Cycle 1
Health 2024-09-21 · Fire 2024-09-21
12 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Tampa, FL
Bayshore Pointe Nursing And Rehab Center
3-star overall rating with 2-star inspections with $23,560 in total fines with 12 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
3117 W Gandy Blvd, Tampa, FL
(813) 261-5500
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
117
Certified beds
Average residents
108
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Sovereign Healthcare Holdings
Operator or chain grouping
Approved since
1989-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
43 facilities
Chain averages 4 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.86
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.67
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.20
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.73
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.53
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.40
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.72
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.20
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.88
CMS adjusted RN staffing hours
Adjusted total hours
3.80
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
53%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,755
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
28.88
Composite VBP score used to determine payment impact.
Payment multiplier
0.9852
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.43
Baseline 21.66% · Performance 20.30% · Measure score 2.43 · Achievement 2.43 · Improvement 2.43
Healthcare-associated infections
3.28
Baseline 6.35% · Performance 6.85% · Measure score 3.28 · Achievement 3.28 · Improvement 0
Total nurse turnover
3.41
Baseline 70.73% · Performance 52.78% · Measure score 3.41 · Achievement 2.67 · Improvement 3.41
Adjusted total nurse staffing
2.42
Baseline 3.94 hours · Performance 3.77 hours · Measure score 2.42 · Achievement 2.42 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.23% |
10.72%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 295 · Observed rate 12.54% · Lower 95% interval 8.74% |
| Discharge to community | 44.34% |
50.57%
6.2 pts worse
|
Worse than the National Rate · Eligible stays 274 · Observed rate 39.05% · Lower 95% interval 37.34% |
| Medicare spending per beneficiary | 1.04 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 98.23% |
95.27%
3 pts better
|
Numerator 222 · Denominator 226 |
| Falls with major injury | 1.33% |
0.77%
0.6 pts worse
|
Numerator 3 · Denominator 226 |
| Discharge self-care score | 57.14% |
53.69%
3.5 pts better
|
Numerator 56 · Denominator 98 |
| Discharge mobility score | 58.16% |
50.94%
7.2 pts better
|
Numerator 57 · Denominator 98 |
| Pressure ulcers or injuries, new or worsened | 0.88% |
2.29%
1.4 pts better
|
Numerator 2 · Denominator 226 · Adjusted rate 0.7% |
| Healthcare-associated infections requiring hospitalization | 6.85% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 154 · Observed rate 6.49% · Lower 95% interval 4.23% |
| Staff COVID-19 vaccination coverage | 8.64% |
8.2%
0.4 pts better
|
Numerator 14 · Denominator 162 |
| Staff flu vaccination coverage | 35.67% |
42%
6.3 pts worse
|
Numerator 61 · Denominator 171 |
| Discharge function score | 63.27% |
56.45%
6.8 pts better
|
Numerator 62 · Denominator 98 |
| Transfer of health information to provider | 68.64% |
95.95%
27.3 pts worse
|
Numerator 81 · Denominator 118 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 33 · Denominator 33 |
| Resident COVID-19 vaccinations up to date | 26.56% |
25.2%
1.4 pts better
|
Numerator 34 · Denominator 128 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
2.1
0.4 pts better
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.5 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
1.2
0.1 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 0.9 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.8%
2.2 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
99.2%
0.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.4% |
2.6%
0.8 pts worse
|
3.3%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 2.5% · Q3 3.7% · Q4 3.5% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 11.6% |
3.7%
7.9 pts worse
|
11.4%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 17.4% · Q3 7.9% · Q4 14.5% · 4Q avg 11.6% |
| Percentage of long-stay residents who lose too much weight | 7.2% |
5.9%
1.3 pts worse
|
5.4%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 9.3% · Q3 5.5% · Q4 11.8% · 4Q avg 7.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.8% |
15.7%
6.9 pts better
|
19.6%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 14.5% · Q3 3.6% · Q4 2.0% · 4Q avg 8.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.0% |
9.8%
0.2 pts worse
|
16.7%
6.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 9.4% · Q3 9.7% · Q4 9.6% · 4Q avg 10.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 7.3% |
11.7%
4.4 pts better
|
16.3%
9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.5% · Q2 7.6% · Q3 3.0% · Q4 8.4% · 4Q avg 7.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.1% |
9.8%
5.7 pts better
|
14.9%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 5.7% · Q3 3.6% · Q4 2.0% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.4%
0.4 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.9% |
0.8%
0.1 pts worse
|
1.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.2% · Q4 2.4% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.4% |
12.5%
5.9 pts worse
|
19.8%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 32.6% · Q2 18.4% · Q3 16.0% · Q4 8.4% · 4Q avg 18.4% |
| Percentage of long-stay residents with pressure ulcers | 1.3% |
5.1%
3.8 pts better
|
5.1%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 1.1% · Q3 1.1% · Q4 0.9% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.7% |
94.3%
3.4 pts better
|
81.7%
16 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.5% · Q2 98.9% · Q3 97.0% · Q4 98.3% · 4Q avg 97.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.5% |
9.3%
2.8 pts better
|
12.0%
5.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.5% · Observed 6.5% · Expected 11.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.5%
0.8 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.1% · Q4 1.8% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.3% |
