Home › Florida › Duval County › Fountains Rehabilitation at Mill Cove
Fountains Rehabilitation at Mill Cove
9960 Atrium Way, Jacksonville, FL 32225 · CMS Certification Number (CCN) 105927
At a glance
- CMS overall rating
- ★★★☆☆ 3 of 5
- Health inspection citations
- 15 in the last 3 inspection cycles (0 immediate jeopardy, 0 actual harm, 0 from complaints)
- Fire safety citations
- 18
- Fines (last 3 years)
- 0 fines, total $0
- Payment denials
- 0
- Most recent standard inspection
- February 12, 2026
- Official record
- Medicare Care Compare page for this facility
Source: CMS Nursing Home Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
CMS star ratings
CMS rates every Medicare- and Medicaid-certified nursing home from 1 to 5 stars. Health inspection stars are relative to other homes in the same state: the top 10% get 5 stars and the bottom 20% get 1 star. CMS says to use the ratings together with other information, including a visit. Technical Users’ Guide
| Rating | This facility | Florida average | U.S. average |
|---|---|---|---|
| Overall | ★★★☆☆ 3 of 5 | 3.3 | 3 |
| Health inspections | ★★★☆☆ 3 of 5 | 2.9 | 2.8 |
| Staffing | ★★★★☆ 4 of 5 | 3.3 | 2.9 |
| Quality measures | ★★★★☆ 4 of 5 | 4.2 | 3.6 |
| Long-stay quality | ★★★★★ 5 of 5 | Not published | Not published |
| Short-stay quality | ★★★☆☆ 3 of 5 | Not published | Not published |
Averages: CMS State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Health inspections
| Inspection cycle | Standard survey date | Health citations | From standard survey | From complaints |
|---|---|---|---|---|
| Cycle 1 (most recent) | February 12, 2026 | 8 | 8 | 0 |
| Cycle 2 | April 11, 2024 | 2 | 2 | 0 |
CMS weighted health inspection score: 41 (lower is better; it counts citation severity, complaints and repeat revisits). Citations from infection control inspections: Not published. How to read these citations
15 health citations across 3 inspection dates, newest first. The letter is CMS’s scope/severity code: A–C means potential for minimal harm, D–F potential for more than minimal harm, G–I actual harm, and J–L immediate jeopardy.
February 12, 2026: 8 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0908 | Keep all essential equipment working safely. Environmental Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/20/2026 |
| E | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/20/2026 |
| F | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/20/2026 |
| D | F-0732 | Post nurse staffing information every day. Nursing and Physician Services Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/20/2026 |
| D | F-0685 | Assist a resident in gaining access to vision and hearing services. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/20/2026 |
| D | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/20/2026 |
| D | F-0620 | Not 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. Resident Rights Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/20/2026 |
| E | F-0582 | Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Resident Rights Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/20/2026 |
April 11, 2024: 2 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 05/08/2024 |
| D | F-0645 | PASARR screening for Mental disorders or Intellectual Disabilities Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 05/08/2024 |
April 28, 2022: 5 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0759 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 05/27/2022 |
| D | F-0695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 05/27/2022 |
| D | F-0693 | 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. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 05/27/2022 |
| D | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 05/27/2022 |
| D | F-0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies | Standard | Deficient, Provider has date of correction Corrected 05/27/2022 |
Source: CMS Health Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Fire safety inspections
18 fire safety citations across 2 inspection dates
| Date | Severity | Tag | What was cited | Status |
|---|---|---|---|---|
| 02/12/2026 | D | K-0920 | Ensure proper usage of power strips and extension cords. Gas, Vacuum, and Electrical Systems Deficiencies | Deficient, Provider has date of correction Corrected 03/24/2026 |
| 02/12/2026 | E | K-0918 | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies | Deficient, Provider has date of correction Corrected 03/24/2026 |
| 02/12/2026 | D | K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Gas, Vacuum, and Electrical Systems Deficiencies | Deficient, Provider has date of correction Corrected 03/24/2026 |
| 02/12/2026 | D | K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Miscellaneous Deficiencies | Deficient, Provider has date of correction Corrected 03/24/2026 |
| 02/12/2026 | D | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies | Deficient, Provider has date of correction Corrected 03/24/2026 |
| 02/12/2026 | D | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 03/24/2026 |
