Acute Care - Veterans AdministrationVeterans Health Admin.Emergency services

BAY PINES VA MEDICAL CENTER

10000 BAY PINES BLVD., BAY PINES, FL, 33744 · (727) 398-6661

CMS facility ID 10009F

CMS overall rating
3 / 5
Rating 3 of 5
Measures reported
70
across 3 measure groups
Patient survey rows
68
HCAHPS responses

How this hospital compares, by group

Counts published by CMS: how many of its measures were better, no different, or worse than the national average.

Measure group comparison counts
GroupBetterNo differentWorseMeasures reported
Mortality2305
Safety0314
Readmission0246

"Compared to National" labels are published by CMS itself. This site displays them as issued and does not derive or re-rank them.

Healthcare-associated infections

Infections patients acquired while in hospital. 36 measures.

MeasureCompared to nationalScore95% intervalCasesPeriod
Catheter Associated Urinary Tract Infections (ICU + select Wards)No different from national0.568——2024-10-01 → 2025-09-30
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence LimitNo different from national0.144——2024-10-01 → 2025-09-30
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter DaysNo different from national4564——2024-10-01 → 2025-09-30
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed CasesNo different from national3——2024-10-01 → 2025-09-30
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted CasesNo different from national5.281——2024-10-01 → 2025-09-30
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence LimitNo different from national1.546——2024-10-01 → 2025-09-30
Central Line Associated Bloodstream Infection (ICU + select Wards)No different from national0.294——2024-10-01 → 2025-09-30
Central Line Associated Bloodstream Infection (ICU + select Wards): Lower Confidence LimitNo different from national0.015——2024-10-01 → 2025-09-30
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed CasesNo different from national1——2024-10-01 → 2025-09-30
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted CasesNo different from national3.404——2024-10-01 → 2025-09-30
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence LimitNo different from national1.449——2024-10-01 → 2025-09-30
Central Line Associated Bloodstream Infection: Number of Device DaysNo different from national3238——2024-10-01 → 2025-09-30
Clostridium Difficile (C.Diff)—Not reported——2024-10-01 → 2025-09-30
Clostridium Difficile (C.Diff): Lower Confidence Limit—Not reported——2024-10-01 → 2025-09-30
Clostridium Difficile (C.Diff): Observed Cases—Not reported——2024-10-01 → 2025-09-30
Clostridium Difficile (C.Diff): Patient Days—Not reported——2024-10-01 → 2025-09-30
Clostridium Difficile (C.Diff): Predicted Cases—Not reported——2024-10-01 → 2025-09-30
Clostridium Difficile (C.Diff): Upper Confidence Limit—Not reported——2024-10-01 → 2025-09-30
MRSA Bacteremia—Not reported——2024-10-01 → 2025-09-30
MRSA Bacteremia: Lower Confidence Limit—Not reported——2024-10-01 → 2025-09-30
MRSA Bacteremia: Observed Cases—Not reported——2024-10-01 → 2025-09-30
MRSA Bacteremia: Patient Days—Not reported——2024-10-01 → 2025-09-30
MRSA Bacteremia: Predicted Cases—Not reported——2024-10-01 → 2025-09-30
MRSA Bacteremia: Upper Confidence Limit—Not reported——2024-10-01 → 2025-09-30
SSI - Abdominal Hysterectomy—Not reported——2024-10-01 → 2025-09-30
SSI - Abdominal Hysterectomy: Lower Confidence Limit—Not reported——2024-10-01 → 2025-09-30
SSI - Abdominal Hysterectomy: Number of Procedures—Not reported——2024-10-01 → 2025-09-30
SSI - Abdominal Hysterectomy: Observed Cases—Not reported——2024-10-01 → 2025-09-30
SSI - Abdominal Hysterectomy: Predicted Cases—Not reported——2024-10-01 → 2025-09-30
SSI - Abdominal Hysterectomy: Upper Confidence Limit—Not reported——2024-10-01 → 2025-09-30
SSI - Colon Surgery—Not reported——2024-10-01 → 2025-09-30
SSI - Colon Surgery: Lower Confidence Limit—Not reported——2024-10-01 → 2025-09-30
SSI - Colon Surgery: Number of Procedures—Not reported——2024-10-01 → 2025-09-30
SSI - Colon Surgery: Observed Cases—Not reported——2024-10-01 → 2025-09-30
SSI - Colon Surgery: Predicted Cases—Not reported——2024-10-01 → 2025-09-30
SSI - Colon Surgery: Upper Confidence Limit—Not reported——2024-10-01 → 2025-09-30

