Data Set (MDS) Section C, Cognitive Patterns, dated
6/28/23, revealed a BIMS score of 4 out of 15 indicating severe cognitive impairment.
A review of Resident #7's care plan revised on 7/5/2023 revealed his ADL (Activities of Daily Living) Self
Care Performance care plan had a goal of Resident will maintain current level of function through the
review date. Interventions included but are not limited to Transfers: Hoyer x2 person assist.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105650
If continuation sheet
Page 3 of 8
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105650
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/11/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Bayshore Pointe Nursing and Rehab Center
3117 W Gandy Blvd
Tampa, FL 33611
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0697
Provide safe, appropriate pain management for a resident who requires such services.
Level of Harm - Actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, interviews, and record review the facility failed to ensure pain was managed in a timely
manner for one resident (#3) out of three sampled residents. The facility failed to provide Resident #3
Physician ordered pain medication for nineteen hours, as she yelled and cried during the night shift, while
waiting for the pharmacy to fill the pain medication order.
Residents Affected - Few
Findings included:
1) On 07/10/2023 at 10:11 a.m. Resident #3 was observed leaving her bedroom with a therapist. Her Home
Companion was present and confirmed the resident had received a pain medication an hour earlier. The
Companion stated she has been with Resident #3 since April 2023, and spends five days a week with her.
She added, I followed her over from the hospital when she was admitted to the nursing home. She said she
knew Resident #3 was having pain when she arrived, but it was close to the end of her shift. She said the
nurse came in and was informed of the pain. The Companion said another companion came in shortly after
it was the end of her shift.
A review of the admission Record revealed Resident #3 was admitted to the facility 06/16/23 at 6:30 p.m.
with a diagnosis to include fracture of other parts of pelvis, subsequent encounter for fracture with routine
healing, encounter for other orthopedic after care, unspecified fracture of sacrum, presence of right artificial
hip and right knee joint.
A review of the hospital Discharge summary, dated [DATE], revealed the following: Discharge medication:
Continue: Oxycodone (Oxycodone 10 milligram (mg) oral tablet) 10 mg=1 tab(s), oral (PO), every (q) 4
hours (hr.) (interval), as needed (PRN): Pain.
Hospital Course: admitted from: emergency department. Chief Complaint: Ground Level Fall (GLF), pelvic
fracture. Found to have a pelvic fracture and therefore for further evaluation and treatment. Pelvic fracture
S2 & S3, compression fx of T5, L4, L5: Orthopedic consulted. Will also consult pain management for pain
control. CT Thoracic (T)/Lumbar (L) spine: acute sacral fracture S1, S2; age indeterminate moderate
compression.
A review of Physician orders revealed the following:
Oxycodone Hydrochloride oral tablet 5 mg Give I tablet by mouth every 4 hours as needed for acute pain
start date 06/17/2023 10:03 a.m.
A review of Nursing Progress Notes dated, 06/17/2023 06:41, Note Text: Resident was admitted on [DATE],
report said around 6:30 p.m. (1830). Resident has been yelling and crying out all shift, keeping her
roommate awake for majority of the night. Writer explained to Resident that her pain medication script will
be sent to pharmacy to be filled. Behaviors continued the entire shift.
A review of the Medication Administration Record (MAR) reflected the first dose of Oxycodone was
administered on 06/17/2023 at 2:10 p.m. for a pain level of 9 (score of 0 means no pain, and 10 means the
worst pain you have ever felt). This indicated Resident #3 was not administered a pain medication for over
nineteen hours after her admission.
On 07/11/2023 at 11:40 a.m. a phone interview was conducted with the facility Orthopedic Consultant
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105650
If continuation sheet
Page 4 of 8
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105650
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/11/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Bayshore Pointe Nursing and Rehab Center
3117 W Gandy Blvd
Tampa, FL 33611
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0697
Level of Harm - Actual harm
Residents Affected - Few
he said he was aware of Resident #3 and the surgical procedure. He said the bilateral screw placement
was to prevent a spinal fracture. He said if it was not performed, she could be paralyzed. The Orthopedic
Consultant stated, it's a painful procedure and indicated post-operatively it's still going to hurt. He said he
was unaware her Oxycodone was not received timely. He stated, that's not ideal. He went on to say they
have my phone number on file; they should have notified me. I would have called in script right away.
On 07/11/2023 at 1:36 p.m. an interview was conducted with the Nursing Home Administrator who
indicated she was unaware Resident #3 was not provided her pain medication until 06/17/2023 at 2:10 p.m.
as documentation reflected and the resident was in pain all night.
