Cycle 1
Health 2024-08-15 · Fire 2024-08-15
4 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Hudson, FL
Bayonet Point Health Center By Harborview
4-star overall rating with 3-star inspections with 4 recent health deficiencies
8132 Hudson Avenue, Hudson, FL
(727) 863-3100
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
115
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Harborview Health Systems
Operator or chain grouping
Approved since
1993-02-22
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
21 facilities
Chain averages 2 overall / 2 health / 3 staffing / 2 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
0.58
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
1.04
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.08
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.71
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.63
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.18
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.27
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.61
CMS adjusted RN staffing hours
Adjusted total hours
3.87
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
65%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
47%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,783
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
22.56
Composite VBP score used to determine payment impact.
Payment multiplier
0.9829
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.79% · Performance 23.12% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 6.35% · Performance 8.45% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
6.83
Baseline 90.60% · Performance 42.39% · Measure score 6.83 · Achievement 5.21 · Improvement 6.83
Adjusted total nurse staffing
2.19
Baseline 3.72 hours · Performance 3.70 hours · Measure score 2.19 · Achievement 2.19 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.17% |
10.72%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 117 · Observed rate 13.68% · Lower 95% interval 7.34% |
| Discharge to community | 43.57% |
50.57%
7 pts worse
|
No Different than the National Rate · Eligible stays 87 · Observed rate 39.08% · Lower 95% interval 34.99% |
| Medicare spending per beneficiary | 0.95 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 95.93% |
95.27%
0.7 pts better
|
Numerator 165 · Denominator 172 |
| Falls with major injury | 0.58% |
0.77%
0.2 pts better
|
Numerator 1 · Denominator 172 |
| Discharge self-care score | 42.47% |
53.69%
11.2 pts worse
|
Numerator 31 · Denominator 73 |
| Discharge mobility score | 31.51% |
50.94%
19.4 pts worse
|
Numerator 23 · Denominator 73 |
| Pressure ulcers or injuries, new or worsened | 1.74% |
2.29%
0.6 pts better
|
Numerator 3 · Denominator 172 · Adjusted rate 1.63% |
| Healthcare-associated infections requiring hospitalization | 8.45% |
7.12%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 64 · Observed rate 10.94% · Lower 95% interval 5.25% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 181 |
| Staff flu vaccination coverage | 9.38% |
42%
32.6 pts worse
|
Numerator 18 · Denominator 192 |
| Discharge function score | 50.68% |
56.45%
5.8 pts worse
|
Numerator 37 · Denominator 73 |
| Transfer of health information to provider | 80.52% |
95.95%
15.4 pts worse
|
Numerator 62 · Denominator 77 |
| Transfer of health information to patient | 94.74% |
96.28%
1.5 pts worse
|
Numerator 54 · Denominator 57 |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 74 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.7 |
2.1
1.4 pts better
|
1.9
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.5 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.5 |
1.2
0.7 pts better
|
1.8
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.4 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
97.8%
1.5 pts better
|
93.4%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.6% · Q3 98.7% · Q4 100.0% · 4Q avg 99.3% |
| 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 | 1.3% |
2.6%
1.3 pts better
|
3.3%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.4% · Q3 1.3% · Q4 1.4% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.4% |
3.7%
3.3 pts better
|
11.4%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.4% · 4Q avg 0.4% |
| Percentage of long-stay residents who lose too much weight | 3.8% |
5.9%
2.1 pts better
|
5.4%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 6.2% · Q3 5.6% · Q4 1.6% · 4Q avg 3.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 30.5% |
15.7%
14.8 pts worse
|
19.6%
10.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 38.8% · Q2 32.4% · Q3 26.8% · Q4 24.2% · 4Q avg 30.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.5% |
9.8%
3.3 pts better
|
16.7%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 8.9% · Q3 6.7% · Q4 5.2% · 4Q avg 6.5% · 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 | 17.4% |
11.7%
5.7 pts worse
|
16.3%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 17.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.4% |
9.8%
0.4 pts better
|
14.9%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 6.0% · Q3 15.7% · Q4 10.9% · 4Q avg 9.4% · 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 | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 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 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 23.8% · Q2 10.3% · Q3 23.6% · Q4 14.9% · 4Q avg 18.4% |
| Percentage of long-stay residents with pressure ulcers | 2.6% |
5.1%
2.5 pts better
|
5.1%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.5% · Q3 3.8% · Q4 4.4% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.2% |
94.3%
0.9 pts better
|
81.7%
13.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 93.2% · Q2 93.7% · Q3 97.2% · Q4 97.2% · 4Q avg 95.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.0% |
9.3%
2.3 pts better
|
12.0%
5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.0% · Observed 6.8% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
1.5%
0.6 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 1.4% · Q3 0.5% · Q4 0.5% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 89.4% |
94.7%
5.3 pts worse
|
79.7%
9.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 89.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.6% |
26.2%
2.4 pts worse
|
23.9%
4.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.6% · Observed 26.2% · Expected 21.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-07-28 · Fire 2022-07-28
3 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2021-04-08 · Fire 2021-04-08
2 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2022-07-28
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2022-08-18
D · Potential for more than minimal harm
2022-07-28
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-08-18
D · Potential for more than minimal harm
2022-07-28
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2022-08-18
D · Potential for more than minimal harm
2021-04-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-04-27
D · Potential for more than minimal harm
2021-04-08
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2021-04-27
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-08-15
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 2024-09-13
E · Potential for more than minimal harm
2024-08-15
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-09-13
D · Potential for more than minimal harm
2024-08-15
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 2024-09-13
D · Potential for more than minimal harm
2024-08-15
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-09-13
E · Potential for more than minimal harm
2022-07-28
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 2022-08-18
D · Potential for more than minimal harm
2022-07-28
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 2022-08-18
D · Potential for more than minimal harm
2022-07-28
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 2022-08-18
D · Potential for more than minimal harm
2021-04-08
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2021-04-27
D · Potential for more than minimal harm
2021-04-08
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 2021-04-27
Penalties and ownership
What sits behind the stars
Ownership
Harborview Bayonet Point Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Cl 2022 Irrv Tr
5% Or Greater Indirect Ownership Interest · Organization
De 2021 Irrv Tr
5% Or Greater Indirect Ownership Interest · Organization
Dilella, Vincent
Operational/Managerial Control · Individual
Fl 7 Nursing And Rehab Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Leibowitz, Chaim
Operational/Managerial Control · Individual
Lucadano, Kimberly
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Windsor Woods Rehab And Healthcare Center
Hudson, FL
3-star overall rating with 3-star inspections with 9 recent health deficiencies
#2
Solaris Healthcare Bayonet Point
Hudson, FL
3-star overall rating with 2-star inspections with $90,650 in total fines with 12 recent health deficiencies
#3
Bear Creek Nursing Center
Hudson, FL
2-star overall rating with 2-star inspections with $37,198 in total fines with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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