94.7%
3.6 pts better
|
79.7%
18.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.8% |
26.2%
1.6 pts worse
|
23.9%
3.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.8% · Observed 26.6% · Expected 22.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-06-23 · Fire 2022-06-23
9 health deficiencies
Top issue: Nutrition and Dietary (4 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2021-02-26 · Fire 2021-02-26
12 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-09-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-31
D · Potential for more than minimal harm
2024-09-21
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-10-31
D · Potential for more than minimal harm
2024-09-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-10-31
D · Potential for more than minimal harm
2022-06-23
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2022-07-21
D · Potential for more than minimal harm
2022-06-23
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-07-21
D · Potential for more than minimal harm
2022-06-23
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-07-21
D · Potential for more than minimal harm
2021-02-26
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2021-03-26
D · Potential for more than minimal harm
2021-02-26
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2021-03-26
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-09-21
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-10-31
E · Potential for more than minimal harm
2024-09-21
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-10-31
E · Potential for more than minimal harm
2024-09-21
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-10-31
E · Potential for more than minimal harm
2024-09-21
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-10-31
E · Potential for more than minimal harm
2024-09-21
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-10-31
E · Potential for more than minimal harm
2024-09-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-31
D · Potential for more than minimal harm
2024-09-21
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-10-31
D · Potential for more than minimal harm
2024-09-21
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-10-31
D · Potential for more than minimal harm
2024-09-21
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-10-31
D · Potential for more than minimal harm
2024-09-21
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-10-31
D · Potential for more than minimal harm
2024-09-21
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2024-10-31
D · Potential for more than minimal harm
2024-09-21
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2024-10-31
D · Potential for more than minimal harm
2023-09-08
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2023-10-08
D · Potential for more than minimal harm
2023-09-08
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-10-08
G · Actual harm
2023-07-11
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-10-08
D · Potential for more than minimal harm
2023-07-11
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-08-11
D · Potential for more than minimal harm
2023-07-11
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-10-08
E · Potential for more than minimal harm
2022-06-23
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2022-07-23
E · Potential for more than minimal harm
2022-06-23
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-07-23
E · Potential for more than minimal harm
2022-06-23
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2022-07-23
E · Potential for more than minimal harm
2022-06-23
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-07-23
D · Potential for more than minimal harm
2022-06-23
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-07-23
D · Potential for more than minimal harm
2022-06-23
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2022-07-23
D · Potential for more than minimal harm
2022-06-23
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-07-23
D · Potential for more than minimal harm
2022-06-23
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-07-23
D · Potential for more than minimal harm
2022-06-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-07-23
E · Potential for more than minimal harm
2021-02-26
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2021-03-26
D · Potential for more than minimal harm
2021-02-26
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2021-03-26
D · Potential for more than minimal harm
2021-02-26
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2021-03-26
D · Potential for more than minimal harm
2021-02-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-03-26
D · Potential for more than minimal harm
2021-02-26
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2021-03-26
D · Potential for more than minimal harm
2021-02-26
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2021-03-26
D · Potential for more than minimal harm
2021-02-26
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2021-03-26
Penalties and ownership
What sits behind the stars
$3,728
2023-07-11
Fine
Fine · fine $3,728
Fine
$3,728
2023-07-11
Fine
Fine · fine $3,728
Fine
$3,728
2023-07-11
Fine
Fine · fine $3,728
Fine
$3,728
2023-07-11
Fine
Fine · fine $3,728
Fine
$8,648
2023-07-11
Fine
Fine · fine $8,648
Fine
Ownership
Chazhikattu, Ambrose John
Operational/Managerial Control · Individual
Cronquist, Royce
Operational/Managerial Control · Individual
Fitzpatrick, Cynthia
Operational/Managerial Control · Individual
Mangine, John
Operational/Managerial Control · Individual
Melton, Donald
Operational/Managerial Control · Individual
Notermann, William
Operational/Managerial Control · Individual
Southern Healthcare Management LLC
Operational/Managerial Control · Organization
Tampa Health Properties, Ltd.
5% Or Greater Security Interest · Organization
Nearby options
Other facilities in reach
#1
Canterbury Towers Inc
Tampa, FL
5-star overall rating with 4-star inspections with 3 recent health deficiencies
#2
Vivo Healthcare Gandy
Tampa, FL
3-star overall rating with 2-star inspections with 12 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Ybor City Center For Rehabilitation And Healing
Tampa, FL
3-star overall rating with 2-star inspections with 13 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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