Fountains Rehabilitation At Mill Cove
9960 Atrium Way, Jacksonville, FL 32225 · For profit - Limited Liability company · 84 certified beds · (904) 724-4001 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- a high number of inspection citations overall (15) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 6.0% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 10.3% | 5.5% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.7% | 0.3% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 0.7% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 12.4% | 4.6% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 1.7% | 2.5% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 7.2% | 9.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 23.1% | 14.4% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 99.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.5% | 4.5% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 30.9% | 10.5% | 21.2% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 7.2% | 8.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 2.2% | 1.5% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 92.9% | 94.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 26.6% | 26.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 6.7% | 9.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 3.04 | 2.13 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.08 | 1.15 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
56.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 335 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 46.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 127 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.50 therapist hours per resident per day in 2026Q1 — more than 81% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 12% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 56.4%CMS range 50.0–62.5 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 14.7%CMS range 11.9–18.2 | 10.7% | Oct 2022–Sep 2024 | worse than U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 46.5% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 38.6% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 42.5% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 97.5% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 97.2% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.5% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.1% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 8.0%CMS range 5.1–10.3 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.99 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 84 beds and averages 82.9 residents a day — about 99% occupied, or roughly 1 bed typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.74 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.63 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.25 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.33 hrs/resident/day on weekends vs 3.91 on weekdays — 15% thinner on weekends. RN hours go from 0.70 to 0.46 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 42% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
15 citations, most serious first. The 10 most serious are shown; the remaining 5 are one tap away and print in full.
- Potential for harm · F2026-02-12 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews and record review, the facility failed to store and label food items in a manner to prevent foodborne illness and maintain sanitary conditions, by failing to appropriately date mark food items in the dry storage area and nourishment rooms. This deficient practice had the potential to affect all residents who receive food and nourishment items prepared and/or stored by the facility.The findings include:During the initial kitchen tour on 2/8/26 at 11:30 AM, the following was observed: A dessert was plated on the walk-in refrigerator's shelving unit, which was wrapped but was not date marked. (Photographic evidence obtained)An observation of the 800 Wing nourishment room on 2/9/26 at 8:44 AM revealed that seven of 13 sandwiches in the refrigerator were not date-marked, and foods brought in from outside the facility were without dates. (Photographic evidence obtained)On 2/9/26 at 8:44 AM, a follow-up observation was conducted with the Certified Dietary Manager (CDM), in which he confirmed that there were seven sandwiches without date markings. In an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-02-12 · tag F0582 — patternGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide documentation to confirm that each resident was informed before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility's per diem rate for three (Residents #49, #998 and #999) of three residents whose Beneficiary Notices were reviewed. The findings include:On [DATE] at 11:57 AM, an entrance conference was conducted with the Administrator. At this time, he was given the Beneficiary Notice form and asked to provide a list of residents discharged within the last six months.On [DATE] at 3:40 PM, the survey team was provided with the completed Beneficiary Notice forms. The Administrator was advised that the Beneficiary Notice forms contained inaccurate information. He was advised that the list contained residents who were discharged to the hospital, other skilled…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-02-12 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, interviews and a review of facility policies and procedures, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections, by failing to monitor and track infections properly between August 2025 and February 2026. This failure can contribute to preventable diseases spreading rapidly, resulting in widespread resident illness with potentially fatal outcomes.The findings include:A review of the facility's infection control tracking information on 2/11/26 with the Director of Nursing (DON) revealed that no tracking was available for August 2025 through November 2025 or for January 2026. During an interview on 2/11/26 at 2:30 PM, the DON stated, Since [previous Infection Preventionist] left, I've been keeping up with it. When asked where the missing data was, the DON replied, I have like four binders; I just have to find it.A review of the facility's infection control tracking information on 2/12/26 at 9:30 AM revealed that antibiotic records generated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-12 · tag F0620 — isolatedNot require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its admissions policy for one (Resident #5) of six residents reviewed for admission agreements.The findings include:A review of Resident #5's record revealed no admission agreement present for his admission on [DATE] or his readmission following hospitalization on 11/21/25.Further review of the record verified an initial admission date of 9/26/25 with the most recent admission on [DATE]. During an interview on 2/11/26 at 9:10 AM, the Admissions Director (AD) stated, I didn't start until November [2025], but I did talk to him [Resident #5] one time about it. When the AD was asked where she documented her conversation with the resident, she stated, I didn't document it anywhere.A review of the facility's policy titled Admissions Process - IDT (Interdisciplinary Team) (revised 1/27/26, previously revised 7/1/23 and 3/1/22) revealed:It is the policy of this facility to follow a consistent and complete process for admission of a resident into the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-12 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interviews and record review, the facility failed to develop and implement a comprehensive, person-centered care plan that reflected the resident's individualized needs for one of (Resident #10) of 21 residents whose care plans were reviewed. Resident #10 had no care plan addressing his vision problems and although he had been referred to an ophthalmologist more than once in 2024 (January and May) for cataract surgery, the facility did not follow through until February of 2025. An interview with the resident revealed this negatively affected his mood and he felt trapped. The findings include: An interview was conducted on 2/09/2026 at 11:23 AM with Resident #10. During the interview the resident became visibly upset and in a raised voice stated he was blind and they (facility staff) were not helping him. He further stated he had cataracts and was supposed to have surgery a year ago and still had not had that. He stated he had insurance and other funds to pay for the surgery, but the facility was not assisting him with arranging for it. He said his loss of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-12 · tag F0685 — isolatedAssist a resident in gaining access to vision and hearing services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure that one (Resident #10) of 2 residents reviewed for vision abilities/status from a total survey sample of 21 residents, received proper treatment and assistance in making appointments and arranging for transportation to and from the office of a practitioner specializing in the treatment of vision impairment or the office of a professional specializing in the provision of vision assistive devices to maintain vision abilities. The findings include:An interview was conducted on 2/09/2026 at 11:23 AM with Resident #10. During the interview the resident became visibly upset and in a raised voice stated he was blind and they (facility staff) were not helping him. He further stated he had cataracts and was supposed to have surgery a year ago and still had not had that. He stated he had insurance and other funds to pay for the surgery, but the facility was not assisting him with arranging for it. He said his loss of vision impacted his mood and made him feel trapped. He did not feel that the facility staff…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-12 · tag F0732 — isolatedPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to ensure that 1) It posted daily, at the beginning of each shift, the facility name, current date, the total number and the actual hours worked by registered nurses, licensed practical nurses, and certified nursing assistants per shift, as well as the resident census on two (2/8/26 and 2/9/26) of five days during the recertification survey.The findings include:During a tour of the facility conducted on 2/8/26 from 11:00 AM - 12:00 PM, no staffing information was posted. A clear frame with no staffing information was observed hanging on a wall next to the reception desk. A whiteboard near the south wing of the facility with staffing posted was dated 2/6/26. (Photographic evidence obtained) During the tour it was observed that all resident rooms had whiteboards next to each bed with spaces to list the current date, current shift and the assigned nurse and certified nursing assistant (CNA) for that shift. Seven of the boards observed had not been updated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-12 · tag F0908 — failed to keep essential equipment working — isolatedKeep all essential equipment working safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews and a review if facility policies and procedures, the facility failed to maintain its equipment in safe operating condition, by failing to ensure lint was promptly removed from facility dryers. Leaving lint in a dryer trap creates a severe fire hazard, as accumulated lint easily ignites from the heating element, potentially causing a fire that can place staff, residents and other facility occupants in danger. It also restricts airflow, which can lead to overheating. The findings include:An observation in the laundry room on 2/11/26 at 9:30 AM revealed that the lint removal log had not been completed for 7:00 AM or 9:00 AM.An observation in the laundry room on 2/11/26 at 9:35 AM revealed that the lint trap in the first dryer was covered with a thick layer of white fluffy material.During an interview with Laundry Assistant A on 2/11/26 at 9:40 AM, she stated, We clean it [lint trap] out after every load. When asked if it had been cleaned this morning, she nodded her head yes. When asked why there was a layer of what appeared to be lint in the trap of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-11 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and medical record review, the facility failed to ensure that a resident in a long term care nursing facility, who was identified with a MD/ID (Mental Disorder/Intellectual Disability) and/or other related conditions was re-evaluated to determine if specialized care and services were required, in the most integrated setting appropriate to their needs, for one resident (Resident #29) in a total sample of 20. The findings include: On 04/09/24 at 10:45 AM, a record review revealed that Resident #29 had a Level 1 PASRR (Preadmission Screening and Resident Review) that indicated she had a serious MI (Mental Illness) and that a Level 2 PASRR evaluation was indicated. The PASRR was signed on 6/10/2020 from an acute-care hospital. There was no Level 2 evaluation available in the electronic medical record (EMR) or in the resident's paper chart. On 04/10/24 at 1:55 PM, an interview was conducted with Social Services Director (SSD) B, who stated she had been employed at the facility…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-11 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and facility policy review, the facility failed to provide one (Resident #25) of a total sample of 20 residents, with necessary services to maintain appropriate grooming and personal hygiene, by failing to provide timely nail care per the resident's comprehensive care plan. The findings include: On 04/08/24 at 12:41 PM, Resident #25 was observed with elongated fingernails with brown matter underneath. His mustache was long with the hair covering his top and bottom lips. Resident # 25 stated, They just asked me yesterday if I wanted my nails trimmed and I said yes. He was alert and oriented during the interview. (Photographic evidence obtained) On 04/09/24 at 9:17 AM, Resident #25 was observed unshaven with a long mustache covering his top and bottom lips. His fingernails were elongated with brown matter underneath and some with jagged edges. (Photographic evidence obtained) On 04/10/24 at 12:22 PM, an interview was conducted with Registered Nurse A, who reported…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 5 citations
