Cycle 1
Health 2024-03-14 · Fire 2024-03-14
6 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Hudson, FL
Bear Creek Nursing Center
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
8041 State Rd 52, Hudson, FL
(727) 863-5488
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
103
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Health Services Management
Operator or chain grouping
Approved since
1981-09-15
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
16 facilities
Chain averages 3 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
0.71
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.61
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.15
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.46
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.31
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.20
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.49
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.73
CMS adjusted RN staffing hours
Adjusted total hours
3.55
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
57%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,476
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
16.67
Composite VBP score used to determine payment impact.
Payment multiplier
0.9817
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.11
Baseline 22.41% · Performance 19.93% · Measure score 4.11 · Achievement 3.24 · Improvement 4.11
Healthcare-associated infections
0
Baseline 7.28% · Performance 8.26% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Performance 64.46% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
2.56
Baseline 4 hours · Performance 3.81 hours · Measure score 2.56 · Achievement 2.56 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.39% |
10.72%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 171 · Observed rate 12.87% · Lower 95% interval 8.16% |
| Discharge to community | 40.93% |
50.57%
9.6 pts worse
|
Worse than the National Rate · Eligible stays 142 · Observed rate 33.8% · Lower 95% interval 33.06% |
| Medicare spending per beneficiary | 0.97 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 99.33% |
95.27%
4.1 pts better
|
Numerator 148 · Denominator 149 |
| Falls with major injury | 0.67% |
0.77%
0.1 pts better
|
Numerator 1 · Denominator 149 |
| Discharge self-care score | 34% |
53.69%
19.7 pts worse
|
Numerator 34 · Denominator 100 |
| Discharge mobility score | 41% |
50.94%
9.9 pts worse
|
Numerator 41 · Denominator 100 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 149 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.26% |
7.12%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 78 · Observed rate 10.26% · Lower 95% interval 5.48% |
| Staff COVID-19 vaccination coverage | 22.09% |
8.2%
13.9 pts better
|
Numerator 38 · Denominator 172 |
| Staff flu vaccination coverage | 60.89% |
42%
18.9 pts better
|
Numerator 246 · Denominator 404 |
| Discharge function score | 31% |
56.45%
25.5 pts worse
|
Numerator 31 · Denominator 100 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 75 · Denominator 75 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 6.82% |
25.2%
18.4 pts worse
|
Numerator 6 · Denominator 88 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.4 |
2.1
0.3 pts worse
|
1.9
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.3 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
1.2
0.3 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.8 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
97.8%
1.6 pts better
|
93.4%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 97.6% · Q4 100.0% · 4Q avg 99.4% |
| 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 | 1.8% |
2.6%
0.8 pts better
|
3.3%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 2.5% · Q3 1.2% · Q4 2.5% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
3.7%
3.7 pts better
|
11.4%
11.4 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 who lose too much weight | 14.1% |
5.9%
8.2 pts worse
|
5.4%
8.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 23.5% · Q3 21.6% · Q4 2.6% · 4Q avg 14.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.4% |
15.7%
8.7 pts worse
|
19.6%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.7% · Q2 26.0% · Q3 23.8% · Q4 26.2% · 4Q avg 24.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.6% |
9.8%
3.2 pts better
|
16.7%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 8.8% · Q3 4.6% · Q4 6.0% · 4Q avg 6.6% · 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 | 2.7% |
11.7%
9 pts better
|
16.3%
13.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 8.3% · Q4 3.4% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.0% |
9.8%
4.8 pts better
|
14.9%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 6.8% · Q3 6.6% · Q4 3.9% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.4%
0.1 pts worse
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.0% · Q4 1.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.3% |
0.8%
0.5 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 7.5% |
12.5%
5 pts better
|
19.8%
12.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 14.6% · Q3 11.9% · Q4 1.3% · 4Q avg 7.5% |
| Percentage of long-stay residents with pressure ulcers | 6.5% |
5.1%
1.4 pts worse
|
5.1%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 8.5% · Q3 9.9% · Q4 3.3% · 4Q avg 6.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.8% |
94.3%
3.5 pts better
|
81.7%