On 07/11/2023 at 2:59 p.m. an interview was conducted with the Regional Clinical Director she confirmed
when Resident #3 was admitted her pain medication was not administered for almost 24 hours. The
Regional Clinical Director stated, She did not come with a script. I spoke to the nurse who said she tried to
call the Physician. He did not call her back until the next morning. She said they don't need to wait for the
attending Physician to call back. They could have called the Medical Director. The Regional Director said
the nurse is a new nurse and we started education on pain management.
On 07/11/2023 at 3:35 p.m. Resident #3 was observed lying in bed on her right hip she smiled and waved
her hand in a gesture to approach on the right side of the bed. She appeared thin and frail and said she
was having pain. She asked, Can you move my leg, it hurts like that. Resident #3's Home Companion was
present and stated, She needs to stay on her side. The Companion stated out loud, You can have another
pain pill in 20 minutes.
On 07/12/2023 at 10:47 a.m. a phone interview was conducted with the facility Medical Director he stated
he was unaware Resident #3's narcotic was delayed for nineteen-hours. He confirmed he knew about
Resident #3 and the surgical procedure that was performed he stated, That should not have ever happened
the patient should not have suffered through this. We have mechanisms in place for emergency
authorization for that. They have access to a Physician on call, if there is no script, we will call it in right way.
That should never have happened. The Medical Director said, They need to educate the nurses, all of their
problems are solvable. Educating the nurses that are not aware on how to get a hard script, again I think it
is more of an education.
A review of the facility policy titled Pain Evaluation Chapter: Neurologic Revised: 08/23/2016 revealed the
following:
PURPOSE: The assessment includes the frequency and intensity of signs and symptoms of pain and can
be used to identify indicators of pain as well as to monitor residents to pain management interventions. It
also attempts to target the site of pain.
FUNDAMENTAL INFORMATION: Pain refers to any type of physical pain, or discomfort in any part of the
body. Pain may be localized to one area or may be more generalized. It may be acute or chronic,
continuous, or intermittent (comes and goes), or occur at rest or with movement. The pain experience is
very subjective; pain is whatever the resident says it is.
Procedure: 3. Observe resident for indicators of pain. Indicators include moaning, crying, and other
vocalizations. 6. Assess on 0-10 scale (Wong-Baker). 7. Ask the resident and observe to determine the
location of pain. 8. Contact the physician or orders.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105650
If continuation sheet
Page 5 of 8
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105650
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/11/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Bayshore Pointe Nursing and Rehab Center
3117 W Gandy Blvd
Tampa, FL 33611
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0867
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop
corrective plans of action.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, interviews, record reviews, and the Plan of Correction (POC) review, the facility failed to
ensure it had a functioning Quality Assurance (QA) Committee. The facility was actively involved in the
effective creation, implementation, and monitoring of the POC for deficient practice identified during a
complaint survey conducted on 07/11/2023. The facility was cited during the complaint survey for F697. On
09/07/2023 through 07/08/2023 a revisit survey was conducted, and the facility was recited at F697. The
facility had developed a Plan of Correction with a completion date by 08/11/2023. The facility had not
comprehensively implemented the Plan of Correction for the identified quality deficiencies.
Findings included:
On 09/07/23 at 10:15 a.m., Resident #6 was observed sitting in her room in a wheelchair next to her bed.
She stated she had a lot of pain in her right shoulder due to a stroke. She stated the nurse gave her Tylenol
for the pain, but it only works for the first two hours. She stated the nurse gave her the medicine at the
correct times, but she is in pain again after two hours.
On 09/08/23 at 9:48 a.m., the resident was observed sitting on the side of her bed. A Physical Therapist
was in the room setting Resident #6 up for therapy. The resident stated she was in pain, and it hurts all the
time in her right arm and right shoulder. She stated she gets Tylenol, but it only works for two hours, and
she has to wait another 2 to 4 hours in pain before she can get another pill. Resident #6 stated maybe if
she had a sling to put the right arm in, it wouldn't hurt so bad.
A review of the admission Record revealed Resident #6 was admitted on [DATE] with a diagnosis to include
hemiplegia and hemiparesis following cerebral infarction affecting right dominant side.
A review of the Minimum Data Set (MDS), dated [DATE], Section C: Cognitive Patterns showed a Brief
Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact.
A review of the Order Summary Report, with active orders as of 09/08/23, revealed the following orders for
pain:
06/06/23- Pain Evaluation- Document pain level and non-pharmacological interventions.
06/10/23- Tylenol Oral Tablet 325 MG (Acetaminophen)- Give 2 tablet by mouth every 6 hours as needed
for pain.