- Potential for harm · D2022-04-28 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure that two (Residents #227 and #31) of 30 sampled residents, were treated with respect and dignity in a manner and in an environment that promoted maintenance or enhancement of their quality of life, recognizing each resident's individuality. Resident #227, who was continent of bowel per interview with nursing management, was told to soil her brief and the CNA would clean her up afterward. Resident #31's CNA turned off his call light and did not return to provide care until prompted by his nurse, approximately three hours later. At that time the CNA told the resident he lied about her and she was not going to speak to him. The findings include: 1. On 04/25/22 at 2:40 PM, Resident #227 stated during the morning shift on 04/25/22, she requested to use the bathroom, and the certified nursing assistant (CNA) that answered her call light said, Go ahead and use your diaper. I will clean you up. The resident stated she was shocked and felt embarrassed,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-04-28 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan, by failing to ensure one (Resident #74) of four residents reviewed, from a total sample of 30 residents, received medication as ordered by the physician. On 4/25/22 at 12:06 p.m., Resident #74 stated she took lithium daily and had not received the medication for the last five days. A review of Resident #74's medical record revealed that she was admitted on [DATE] with diagnoses including insomnia, anxiety disorder and bipolar disorder. A review of the admission Minimum Data Set (MDS) assessment, dated 4/13/22, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of a possible 15 points, indicating intact cognition. She required limited assistance for bed mobility, transfers, eating and toilet use. She received hypnotic and anxiolytic medications. A nursing note dated 4/18/22, indicated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-04-28 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure 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.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to adminster tube feedings as ordered by the physician for one (Resident #44) of one resident reviewed for compliance with enteral nutrition from a total of 30 sampled residents. The findings include: A review of Resident #44's medical record revealed an admission date of 3/22/2022. His primary medical diagnosis was hemiplegia following cerebrovascular disease affecting the right dominant side. Secondary diagnoses included oropharyngeal dysphagia, diabetes, and cognitive/communication deficit. A five-day Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 09 out of a possible 15 points, indicating moderately impaired cognition. Resident #44 required extensive to total assistance with activities of daily living (ADLs) and received his nutrition via enteral feeding (liquid nutrition delivered through a feeding tube). On 4/25/2022 at 1:35 p.m., Resident #44 was observed lying in his…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-04-28 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record reviews, and interviews, the facility failed to provide oxygen at the prescribed flow rate for one (Resident #31) of 19 residents receiving respiratory treatments from a total of 30 residents in the sample. The findings include: A review of Resident #31's medical record revealed his most recent admission date was 12/28/2021. His diagnoses included congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and obstructive sleep apnea (OSA). An active physician's order revealed oxygen was to be provided at 3 liters per nasal cannula continuous, Check oxygen saturation, respirations and temperature qshift (every shift). A review of the care plans revealed a focus area for COPD with an intervention that read, Give oxygen therapy as ordered by the physician. Resident #31 was observed on 4/26/2022 at approximately 11:11 AM. He was wearing his oxygen cannula and the concentrator was dispensing oxygen at a flow rate of 4 liters per minute (LPM). On 4/27/2022 at 1:16 PM, the flow rate for Resident #31's oxygen was set between 3.5 and 4 LPM.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-04-28 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record reviews, and staff interviews, the facility failed to ensure a medication error rate of 5% or less, based on four errors out of 30 opportunities for error, resulting in a facility error rate of 13.33%, and involving Residents #59, #6, #23, and #228. The findings include: 1. During medication administration on 4/26/22 at 11:30 a.m., Licensed Practical Nurse (LPN) A reviewed the Medication Administration Record (MAR) for Resident #59. He obtained the equipment necessary for blood sugar monitoring. He explained the process to the resident and obtained a blood glucose reading of 194 milligrams per deciliter (mg/dl). He then obtained the resident's Novolog flex pen (insulin) and administered 5 units in the resident's left upper arm. He performed hand hygiene and documented in the MAR. (Copy obtained) In an interview on 4/26/22 at 11:40 a.m., LPN A confirmed that he had administered 5 units of Novolog insulin. He added that the resident had a standard order for 5 units before meals. When asked to review the physician's orders, LPN A revealed orders for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| ATRIUM SNF HOLDINGS LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 06/16/2020 |
| ATRIUM MASTER HOLDINGS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 06/16/2020 |
| BHP SERVICES | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 06/16/2020 |
| WIERZBA, KYLE | Individual | W-2 MANAGING EMPLOYEE | — | since 09/01/2020 |
| SOFIA, LISA | Individual | CORPORATE OFFICER | — | since 09/01/2020 |
3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $327K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in FL
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Florida Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 105927. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-12, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.