Complications and deaths

Rates of death and serious complications for common conditions, compared with the national average. 20 measures.

MeasureCompared to nationalScore95% intervalCasesPeriod
Abdominopelvic accidental puncture or laceration rateNo different from national1.470.52 – 2.421,6492022-07-01 → 2024-06-30
CMS Medicare PSI 90: Patient safety and adverse events compositeWorse Than the National Value1.381.08 – 1.67—2022-07-01 → 2024-06-30
Death rate among surgical inpatients with serious treatable complicationsNo different from national15093.16 – 206.85752022-07-01 → 2024-06-30
Death rate for CABG surgery patients—Not reported——2022-07-01 → 2025-06-30
Death rate for COPD patientsBetter Than the National Rate5.23.2 – 8.33622022-07-01 → 2025-06-30
Death rate for heart attack patientsNo different from national117.9 – 14.8982022-07-01 → 2025-06-30
Death rate for heart failure patientsNo different from national8.66 – 12.44372022-07-01 → 2025-06-30
Death rate for pneumonia patientsBetter Than the National Rate11.18 – 15.15252022-07-01 → 2025-06-30
Death rate for stroke patients—Not reported——2023-07-01 → 2025-06-30
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality RateBetter Than the National Rate3.12.6 – 3.82,3692024-07-01 → 2025-06-30
Iatrogenic pneumothorax rateNo different from national0.260.06 – 0.4710,8562022-07-01 → 2024-06-30
In-hospital fall-associated fracture rateNo different from national0.30.11 – 0.4811,4272022-07-01 → 2024-06-30
Perioperative pulmonary embolism or deep vein thrombosis rateNo different from national4.982.98 – 6.981,9752022-07-01 → 2024-06-30
Postoperative acute kidney injury requiring dialysis rateNo different from national1.270 – 2.781,2192022-07-01 → 2024-06-30
Postoperative hemorrhage or hematoma rateNo different from national2.30.93 – 3.681,7842022-07-01 → 2024-06-30
Postoperative respiratory failure rateNo different from national9.693.6 – 15.791,1642022-07-01 → 2024-06-30
Postoperative sepsis rateNo different from national5.572.33 – 8.811,1852022-07-01 → 2024-06-30
Postoperative wound dehiscence rateNo different from national1.530.1 – 2.952862022-07-01 → 2024-06-30
Pressure ulcer rateWorse Than the National Rate1.631 – 2.266,7842022-07-01 → 2024-06-30
Rate of complications for hip/knee replacement patientsNo different from national3.82 – 72382023-04-01 → 2025-03-31

Unplanned hospital visits

How often patients came back to hospital unexpectedly after discharge. 14 measures.

