Cycle 1
Health 2025-03-13 · Fire 2025-03-13
6 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Bradenton, FL
Surrey Place Healthcare And Rehabilitation
4-star overall rating with 3-star inspections with 6 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
5525 21st Ave W, Bradenton, FL
(941) 795-0448
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
74
Certified beds
Average residents
63
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Summitt Care Ii, Inc.
Operator or chain grouping
Approved since
1989-02-08
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
0.72
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
2.30
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
4.06
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.76
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.75
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.52
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.18
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.60
CMS adjusted RN staffing hours
Adjusted total hours
3.36
CMS adjusted total nurse staffing hours
Case-mix index
1.66
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,951
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
14.55
Composite VBP score used to determine payment impact.
Payment multiplier
0.9813
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.14% · Performance 22.34% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 7.66% · Performance 8.74% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
4.57
Baseline 48.19% · Performance 45.00% · Measure score 4.57 · Achievement 4.57 · Improvement 0.87
Adjusted total nurse staffing
1.25
Baseline 4.50 hours · Performance 3.43 hours · Measure score 1.25 · Achievement 1.25 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.7% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 624 · Observed rate 8.65% · Lower 95% interval 8.36% |
| Discharge to community | 66.89% |
50.57%
16.3 pts better
|
Better than the National Rate · Eligible stays 624 · Observed rate 66.83% · Lower 95% interval 63.56% |
| Medicare spending per beneficiary | 1.11 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 99.49% |
95.27%
4.2 pts better
|
Numerator 392 · Denominator 394 |
| Falls with major injury | 1.52% |
0.77%
0.8 pts worse
|
Numerator 6 · Denominator 394 |
| Discharge self-care score | 65.93% |
53.69%
12.2 pts better
|
Numerator 178 · Denominator 270 |
| Discharge mobility score | 81.85% |
50.94%
30.9 pts better
|
Numerator 221 · Denominator 270 |
| Pressure ulcers or injuries, new or worsened | 1.27% |
2.29%
1 pts better
|
Numerator 5 · Denominator 394 · Adjusted rate 1.35% |
| Healthcare-associated infections requiring hospitalization | 8.74% |
7.12%
1.6 pts worse
|
No Different than the National Rate · Eligible stays 407 · Observed rate 7.13% · Lower 95% interval 6.22% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 118 |
| Staff flu vaccination coverage | 8.17% |
42%
33.8 pts worse
|
Numerator 17 · Denominator 208 |
| Discharge function score | 76.3% |
56.45%
19.8 pts better
|
Numerator 206 · Denominator 270 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 331 · Denominator 331 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 32 · Denominator 32 |
| Resident COVID-19 vaccinations up to date | 29.95% |
25.2%
4.8 pts better
|
Numerator 59 · Denominator 197 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
2.1
0.3 pts better
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.6 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.2
About the same
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.0 · 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 | 1.4% |
2.6%
1.2 pts better
|
3.3%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 5.7% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.8% |
3.7%
2.9 pts better
|
11.4%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.9% · Q4 0.0% · 4Q avg 0.8% |
| Percentage of long-stay residents who lose too much weight | 14.2% |
5.9%
8.3 pts worse
|
5.4%
8.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 14.3% · Q3 10.3% · Q4 18.8% · 4Q avg 14.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.2% |
15.7%
6.5 pts better
|
19.6%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.0% · Q2 6.5% · Q3 6.5% · Q4 12.1% · 4Q avg 9.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 1.0% |
9.8%
8.8 pts better
|
16.7%
15.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% · 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 | 10.1% |
11.7%
1.6 pts better
|
16.3%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.5% |
9.8%
5.3 pts better
|
14.9%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 6.9% · Q3 6.9% · Q4 3.3% · 4Q avg 4.5% · 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 | 9.2% |
12.5%
3.3 pts better
|
19.8%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 9.9% · Q3 9.4% · Q4 9.5% · 4Q avg 9.2% |
| Percentage of long-stay residents with pressure ulcers | 4.4% |
5.1%
0.7 pts better
|
5.1%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 8.1% · Q3 2.4% · Q4 0.0% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
94.3%
5.1 pts better
|
81.7%
17.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.5% · Q3 99.0% · Q4 100.0% · 4Q avg 99.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.9% |
9.3%
2.4 pts better
|
12.0%
5.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.9% · Observed 5.7% · Expected 9.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.5%
0.7 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.3% · Q4 2.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.5% |
94.7%
3.8 pts better
|
79.7%
18.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.3% |
26.2%
1.9 pts better
|
23.9%
0.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.3% · Observed 20.1% · Expected 19.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-06-01 · Fire 2023-06-01
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-07-22 · Fire 2021-07-22
4 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
C · Minimal harm
2025-03-13
K200 · Egress Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2025-04-12
D · Potential for more than minimal harm
2021-07-22
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-08-21
D · Potential for more than minimal harm
2021-07-22
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2021-08-21
D · Potential for more than minimal harm
2021-07-22
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-08-21
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-03-13
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 2025-04-12
E · Potential for more than minimal harm
2025-03-13
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2025-04-12
D · Potential for more than minimal harm
2025-03-13
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-04-12
D · Potential for more than minimal harm
2025-03-13
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-04-12
D · Potential for more than minimal harm
2025-03-13
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-04-12
D · Potential for more than minimal harm
2025-03-13
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-04-12
D · Potential for more than minimal harm
2023-06-01
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 2023-07-01
E · Potential for more than minimal harm
2021-07-22
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 2021-08-21
D · Potential for more than minimal harm
2021-07-22
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 2021-08-21
D · Potential for more than minimal harm
2021-07-22
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-08-21
D · Potential for more than minimal harm
2021-07-22
F807 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Corrected 2021-08-21
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
Christian, Shelley
W-2 Managing Employee · Individual
Davis, Alan
Operational/Managerial Control · Individual
Davis, Alan
Corporate Director · Individual
Davis, Alan
Corporate Officer · Individual
Mitchell, Joseph
Operational/Managerial Control · Individual
Mitchell, Joseph
Corporate Director · Individual
Mitchell, Joseph
Corporate Officer · Individual
Summitt Care Ii LLC
Operational/Managerial Control · Organization
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#2
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#3
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3-star overall rating with 3-star inspections with 9 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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