Cycle 1
Health 2025-01-09 · Fire 2025-01-09
5 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Lutz, FL
Tampa Lakes Health And Rehabilitation Center
4-star overall rating with 3-star inspections with 5 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
750 Hayes Rd, Lutz, FL
(813) 559-1500
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
179
Certified beds
Average residents
170
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Summitt Care Ii, Inc.
Operator or chain grouping
Approved since
2017-04-10
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
0.84
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.44
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
4.00
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.56
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.76
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
0.06
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.65
CMS adjusted RN staffing hours
Adjusted total hours
3.64
CMS adjusted total nurse staffing hours
Case-mix index
1.50
Higher values indicate more complex resident acuity
RN turnover
47%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
53%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,947
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
18.54
Composite VBP score used to determine payment impact.
Payment multiplier
0.9820
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 17.19% · Performance 24.12% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
6.08
Baseline 6.05% · Performance 6.02% · Measure score 6.08 · Achievement 6.08 · Improvement 0
Total nurse turnover
0
Performance 63.46% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
1.34
Baseline 4.01 hours · Performance 3.46 hours · Measure score 1.34 · Achievement 1.34 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.33% |
10.72%
2.6 pts worse
|
Worse than the National Rate · Eligible stays 704 · Observed rate 14.49% · Lower 95% interval 11.55% |
| Discharge to community | 55.96% |
50.57%
5.4 pts better
|
Better than the National Rate · Eligible stays 671 · Observed rate 48.58% · Lower 95% interval 52.14% |
| Medicare spending per beneficiary | 1.01 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 97.09% |
95.27%
1.8 pts better
|
Numerator 534 · Denominator 550 |
| Falls with major injury | 1.27% |
0.77%
0.5 pts worse
|
Numerator 7 · Denominator 550 |
| Discharge self-care score | 61.13% |
53.69%
7.4 pts better
|
Numerator 206 · Denominator 337 |
| Discharge mobility score | 51.63% |
50.94%
0.7 pts better
|
Numerator 174 · Denominator 337 |
| Pressure ulcers or injuries, new or worsened | 1.09% |
2.29%
1.2 pts better
|
Numerator 6 · Denominator 550 · Adjusted rate 0.79% |
| Healthcare-associated infections requiring hospitalization | 6.02% |
7.12%
1.1 pts better
|
No Different than the National Rate · Eligible stays 462 · Observed rate 5.84% · Lower 95% interval 3.96% |
| Staff COVID-19 vaccination coverage | 0.87% |
8.2%
7.3 pts worse
|
Numerator 3 · Denominator 346 |
| Staff flu vaccination coverage | 4.51% |
42%
37.5 pts worse
|
Numerator 26 · Denominator 577 |
| Discharge function score | 60.53% |
56.45%
4.1 pts better
|
Numerator 204 · Denominator 337 |
| Transfer of health information to provider | 99.72% |
95.95%
3.8 pts better
|
Numerator 360 · Denominator 361 |
| Transfer of health information to patient | 96.55% |
96.28%
0.3 pts better
|
Numerator 28 · Denominator 29 |
| Resident COVID-19 vaccinations up to date | 29.23% |
25.2%
4 pts better
|
Numerator 76 · Denominator 260 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.9 |
2.1
0.8 pts worse
|
1.9
1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 3.2 · Expected 2.1 · 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 0.9 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
97.8%
2 pts better
|
93.4%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 99.3% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.8% |
| 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 | 2.5% |
2.6%
0.1 pts better
|
3.3%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 1.4% · Q3 1.4% · Q4 2.8% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.1% |
3.7%
2.6 pts better
|
11.4%
10.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 1.0% · Q3 0.0% · Q4 1.0% · 4Q avg 1.1% |
| Percentage of long-stay residents who lose too much weight | 5.8% |
5.9%
0.1 pts better
|
5.4%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 5.5% · Q3 5.2% · Q4 5.9% · 4Q avg 5.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.4% |
15.7%
6.3 pts better
|
19.6%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.8% · Q2 9.3% · Q3 9.2% · Q4 6.5% · 4Q avg 9.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.8% |
9.8%
3 pts better
|
16.7%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 4.1% · Q3 9.3% · Q4 8.7% · 4Q avg 6.8% · 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 | 11.6% |
11.7%
0.1 pts better
|
16.3%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 14.7% · Q3 11.3% · Q4 8.9% · 4Q avg 11.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.1% |
9.8%
4.7 pts better
|
14.9%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 3.8% · Q3 6.4% · Q4 5.9% · 4Q avg 5.1% · 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 | 0.7% |
0.8%
0.1 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.7% · Q4 2.2% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 5.2% |
12.5%
7.3 pts better
|
19.8%
14.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 7.8% · Q3 2.4% · Q4 4.2% · 4Q avg 5.2% |
| Percentage of long-stay residents with pressure ulcers | 2.8% |
5.1%
2.3 pts better
|
5.1%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 2.8% · Q3 2.7% · Q4 1.7% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.7% |
94.3%
4.4 pts better
|
81.7%
17 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.2% · Q2 97.8% · Q3 99.6% · Q4 99.2% · 4Q avg 98.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.7% |
9.3%
3.6 pts better
|
12.0%
6.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.7% · Observed 5.7% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.5%
0.8 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.7% · Q3 0.7% · Q4 1.4% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.5% |
94.7%
1.8 pts better
|
79.7%
16.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.6% |
26.2%
3.4 pts worse
|
23.9%
5.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.6% · Observed 29.0% · Expected 23.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-10-27 · Fire 2022-10-27
5 health deficiencies
Top issue: Administration (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-05-07 · Fire 2021-05-07
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
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
2025-01-09
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2025-02-07
D · Potential for more than minimal harm
2025-01-09
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-02-07
D · Potential for more than minimal harm
2025-01-09
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-02-07
D · Potential for more than minimal harm
2025-01-09
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-02-07
D · Potential for more than minimal harm
2025-01-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-02-07
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-01-09
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-02-07
E · Potential for more than minimal harm
2025-01-09
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 2025-02-07
E · Potential for more than minimal harm
2025-01-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-07
D · Potential for more than minimal harm
2025-01-09
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-02-07
D · Potential for more than minimal harm
2025-01-09
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 2025-02-07
D · Potential for more than minimal harm
2024-05-15
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-06-14
F · Potential for more than minimal harm
2024-03-13
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 2024-04-03
D · Potential for more than minimal harm
2023-05-31
F573 · Resident Rights Deficiencies
Health
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Corrected 2023-06-30
D · Potential for more than minimal harm
2022-10-27
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 2022-11-25
D · Potential for more than minimal harm
2022-10-27
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2022-11-25
D · Potential for more than minimal harm
2022-10-27
F885 · Infection Control Deficiencies
Health
Report COVID19 data to residents and families.
Corrected 2022-11-25
F · Potential for more than minimal harm
2021-05-07
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 2021-06-07
E · Potential for more than minimal harm
2021-05-07
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2021-06-07
D · Potential for more than minimal harm
2021-05-07
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2021-06-07
D · Potential for more than minimal harm
2021-05-07
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 2021-06-07
D · Potential for more than minimal harm
2021-05-07
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 2021-06-07
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
Operational/Managerial Control · 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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#3
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