16.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 95.3% · Q4 96.5% · 4Q avg 97.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.0% |
9.3%
2.7 pts worse
|
12.0%
About the same
|
Short Stay · 20240701-20250630 · Adjusted 12.0% · Observed 12.0% · Expected 11.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.4% |
94.7%
4.7 pts better
|
79.7%
19.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.1% |
26.2%
3.9 pts worse
|
23.9%
6.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.1% · Observed 30.6% · Expected 24.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-12-16 · Fire 2021-12-16
4 health deficiencies
Top issue: Environmental (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2020-10-02 · Fire 2020-10-02
10 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-03-14
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2024-04-12
D · Potential for more than minimal harm
2024-03-14
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2024-04-12
D · Potential for more than minimal harm
2024-03-14
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-04-12
D · Potential for more than minimal harm
2024-03-14
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-04-12
D · Potential for more than minimal harm
2021-12-16
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 2022-01-16
D · Potential for more than minimal harm
2021-12-16
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2022-01-16
D · Potential for more than minimal harm
2020-10-02
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2020-11-01
D · Potential for more than minimal harm
2020-10-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-11-01
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-03-14
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-04-12
E · Potential for more than minimal harm
2024-03-14
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-04-12
E · Potential for more than minimal harm
2024-03-14
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-04-12
D · Potential for more than minimal harm
2024-03-14
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-04-12
D · Potential for more than minimal harm
2024-03-14
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-04-12
D · Potential for more than minimal harm
2024-03-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-12
D · Potential for more than minimal harm
2023-12-18
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 2023-12-28
J · Immediate jeopardy
2023-10-27
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-11-14
J · Immediate jeopardy
2023-10-27
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-11-14
D · Potential for more than minimal harm
2023-10-27
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-11-14
D · Potential for more than minimal harm
2023-10-27
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-11-14
E · Potential for more than minimal harm
2021-12-16
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2022-01-16
D · Potential for more than minimal harm
2021-12-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-01-16
D · Potential for more than minimal harm
2021-12-16
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-01-16
D · Potential for more than minimal harm
2021-12-16
F909 · Environmental Deficiencies
Health
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected 2022-01-16
D · Potential for more than minimal harm
2020-10-02
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2020-11-01
D · Potential for more than minimal harm
2020-10-02
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 2020-11-01
D · Potential for more than minimal harm
2020-10-02
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 2020-11-01
D · Potential for more than minimal harm
2020-10-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2020-11-01
D · Potential for more than minimal harm
2020-10-02
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 2020-11-01
Penalties and ownership
What sits behind the stars
$34,053
2023-10-27
Fine
Fine · fine $34,053
Fine
$3,145
2023-07-17
Fine
Fine · fine $3,145
Fine
Ownership
Health Services Management, Inc.
5% Or Greater Direct Ownership Interest · Organization
Baxter, Kevin
Operational/Managerial Control · Individual
Baxter, Kevin
Corporate Officer · Individual
Fisher, Scott
Operational/Managerial Control · Individual
Fisher, Scott
Corporate Officer · Individual
Health Services Management, Inc.
Operational/Managerial Control · Organization
Jackson, Brian
Operational/Managerial Control · Individual
Jackson, Brian
Corporate Officer · Individual
National Health Investors, Inc.
5% Or Greater Mortgage Interest · Organization
Nhi-Reit Of Florida, LLC
5% Or Greater Mortgage Interest · Organization
Shatz, Jim
Operational/Managerial Control · Individual
Shatz, Jim
Corporate Officer · Individual
Talanga, Mario
Operational/Managerial Control · Individual
Timmons, Teresa
Operational/Managerial Control · Individual
White, Joshua
Operational/Managerial Control · Individual
White, Joshua
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
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
#2
Windsor Woods Rehab And Healthcare Center
Hudson, FL
3-star overall rating with 3-star inspections with 9 recent health deficiencies
#3
Bayonet Point Health Center By Harborview
Hudson, FL
4-star overall rating with 3-star inspections with 4 recent health deficiencies
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