Cycle 1
Health 2024-04-11 · Fire 2024-04-11
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Jacksonville, FL
Fountains Rehabilitation At Mill Cove
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
9960 Atrium Way, Jacksonville, FL
(904) 724-4001
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
84
Certified beds
Average residents
76
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1996-09-13
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
0.73
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.91
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.40
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
4.05
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.65
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.69
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
0.11
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.73
CMS adjusted RN staffing hours
Adjusted total hours
4.04
CMS adjusted total nurse staffing hours
Case-mix index
1.37
Higher values indicate more complex resident acuity
RN turnover
27%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
47%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,959
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
25.16
Composite VBP score used to determine payment impact.
Payment multiplier
0.9837
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.80
Baseline 25.22% · Performance 23.33% · Measure score 1.80 · Achievement 0 · Improvement 1.80
Healthcare-associated infections
0.70
Baseline 8.37% · Performance 7.96% · Measure score 0.70 · Achievement 0 · Improvement 0.70
Total nurse turnover
4.77
Baseline 58.59% · Performance 44.19% · Measure score 4.77 · Achievement 4.77 · Improvement 3.77
Adjusted total nurse staffing
2.79
Baseline 3.76 hours · Performance 3.87 hours · Measure score 2.79 · Achievement 2.79 · Improvement 0.04
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 14.7% |
10.72%
4 pts worse
|
Worse than the National Rate · Eligible stays 353 · Observed rate 17.56% · Lower 95% interval 11.89% |
| Discharge to community | 56.42% |
50.57%
5.9 pts better
|
No Different than the National Rate · Eligible stays 335 · Observed rate 48.66% · Lower 95% interval 49.97% |
| Medicare spending per beneficiary | 0.99 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 180 · Denominator 180 |
| Falls with major injury | 0.56% |
0.77%
0.2 pts better
|
Numerator 1 · Denominator 180 |
| Discharge self-care score | 51.22% |
53.69%
2.5 pts worse
|
Numerator 63 · Denominator 123 |
| Discharge mobility score | 45.53% |
50.94%
5.4 pts worse
|
Numerator 56 · Denominator 123 |
| Pressure ulcers or injuries, new or worsened | 1.11% |
2.29%
1.2 pts better
|
Numerator 2 · Denominator 180 · Adjusted rate 0.76% |
| Healthcare-associated infections requiring hospitalization | 7.96% |
7.12%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 172 · Observed rate 8.72% · Lower 95% interval 5.06% |
| Staff COVID-19 vaccination coverage | 28.82% |
8.2%
20.6 pts better
|
Numerator 49 · Denominator 170 |
| Staff flu vaccination coverage | 58.99% |
42%
17 pts better
|
Numerator 164 · Denominator 278 |
| Discharge function score | 52.03% |
56.45%
4.4 pts worse
|
Numerator 64 · Denominator 123 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 53 · Denominator 53 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 92 · Denominator 92 |
| Resident COVID-19 vaccinations up to date | 10.53% |
25.2%
14.7 pts worse
|
Numerator 8 · Denominator 76 |
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 2.4 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.0 |
1.2
0.8 pts worse
|
1.8
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.6 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
97.8%
1.6 pts better
|
93.4%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 97.5% · Q3 100.0% · Q4 100.0% · 4Q avg 99.4% |
| 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 | 0.0% |
2.6%
2.6 pts better
|
3.3%
3.3 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 who have depressive symptoms | 8.3% |
3.7%
4.6 pts worse
|
11.4%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 6.2% · Q3 13.5% · Q4 10.8% · 4Q avg 8.3% |
| Percentage of long-stay residents who lose too much weight | 12.3% |
5.9%
6.4 pts worse
|
5.4%
6.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 18.2% · Q3 15.2% · Q4 14.3% · 4Q avg 12.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.9% |
15.7%
0.2 pts worse
|
19.6%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 9.1% · Q3 15.2% · Q4 31.4% · 4Q avg 15.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.9% |
9.8%
2.9 pts better
|
16.7%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 0.0% · Q3 8.0% · Q4 12.0% · 4Q avg 6.9% · 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 | 7.0% |
11.7%
4.7 pts better
|
16.3%
9.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.7% |
9.8%
4.1 pts better
|
14.9%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 13.8% · Q3 6.9% · Q4 0.0% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
0.4%
0.3 pts worse
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.0% · Q4 0.0% · 4Q avg 0.7% · 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 | 31.6% |
12.5%
19.1 pts worse
|
19.8%
11.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.9% · Q2 40.4% · Q3 31.8% · Q4 22.7% · 4Q avg 31.6% |
| Percentage of long-stay residents with pressure ulcers | 4.9% |
5.1%
0.2 pts better
|
5.1%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 6.2% · Q3 6.1% · Q4 3.5% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.4% |
94.3%
3.1 pts better
|
81.7%
15.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 95.2% · Q3 95.5% · Q4 99.2% · 4Q avg 97.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.9% |
9.3%
1.4 pts better
|
12.0%
4.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.9% · Observed 7.9% · Expected 11.2% · 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 0.6% · Q2 1.1% · Q3 2.3% · Q4 2.5% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.9% |
94.7%
1.8 pts worse
|
79.7%
13.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.5% |
26.2%
2.3 pts worse
|
23.9%
4.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.5% · Observed 28.1% · Expected 23.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-04-28 · Fire 2022-04-28
5 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2020-10-08 · Fire 2020-10-08
1 health deficiencies
Top issue: Resident Rights (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-04-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-08
E · Potential for more than minimal harm
2024-04-11
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-05-08
D · Potential for more than minimal harm
2024-04-11
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-05-08
D · Potential for more than minimal harm
2020-10-08
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2020-11-02
D · Potential for more than minimal harm
2020-10-08
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2020-11-02
D · Potential for more than minimal harm
2020-10-08
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2020-11-02
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-04-11
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-05-08
D · Potential for more than minimal harm
2024-04-11
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 2024-05-08
D · Potential for more than minimal harm
2022-04-28
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 2022-05-27
D · Potential for more than minimal harm
2022-04-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-05-27
D · Potential for more than minimal harm
2022-04-28
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2022-05-27
D · Potential for more than minimal harm
2022-04-28
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-05-27
D · Potential for more than minimal harm
2022-04-28
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-05-27
D · Potential for more than minimal harm
2020-10-08
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 2020-11-06
Penalties and ownership
What sits behind the stars
Ownership
Atrium SNF Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Atrium Master Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Bhp Services
5% Or Greater Indirect Ownership Interest · Organization
Sofia, Lisa
Corporate Officer · Individual
Wierzba, Kyle
W-2 Managing Employee · Individual
Nearby options
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#3
Dolphin Pointe Health Care Center
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3-star overall rating with 3-star inspections with 9 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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