MeasureCompared to nationalScore95% intervalCasesPeriod
Acute Myocardial Infarction (AMI) 30-Day Readmission RateNo different from national14.412 – 17.4612023-07-01 → 2025-06-30
Heart failure (HF) 30-Day Readmission RateNo different from national22.919.8 – 26.23672023-07-01 → 2025-06-30
Hospital return days for heart attack patientsAverage Days per 100 Discharges3.8-42.3 – 93.91042022-07-01 → 2025-06-30
Hospital return days for heart failure patientsAverage Days per 100 Discharges10.4-44.2 – 89.45552022-07-01 → 2025-06-30
Hospital return days for pneumonia patientsAverage Days per 100 Discharges1.8-40.4 – 59.36122022-07-01 → 2025-06-30
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)—Not reported——2024-07-01 → 2025-06-30
Pneumonia (PN) 30-Day Readmission RateNo different from national20.217.1 – 23.44212023-07-01 → 2025-06-30
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy—Not reported——2024-01-01 → 2024-12-31
Rate of inpatient admissions for patients receiving outpatient chemotherapy—Not reported——2024-01-01 → 2024-12-31
Rate of readmission after hip/knee replacementNo different from national6.24 – 9.42322023-07-01 → 2025-06-30
Rate of readmission for CABG—Not reported——2023-07-01 → 2025-06-30
Rate of readmission for chronic obstructive pulmonary disease (COPD) patientsNo different from national23.119.5 – 272872023-07-01 → 2025-06-30
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)—Not reported——2022-01-01 → 2024-12-31
Ratio of unplanned hospital visits after hospital outpatient surgery—Not reported——2024-01-01 → 2024-12-31

Score units differ between measures (rates, ratios, and Medicare dollars per beneficiary). Each measure is shown with its own name and reporting period; do not compare scores across measures.

Patient experience (HCAHPS)

Survey responses from patients, as published by CMS. Star ratings are 1–5; a blank means CMS withheld it.

Patients who reported that their room and bathroom were "Always" clean

Not rated
Room was "always" clean73%

528 completed surveys · response rate 37% · 2024-10-01 → 2025-09-30

Patients who reported that their room and bathroom were "Sometimes" or "Never" clean

Not rated
Room was "sometimes" or "never" clean8%

528 completed surveys · response rate 37% · 2024-10-01 → 2025-09-30

Patients who reported that their room and bathroom were "Usually" clean

Not rated
Room was "usually" clean19%

528 completed surveys · response rate 37% · 2024-10-01 → 2025-09-30

Cleanliness - linear mean score

Not rated

No answer breakdown reported.

528 completed surveys · response rate 37% · 2024-10-01 → 2025-09-30

Cleanliness - star rating

4 / 5 — Rating 4 of 5

No answer breakdown reported.

528 completed surveys · response rate 37% · 2024-10-01 → 2025-09-30

Patients who reported that their nurses "Always" communicated well

Not rated
Nurses "always" communicated well85%

528 completed surveys · response rate 37% · 2024-10-01 → 2025-09-30

Nurse communication - linear mean score

Not rated

No answer breakdown reported.

528 completed surveys · response rate 37% · 2024-10-01 → 2025-09-30

Patients who reported that their nurses "Sometimes" or "Never" communicated well

Not rated
Nurses "sometimes" or "never" communicated well3%

528 completed surveys · response rate 37% · 2024-10-01 → 2025-09-30

Nurse communication - star rating

5 / 5 — Highest

No answer breakdown reported.

528 completed surveys · response rate 37% · 2024-10-01 → 2025-09-30

Patients who reported that their nurses "Usually" communicated well

Not rated
Nurses "usually" communicated well12%

528 completed surveys · response rate 37% · 2024-10-01 → 2025-09-30

Patients who reported that their doctors "Always" communicated well

Not rated
Doctors "always" communicated well79%

528 completed surveys · response rate 37% · 2024-10-01 → 2025-09-30

Doctor communication - linear mean score

Not rated

No answer breakdown reported.

528 completed surveys · response rate 37% · 2024-10-01 → 2025-09-30

Patients who reported that their doctors "Sometimes" or "Never" communicated well

Not rated
Doctors "sometimes" or "never" communicated well6%

528 completed surveys · response rate 37% · 2024-10-01 → 2025-09-30

Doctor communication - star rating

3 / 5 — Rating 3 of 5

No answer breakdown reported.