| 02/12/2026 | D | K-0363 | Install corridor and hallway doors that block smoke. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 03/24/2026 |
| 02/12/2026 | E | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 03/24/2026 |
| 02/12/2026 | E | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 03/24/2026 |
| 02/12/2026 | D | E-0025 | Create arrangements with other facilities to receive patients. Emergency Preparedness Deficiencies | Deficient, Provider has date of correction Corrected 03/24/2026 |
| 02/12/2026 | D | E-0023 | Establish policies and procedures for medical documentation. Emergency Preparedness Deficiencies | Deficient, Provider has date of correction Corrected 03/24/2026 |
| 02/12/2026 | D | E-0022 | Establish policies and procedures for sheltering. Emergency Preparedness Deficiencies | Deficient, Provider has date of correction Corrected 03/24/2026 |
| 02/12/2026 | D | E-0015 | Address subsistence needs for staff and patients. Emergency Preparedness Deficiencies | Deficient, Provider has date of correction Corrected 03/24/2026 |
| 02/12/2026 | D | E-0009 | Include a process for Emergency Preparedness collaboration. Emergency Preparedness Deficiencies | Deficient, Provider has date of correction Corrected 03/24/2026 |
| 02/12/2026 | D | E-0004 | Develop and maintain an Emergency Preparedness Program (EP). Emergency Preparedness Deficiencies | Deficient, Provider has date of correction Corrected 03/24/2026 |
| 04/11/2024 | D | K-0920 | Ensure proper usage of power strips and extension cords. Gas, Vacuum, and Electrical Systems Deficiencies | Deficient, Provider has date of correction Corrected 05/08/2024 |
| 04/11/2024 | E | K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Services Deficiencies | Deficient, Provider has date of correction Corrected 05/08/2024 |
| 04/11/2024 | E | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 05/08/2024 |
Automatic sprinklers in all required areas: Yes. CMS does not count fire safety citations in the health inspection star rating.
Source: CMS Fire Safety Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Penalties
No fines or payment denials published for this facility in the CMS Penalties file (last 3 years).
Source: CMS Penalties: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Staffing
| Measure | This facility | Florida average | U.S. average |
|---|---|---|---|
| Total nurse staff hours per resident per day | 3.74 | 3.82 | 3.86 |
| Registered nurse (RN) hours per resident per day | 0.63 | 0.73 | 0.69 |
| LPN/LVN hours per resident per day | 0.86 | Not published | Not published |
| Nurse aide hours per resident per day | 2.25 | Not published | Not published |
| Total nurse staff hours per resident per day, weekends | 3.33 | Not published | Not published |
| RN hours per resident per day, weekends | 0.46 | Not published | Not published |
| Total nursing staff turnover (%) | 41.6 | 41.4 | 45.8 |
| Registered nurse turnover (%) | 38.5 | Not published | Not published |
| Administrators who have left | 0 | Not published | Not published |
Reported hours come from the Payroll-Based Journal (PBJ) staffing data that facilities submit to CMS each quarter.
Source: CMS Provider Information; State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Facility details
- Legal business name
- Atrium SNF Operating LLC
- Ownership type
- For profit - Limited Liability company
- Chain
- Not published
- Ownership changed in last 12 months
- No
- Certified beds
- 84
- Average residents per day
- 82.9
- Participates in
- Medicare and Medicaid
- Located inside a hospital
- No
- Continuing care retirement community
- No
- Resident and family council
- Resident
- First approved for Medicare/Medicaid
- September 13, 1996
- County/parish
- Duval
Source: CMS Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Owners and managers reported to CMS
5 ownership and management records
| Name | Role | Type | Ownership % | Since |
|---|---|---|---|---|
| ATRIUM SNF HOLDINGS LLC | 5% OR GREATER DIRECT OWNERSHIP INTEREST | Organization | 100% | undefined undefined, NaN |
| ATRIUM MASTER HOLDINGS LLC | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | Organization | NO PERCENTAGE PROVIDED | undefined undefined, NaN |
| BHP SERVICES | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | Organization | NO PERCENTAGE PROVIDED | undefined undefined, NaN |
| WIERZBA, KYLE | W-2 MANAGING EMPLOYEE | Individual | NOT APPLICABLE | undefined undefined, NaN |
| SOFIA, LISA | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
Source: CMS Ownership: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Check it yourself
- Medicare Care Compare: Fountains Rehabilitation at Mill Cove. Full inspection reports, quality measures and staffing.
- AHCA licensed health care facility complaint form. The state agency also takes nursing home complaints.
- Ask the facility to show you its most recent inspection report and plan of correction.
Page built from CMS data files processed September 1, 2026 (CMS refreshes monthly). Last checked October 26, 2026. Not a ranking or endorsement.