Cycle 1
Health 2024-11-15 · Fire 2024-11-15
5 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
North Miami, FL
Fountain Manor Health & Rehabilitation Center
5-star overall rating with 4-star inspections with 5 recent health deficiencies
390 Ne 135th St, North Miami, FL
(305) 895-4804
Overall
5 / 5
CMS overall stars
Health inspections
4 / 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
139
Certified beds
Average residents
135
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1968-06-17
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
1.01
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.54
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.61
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
4.16
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.55
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.55
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.62
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.82
CMS adjusted RN staffing hours
Adjusted total hours
3.40
CMS adjusted total nurse staffing hours
Case-mix index
1.67
Higher values indicate more complex resident acuity
RN turnover
44%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
36%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,716
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.23
Composite VBP score used to determine payment impact.
Payment multiplier
0.9889
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.90
Baseline 19.64% · Performance 20.55% · Measure score 1.90 · Achievement 1.90 · Improvement 0
Healthcare-associated infections
3.07
Baseline 5.54% · Performance 6.92% · Measure score 3.07 · Achievement 3.07 · Improvement 0
Total nurse turnover
7.91
Baseline 41.13% · Performance 31.34% · Measure score 7.91 · Achievement 7.91 · Improvement 5.51
Adjusted total nurse staffing
1.21
Baseline 3.64 hours · Performance 3.42 hours · Measure score 1.21 · Achievement 1.21 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.77% |
10.72%
1 pts worse
|
No Different than the National Rate · Eligible stays 100 · Observed rate 17% · Lower 95% interval 8.44% |
| Discharge to community | 56.71% |
50.57%
6.1 pts better
|
No Different than the National Rate · Eligible stays 85 · Observed rate 34.12% · Lower 95% interval 42.8% |
| Medicare spending per beneficiary | 1.34 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 98.68% |
95.27%
3.4 pts better
|
Numerator 299 · Denominator 303 |
| Falls with major injury | 0.66% |
0.77%
0.1 pts better
|
Numerator 2 · Denominator 303 |
| Discharge self-care score | 53.17% |
53.69%
0.5 pts worse
|
Numerator 67 · Denominator 126 |
| Discharge mobility score | 46.03% |
50.94%
4.9 pts worse
|
Numerator 58 · Denominator 126 |
| Pressure ulcers or injuries, new or worsened | 2.64% |
2.29%
0.4 pts worse
|
Numerator 8 · Denominator 303 · Adjusted rate 1.7% |
| Healthcare-associated infections requiring hospitalization | 6.92% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 65 · Observed rate 9.23% · Lower 95% interval 4.15% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 198 |
| Staff flu vaccination coverage | 27.99% |
42%
14 pts worse
|
Numerator 82 · Denominator 293 |
| Discharge function score | 57.94% |
56.45%
1.5 pts better
|
Numerator 73 · Denominator 126 |
| Transfer of health information to provider | 98.18% |
95.95%
2.2 pts better
|
Numerator 162 · Denominator 165 |
| Transfer of health information to patient | 97.53% |
96.28%
1.2 pts better
|
Numerator 79 · Denominator 81 |
| Resident COVID-19 vaccinations up to date | 5.15% |
25.2%
20 pts worse
|
Numerator 10 · Denominator 194 |
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 1.8 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.2 |
1.2
1 pts better
|
1.8
1.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.2 · Observed 0.2 · Expected 1.7 · 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 | 0.3% |
2.6%
2.3 pts better
|
3.3%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.1% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.7% |
3.7%
About the same
|
11.4%
7.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 1.1% · Q3 1.2% · Q4 5.1% · 4Q avg 3.7% |
| Percentage of long-stay residents who lose too much weight | 2.5% |
5.9%
3.4 pts better
|
5.4%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 3.3% · Q3 1.2% · Q4 3.5% · 4Q avg 2.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.3% |
15.7%
5.6 pts worse
|
19.6%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.5% · Q2 19.4% · Q3 19.0% · Q4 19.5% · 4Q avg 21.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.3% |
9.8%
8.5 pts worse
|
16.7%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.9% · Q2 20.7% · Q3 10.8% · Q4 14.3% · 4Q avg 18.3% · 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 | 2.3% |
11.7%
9.4 pts better
|
16.3%
14 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 9.8% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 1.7% |
9.8%
8.1 pts better
|
14.9%
13.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.9% · Q4 4.3% · 4Q avg 1.7% · 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 | 1.6% |
12.5%
10.9 pts better
|
19.8%
18.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 4.4% · Q4 1.2% · 4Q avg 1.6% |
| Percentage of long-stay residents with pressure ulcers | 7.5% |
5.1%
2.4 pts worse
|
5.1%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 8.9% · Q3 9.1% · Q4 7.3% · 4Q avg 7.5% · 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 | 8.5% |
9.3%
0.8 pts better
|
12.0%
3.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.5% · Observed 11.5% · Expected 15.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.6% |
1.5%
0.1 pts worse
|
1.6%
About the same
|
Short Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 1.9% · Q3 0.0% · Q4 1.2% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.7%
5.3 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.8% |
26.2%
1.4 pts better
|
23.9%
0.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.8% · Observed 37.7% · Expected 36.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-06-29 · Fire 2023-06-29
3 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cycle 3
Health 2022-05-26 · Fire 2022-05-26
5 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-06-29
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-07-19
D · Potential for more than minimal harm
2023-06-29
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 2023-07-19
F · Potential for more than minimal harm
2022-05-26
K917 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure electrical receptacles or cover plates have distinctive color or marking.
Corrected 2022-07-18
D · Potential for more than minimal harm
2022-05-26
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2022-05-26
D · Potential for more than minimal harm
2022-05-26
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2022-05-26
D · Potential for more than minimal harm
2022-05-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-06-02
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-07-28
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 2025-08-15
D · Potential for more than minimal harm
2025-06-18
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-07-18
D · Potential for more than minimal harm
2025-06-18
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-07-18
E · Potential for more than minimal harm
2025-02-10
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 2025-03-07
E · Potential for more than minimal harm
2025-02-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-07
D · Potential for more than minimal harm
2024-11-15
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 2024-11-27
D · Potential for more than minimal harm
2024-11-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-27
D · Potential for more than minimal harm
2023-10-30
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 2023-11-15
D · Potential for more than minimal harm
2023-06-29
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 2023-07-19
D · Potential for more than minimal harm
2022-05-26
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2022-07-13
D · Potential for more than minimal harm
2022-05-26
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 2022-07-13
D · Potential for more than minimal harm
2022-05-26
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 2022-07-13
D · Potential for more than minimal harm
2022-05-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-07-13
Penalties and ownership
What sits behind the stars
Ownership
Fountain Manor Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Chavin, Samuel
5% Or Greater Direct Ownership Interest · Individual
Burstein, Jonathan
5% Or Greater Direct Ownership Interest · Individual
Tapia, Jill
5% Or Greater Indirect Ownership Interest · Individual
Burstein, Jonathan
Operational/Managerial Control · Individual
Chavin, Samuel
Operational/Managerial Control · Individual
Ortiz, Edwin
Operational/Managerial Control · Individual
Roth, Daniel
Operational/Managerial Control · Individual
Roth, Daniel
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Pinecrest Center for Rehabilitation and Healing
North Miami, FL
4-star overall rating with 4-star inspections with $27,593 in total fines with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Claridge House Nursing And Rehabilitation Center
North Miami, FL
1-star overall rating with 1-star inspections with $24,850 in total fines with 10 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Pines Nursing Home
Miami, FL
4-star overall rating with 3-star inspections with $11,187 in total fines with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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