Cycle 1
Health 2025-07-31 · Fire 2025-07-31
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Madison, FL
Madison Health And Rehabilitation Center
5-star overall rating with 5-star inspections
2481 West Us 90, Madison, FL
(850) 973-4880
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
57
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Summitt Care Ii, Inc.
Operator or chain grouping
Approved since
1993-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
9 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
0.45
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.98
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
3.63
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.43
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.29
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.45
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.50
CMS adjusted RN staffing hours
Adjusted total hours
4.02
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
70%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
40%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,150
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
30.61
Composite VBP score used to determine payment impact.
Payment multiplier
0.9861
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.36% · Performance 22.20% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
1.54
Baseline 9.59% · Performance 8.65% · Measure score 1.54 · Achievement 0 · Improvement 1.54
Total nurse turnover
7.02
Baseline 45.07% · Performance 35.00% · Measure score 7.02 · Achievement 7.02 · Improvement 4.48
Adjusted total nurse staffing
3.69
Baseline 4.51 hours · Performance 4.13 hours · Measure score 3.69 · Achievement 3.69 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.3% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 70 · Observed rate 10% · Lower 95% interval 6.71% |
| Discharge to community | 33.86% |
50.57%
16.7 pts worse
|
Worse than the National Rate · Eligible stays 46 · Observed rate 23.91% · Lower 95% interval 21.77% |
| Medicare spending per beneficiary | 1.01 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 81 · Denominator 81 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 81 |
| Discharge self-care score | 50% |
53.69%
3.7 pts worse
|
Numerator 27 · Denominator 54 |
| Discharge mobility score | 33.33% |
50.94%
17.6 pts worse
|
Numerator 18 · Denominator 54 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 81 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.65% |
7.12%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 41 · Observed rate 14.63% · Lower 95% interval 5.24% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 133 |
| Staff flu vaccination coverage | 16.81% |
42%
25.2 pts worse
|
Numerator 19 · Denominator 113 |
| Discharge function score | 44.44% |
56.45%
12 pts worse
|
Numerator 24 · Denominator 54 |
| Transfer of health information to provider | 69.05% |
95.95%
26.9 pts worse
|
Numerator 29 · Denominator 42 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 41 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
2.1
0.6 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.3 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.0 |
1.2
1.8 pts worse
|
1.8
1.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.0 · Observed 2.6 · Expected 1.4 · 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 | 1.0% |
2.6%
1.6 pts better
|
3.3%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 3.9% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.4% |
3.7%
0.3 pts better
|
11.4%
8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.0% · Q3 2.2% · Q4 6.2% · 4Q avg 3.4% |
| Percentage of long-stay residents who lose too much weight | 10.4% |
5.9%
4.5 pts worse
|
5.4%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 10.3% · Q3 24.4% · Q4 2.4% · 4Q avg 10.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.2% |
15.7%
1.5 pts better
|
19.6%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.1% · Q2 12.2% · Q3 8.7% · Q4 15.9% · 4Q avg 14.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.4% |
9.8%
0.4 pts better
|
16.7%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 15.6% · Q3 8.1% · Q4 2.7% · 4Q avg 9.4% · 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 | 11.9% |
11.7%
0.2 pts worse
|
16.3%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.5% · Q2 15.4% · Q3 12.3% · 4Q avg 11.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.0% |
9.8%
0.8 pts better
|
14.9%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 8.1% · Q3 11.9% · Q4 4.9% · 4Q avg 9.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
0.4%
0.4 pts worse
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.4% · Q4 1.6% · 4Q avg 0.8% · 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 | 7.6% |
12.5%
4.9 pts better
|
19.8%
12.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 15.1% · Q3 4.2% · Q4 2.2% · 4Q avg 7.6% |
| Percentage of long-stay residents with pressure ulcers | 7.6% |
5.1%
2.5 pts worse
|
5.1%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 5.5% · Q3 12.8% · Q4 5.2% · 4Q avg 7.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
94.3%
5.7 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.2% |
9.3%
0.1 pts better
|
12.0%
2.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.2% · Observed 9.7% · Expected 11.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.3% |
1.5%
1.8 pts worse
|
1.6%
1.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 2.3% · Q3 5.7% · Q4 3.0% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.0% |
94.7%
2.3 pts better
|
79.7%
17.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 31.1% |
26.2%
4.9 pts worse
|
23.9%
7.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.1% · Observed 35.5% · Expected 27.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-15 · Fire 2024-08-15
2 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2023-06-01 · Fire 2023-06-01
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-08-15
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-10-28
Inspection history
Recent health citations
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 2024-09-20
D · Potential for more than minimal harm
2024-08-15
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 2024-09-20
Penalties and ownership
What sits behind the stars
Ownership
Summit Care Group Ii Operations Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Mitchell, Joseph
5% Or Greater Direct Ownership Interest · Individual
Davis, Alan
5% Or Greater Direct Ownership Interest · Individual
Herzka, Yisroel
5% Or Greater Indirect Ownership Interest · Individual
Klein, Esther
5% Or Greater Indirect Ownership Interest · Individual
Klein, Solomon
5% Or Greater Indirect Ownership Interest · Individual
Davis, Alan
Corporate Director · Individual
Davis, Alan
Corporate Officer · Individual
Kovary, Paul
W-2 Managing Employee · Individual
Mitchell, Joseph
Operational/Managerial Control · Individual
Mitchell, Joseph
Corporate Director · Individual
Mitchell, Joseph
Corporate Officer · Individual
Summit Care Management LLC
Operational/Managerial Control · Organization
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#2
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#3
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5-star overall rating with 4-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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