A review of the Progress Notes revealed the following:
08/04/23 10:06 a.m.- Placed a call to the doctor on call in reference to the resident requesting Tylenol every
4 hours instead of every 6 hours. Message left with answering services. Awaiting medical doctor return call.
A review of the care plan revealed the following focus area:
Chronic pain, initiated on 06/06/23, and included the following intervention: discuss with resident
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105650
If continuation sheet
Page 6 of 8
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105650
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/11/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Bayshore Pointe Nursing and Rehab Center
3117 W Gandy Blvd
Tampa, FL 33611
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0867
the need to request pain medications before pain becomes severe.
Level of Harm - Minimal harm
or potential for actual harm
On 09/08/23 at 9:50 a.m., an interview was conducted with Staff E, Licensed Practical Nurse (LPN). Staff E
stated she received report from the night nurse that she gave Resident #6 pain medication on her shift.
Staff E, LPN, stated the nurse aide also told her Resident #6 was in pain earlier this shift but she had not
made it to her room yet to give the resident pain medication. She stated if she would have known Resident
#6 was in a lot of pain since yesterday, she would have reported this to pain management.
Residents Affected - Few
On 09/08/23 at 12:36 p.m., the Interim Director of Nursing (DON) stated Resident #6 never mentioned a
concern about pain to the Nurse Practitioner and she never mentioned being in pain to any staff member.
The Interim DON stated she got an order for scheduled Tylenol for pain this morning and Pain Management
will be seeing the resident. She confirmed there was no follow up note related to Resident #6 requesting
Tylenol every 4 hours instead of every 6 hours. The Interim DON stated when she completed the audits
related to pain, she focused on residents with scheduled pain medications versus residents with orders for
as needed (PRN) medications.
A review of the facility policy titled Pain Evaluation Chapter: Neurologic Revised: 08/23/2016 revealed the
following:
PURPOSE: The assessment includes the frequency and intensity of signs and symptoms of pain and can
be used to identify indicators of pain as well as to monitor residents to pain management interventions. It
also attempts to target the site of pain.
FUNDAMENTAL INFORMATION: Pain refers to any type of physical pain, or discomfort in any part of the
body. Pain may be localized to one area or may be more generalized. It may be acute or chronic,
continuous, or intermittent (comes and goes), or occur at rest or with movement. The pain experience is
very subjective; pain is whatever the resident says it is.
PROCEDURE: 3. Observe resident for indicators of pain. Indicators include moaning, crying, and other
vocalizations.
6. Assess on 0-10 scale (Wong-Baker).
7. Ask the resident and observe to determine the location of pain.
8. Contact the physician for orders.
A review of the facility policy titled Quality Assurance and Performance Improvement- QAPI Chapter:
Center Administration Revised: 08/30/2022 revealed the following:
POLICY
Each center maintains a Quality Assessment and Assurance QA&A Committee, which is responsible for
developing the Quality Assessment and Performance Improvement (QAPI) plans.
The committee develops, implements, monitors, and maintains appropriate date-driven programs that
focuses on indicators of the outcomes of care and quality of life; plans of action to address quality issues
identified internally or by regulatory agencies. Centers must present evidence of their
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105650
If continuation sheet
Page 7 of 8
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105650
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/11/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Bayshore Pointe Nursing and Rehab Center
3117 W Gandy Blvd
Tampa, FL 33611
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0867
ongoing QAPI program implementation and compliance with the requirements.
Level of Harm - Minimal harm
or potential for actual harm
e) Corrective actions address potential gaps in system processes, and are reevaluated for effectiveness;
and
Residents Affected - Few
f) Clear expectations are set around safety, quality, rights, choice, and respect.
Purpose:
The center develops a plan that describes the process for conducting QAA activities, such as identifying
and correcting quality deficiencies as well as opportunities for improvement, which will lead to improvement
in the lives of the residents, through continuous attention to quality of care, quality of life and resident
safety.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105650
If continuation sheet
Page 8 of 8
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Back to topCitations
3 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F697 - Pain Management
Provide safe, appropriate pain management for a resident who requires such services.
F867 - Program feedback, data systems and monitoring
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
FAQ · About this visit
Common questions about this visit
What happened during the July 11, 2023 survey of BAYSHORE POINTE NURSING AND REHAB CENTER?
This was a inspection survey of BAYSHORE POINTE NURSING AND REHAB CENTER on July 11, 2023. The surveyor cited 3 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at BAYSHORE POINTE NURSING AND REHAB CENTER on July 11, 2023?
Yes, 3 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide safe, appropriate pain management for a resident who requires such services."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.