528 completed surveys · response rate 37% · 2024-10-01 → 2025-09-30

Patients who reported that their doctors "Usually" communicated well

Not rated
Doctors "usually" communicated well15%

528 completed surveys · response rate 37% · 2024-10-01 → 2025-09-30

Patients who reported that staff "Always" explained about medicines before giving it to them

Not rated
Staff "always" explained69%

528 completed surveys · response rate 37% · 2024-10-01 → 2025-09-30

Communication about medicines - linear mean score

Not rated

No answer breakdown reported.

528 completed surveys · response rate 37% · 2024-10-01 → 2025-09-30

Patients who reported that staff "Sometimes" or "Never" explained about medicines before giving it to them

Not rated
Staff "sometimes" or "never" explained16%

528 completed surveys · response rate 37% · 2024-10-01 → 2025-09-30

Communication about medicines - star rating

4 / 5 — Rating 4 of 5

No answer breakdown reported.

528 completed surveys · response rate 37% · 2024-10-01 → 2025-09-30

Patients who reported that staff "Usually" explained about medicines before giving it to them

Not rated
Staff "usually" explained15%

528 completed surveys · response rate 37% · 2024-10-01 → 2025-09-30

Discharge information - linear mean score

Not rated

No answer breakdown reported.

528 completed surveys · response rate 37% · 2024-10-01 → 2025-09-30

Patients who reported that NO, they were not given information about what to do during their recovery at home

Not rated
No, staff "did not" give patients this information14%

528 completed surveys · response rate 37% · 2024-10-01 → 2025-09-30

Discharge information - star rating

3 / 5 — Rating 3 of 5

No answer breakdown reported.

528 completed surveys · response rate 37% · 2024-10-01 → 2025-09-30

Patients who reported that YES, they were given information about what to do during their recovery at home

Not rated
Yes, staff "did" give patients this information86%

528 completed surveys · response rate 37% · 2024-10-01 → 2025-09-30

Patients who reported that NO, they did not discuss whether they would need help after discharge

Not rated
No, staff "did not" give patients information about help after discharge16%

528 completed surveys · response rate 37% · 2024-10-01 → 2025-09-30

Patients who reported that YES, they did discuss whether they would need help after discharge

Not rated
Yes, staff "did" give patients information about help after discharge84%

528 completed surveys · response rate 37% · 2024-10-01 → 2025-09-30

Patients who reported that their doctors "Always" explained things in a way they could understand

Not rated
Doctors "always" explained things so they could understand76%

528 completed surveys · response rate 37% · 2024-10-01 → 2025-09-30

Patients who reported that their doctors "Sometimes" or "Never" explained things in a way they could understand

Not rated
Doctors "sometimes" or "never" explained things so they could understand7%

528 completed surveys · response rate 37% · 2024-10-01 → 2025-09-30

Patients who reported that their doctors "Usually" explained things in a way they could understand

Not rated
Doctors "usually" explained things so they could understand17%

528 completed surveys · response rate 37% · 2024-10-01 → 2025-09-30

Patients who reported that their doctors "Always" listened carefully to them

Not rated
Doctors "always" listened carefully78%

528 completed surveys · response rate 37% · 2024-10-01 → 2025-09-30

Patients who reported that their doctors "Sometimes" or "Never" listened carefully to them

Not rated
Doctors "sometimes" or "never" listened carefully6%

528 completed surveys · response rate 37% · 2024-10-01 → 2025-09-30

Patients who reported that their doctors "Usually" listened carefully to them

Not rated
Doctors "usually" listened carefully16%

528 completed surveys · response rate 37% · 2024-10-01 → 2025-09-30

Patients who reported that their doctors "Always" treated them with courtesy and respect

Not rated
Doctors "always" treated them with courtesy and respect86%

528 completed surveys · response rate 37% · 2024-10-01 → 2025-09-30

Patients who reported that their doctors "Sometimes" or "Never" treated them with courtesy and respect

Not rated
Doctors "sometimes" or "never" treated them with courtesy and respect3%

528 completed surveys · response rate 37% · 2024-10-01 → 2025-09-30

Patients who reported that their doctors "Usually" treated them with courtesy and respect

Not rated
Doctors "usually" treated them with courtesy and respect11%

528 completed surveys · response rate 37% · 2024-10-01 → 2025-09-30

Patients who gave their hospital a rating of 6 or lower on a scale from 0 (lowest) to 10 (highest)

Not rated
Patients who gave a rating of "6" or lower (low)5%

528 completed surveys · response rate 37% · 2024-10-01 → 2025-09-30

Patients who gave their hospital a rating of 7 or 8 on a scale from 0 (lowest) to 10 (highest)

Not rated
Patients who gave a rating of "7" or "8" (medium)16%

528 completed surveys · response rate 37% · 2024-10-01 → 2025-09-30

Patients who gave their hospital a rating of 9 or 10 on a scale from 0 (lowest) to 10 (highest)

Not rated
Patients who gave a rating of "9" or "10" (high)79%

528 completed surveys · response rate 37% · 2024-10-01 → 2025-09-30

Overall hospital rating - linear mean score

Not rated

No answer breakdown reported.

528 completed surveys · response rate 37% · 2024-10-01 → 2025-09-30

Overall hospital rating - star rating

4 / 5 — Rating 4 of 5

No answer breakdown reported.

528 completed surveys · response rate 37% · 2024-10-01 → 2025-09-30

Patients who reported that when receiving new medication the staff "Always" communicated what the medication was for

Not rated
Staff "always" explained new medications80%

528 completed surveys · response rate 37% · 2024-10-01 → 2025-09-30

Patients who reported that when receiving new medication the staff "Sometimes" or "Never" communicated what the medication was for

Not rated
Staff "sometimes" or "never" explained new medications7%

528 completed surveys · response rate 37% · 2024-10-01 → 2025-09-30

Patients who reported that when receiving new medication the staff "Usually" communicated what the medication was for.

Not rated
Staff "usually" explained new medications13%

528 completed surveys · response rate 37% · 2024-10-01 → 2025-09-30

Patients who reported that their nurses "Always" explained things in a way they could understand

Not rated
Nurses "always" explained things so they could understand78%

528 completed surveys · response rate 37% · 2024-10-01 → 2025-09-30

Patients who reported that their nurses "Sometimes" or "Never" explained things in a way they could understand

Not rated
Nurses "sometimes" or "never" explained things so they could understand5%

528 completed surveys · response rate 37% · 2024-10-01 → 2025-09-30

Patients who reported that their nurses "Usually" explained things in a way they could understand

Not rated
Nurses "usually" explained things so they could understand17%

528 completed surveys · response rate 37% · 2024-10-01 → 2025-09-30

Patients who reported that their nurses "Always" listened carefully to them

Not rated
Nurses "always" listened carefully80%

528 completed surveys · response rate 37% · 2024-10-01 → 2025-09-30

Patients who reported that their nurses "Sometimes" or "Never" listened carefully to them

Not rated
Nurses "sometimes" or "never" listened carefully4%

528 completed surveys · response rate 37% · 2024-10-01 → 2025-09-30

Patients who reported that their nurses "Usually" listened carefully to them

Not rated
Nurses "usually" listened carefully16%

528 completed surveys · response rate 37% · 2024-10-01 → 2025-09-30

Patients who reported that their nurses "Always" treated them with courtesy and respect

Not rated
Nurses "always" treated them with courtesy and respect89%

528 completed surveys · response rate 37% · 2024-10-01 → 2025-09-30

Patients who reported that their nurses "Sometimes" or "Never" treated them with courtesy and respect

Not rated
Nurses "sometimes" or "never" treated them with courtesy and respect2%

528 completed surveys · response rate 37% · 2024-10-01 → 2025-09-30

Patients who reported that their nurses "Usually" treated them with courtesy and respect

Not rated
Nurses "usually" treated them with courtesy and respect9%

528 completed surveys · response rate 37% · 2024-10-01 → 2025-09-30

Patients who reported that the area around their room was "Always" quiet at night

Not rated
"Always" quiet at night63%

528 completed surveys · response rate 37% · 2024-10-01 → 2025-09-30

Patients who reported that the area around their room was "Sometimes" or "Never" quiet at night

Not rated
"Sometimes" or "never" quiet at night8%

528 completed surveys · response rate 37% · 2024-10-01 → 2025-09-30

Patients who reported that the area around their room was "Usually" quiet at night

Not rated
"Usually" quiet at night29%

528 completed surveys · response rate 37% · 2024-10-01 → 2025-09-30

Quietness - linear mean score

Not rated

No answer breakdown reported.

528 completed surveys · response rate 37% · 2024-10-01 → 2025-09-30

Quietness - star rating

4 / 5 — Rating 4 of 5

No answer breakdown reported.

528 completed surveys · response rate 37% · 2024-10-01 → 2025-09-30

Patients who reported NO, they would probably not or definitely not recommend the hospital

Not rated
"NO", patients would not recommend the hospital (they probably would not or definitely would not recommend it)3%

528 completed surveys · response rate 37% · 2024-10-01 → 2025-09-30

Patients who reported YES, they would definitely recommend the hospital

Not rated
"YES", patients would definitely recommend the hospital79%

528 completed surveys · response rate 37% · 2024-10-01 → 2025-09-30

Recommend hospital - linear mean score

Not rated

No answer breakdown reported.

528 completed surveys · response rate 37% · 2024-10-01 → 2025-09-30

Patients who reported YES, they would probably recommend the hospital

Not rated
"YES", patients would probably recommend the hospital18%

528 completed surveys · response rate 37% · 2024-10-01 → 2025-09-30

Recommend hospital - star rating

5 / 5 — Highest

No answer breakdown reported.

528 completed surveys · response rate 37% · 2024-10-01 → 2025-09-30

Patients who reported that when receiving new medication the staff "Always" discussed possible side effects

Not rated
Staff "always" explained possible side effects53%

528 completed surveys · response rate 37% · 2024-10-01 → 2025-09-30

Patients who reported that when receiving new medication the staff "Sometimes" or "Never" discussed possible side effects

Not rated
Staff "sometimes" or "never" explained possible side effects27%

528 completed surveys · response rate 37% · 2024-10-01 → 2025-09-30

Patients who reported that when receiving new medication the staff "Usually" discussed possible side effects

Not rated
Staff "usually" explained possible side effects20%

528 completed surveys · response rate 37% · 2024-10-01 → 2025-09-30

Summary star rating

4 / 5 — Rating 4 of 5

No answer breakdown reported.

528 completed surveys · response rate 37% · 2024-10-01 → 2025-09-30

Patients who reported that NO, they did not receive written information about possible symptoms to look out for after discharge

Not rated
No, staff "did not" give patients information about possible symptoms12%

528 completed surveys · response rate 37% · 2024-10-01 → 2025-09-30

Patients who reported that YES, they did receive written information about possible symptoms to look out for after discharge

Not rated
Yes, staff "did" give patients information about possible symptoms88%

528 completed surveys · response rate 37% · 2024-10-01 → 2025-09-30

Missing measures are not poor results

CMS suppresses a measure when too few cases were reported for the result to be reliable — common for smaller hospitals. A blank means not reported, which is different from a poor result. Hospitals with more blanks are not necessarily worse.

This is not medical advice

These are historical, aggregate measures about an institution. They do not describe the care any individual will receive, and they cannot account for your condition.

Talk to a clinician about your own care. In an emergency, call your local emergency number.

Other Acute Care - Veterans Administration in FL

Source: Centers for Medicare & Medicaid Services (CMS), Provider Data Catalog (data updated 2026-07-22) — https://data.cms.gov/provider-data/ · Data last updated 2026-09-27