Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Fountains Rehabilitation At Mill Cove during CMS and state inspections, most recent first.
Food Items Not Date Marked in Kitchen and Nourishment Areas The facility failed to properly date mark food items in the dry storage area and nourishment rooms. Surveyors observed a wrapped dessert in the walk-in refrigerator without a date, seven of 13 sandwiches in a nourishment room refrigerator without date markings, outside food without dates, and an opened half-full peanut butter container in dry storage without a date. The CDM and dietary staff confirmed the items should have been dated and identified staff responsibility for date marking and discarding unlabeled items.
Beneficiary notice documentation was not maintained accurately for three residents, including a resident who remained in the facility and two others selected from the facility’s lists. The Administrator, DON, and BOM provided multiple versions of the Beneficiary Notice Review forms, but each version contained errors or omissions, including residents who should have been excluded and residents who were not listed at all. When the three selected forms were finally produced, they still contained inaccurate information.
Infection control tracking was not maintained. Record review and interviews with the DON showed missing surveillance data for several months, and antibiotic records from the EHR were only generated during the survey. The DON stated that after the prior Infection Preventionist left, she had been keeping up with the records but had multiple binders to locate, and later said she thought others were tracking it while she ended up with the papers.
Failure to complete and document an admission agreement for a resident. Record review showed no admission agreement for the resident's initial admission or readmission after hospitalization. The AD stated she spoke with the resident once about the paperwork but did not document the conversation, and the facility policy and AD job description identified responsibilities related to the admission process and explaining admission paperwork.
Failure to address a resident’s impaired vision in the care plan. A resident with CVA, AFIB, HTN, and severely impaired vision had a care plan that covered mood/behavior, ADL refusals, anticoagulant therapy, and fall risk, but not his vision needs. He had repeated referrals for cataract surgery and documentation that nothing had been done, no glasses or readers were ordered, and the surgery follow-up was delayed for months. The resident stated he was blind, felt trapped, and believed staff were not helping him arrange the surgery.
A resident with severely impaired vision and cataracts stated staff were not helping him arrange surgery, despite his report that he had insurance and funds to pay for it. His care plan did not address impaired vision, and the record showed repeated optometry referrals for cataract surgery with notes that nothing had been done, no glasses were ordered, and no readers were assigned. Staff interviews showed uncertainty about scheduling and transportation, and no documentation was provided to verify that the eye appointment had been arranged or refused.
Failure to post daily staffing information: The facility did not ensure that required staffing details were posted at the beginning of each shift. Surveyors found no staffing posting at the entrance, an outdated staffing board near the south wing, and resident room boards with missing or outdated dates and missing assigned nurse/CNA information. The DON acknowledged the postings were not updated, and the Administrator stated the information should have been corrected by the nurses and/or CNAs.
Failure to Clean Dryer Lint Traps After Each Load: The facility failed to keep dryer equipment in safe operating condition by not ensuring lint was removed promptly. In the laundry room, the lint removal log was not completed for two scheduled entries, and a dryer lint trap was observed covered with a thick layer of white fluffy material. An LA stated lint is cleaned after every load and said it had been cleaned that morning, but could not explain why lint remained in the trap. The facility policy stated lint catchers should be cleaned after each load.
The facility failed to ensure a resident with a serious mental illness received a required Level 2 PASRR evaluation. Despite the resident's significant mental health diagnoses and ongoing concerns, the necessary evaluation was not conducted, representing a significant oversight in care management.
The facility failed to provide necessary grooming and personal hygiene services for a resident, as evidenced by observations of elongated fingernails with brown matter and an untrimmed mustache. Despite the resident's consent for nail trimming, the care was not provided timely, and staff interviews revealed inconsistencies in executing ADL care responsibilities.
Food Items Not Date Marked in Kitchen and Nourishment Areas
Penalty
Summary
The facility failed to store and label food items in a manner to prevent foodborne illness and maintain sanitary conditions by not appropriately date marking food items in the dry storage area and nourishment rooms. During an initial kitchen tour, a dessert was observed plated on the walk-in refrigerator shelving unit, wrapped but not date marked. In the 800 Wing nourishment room, seven of 13 sandwiches in the refrigerator were not date-marked, and foods brought in from outside the facility were without dates. During a follow-up observation with the Certified Dietary Manager, the seven sandwiches without date markings were confirmed to be from the kitchen and should have been dated. The CDM stated the sandwiches were removed and discarded because they were not labeled, and explained that kitchen staff were responsible for date marking items from the kitchen and removing items older than three days and not labeled in the nourishment rooms. In a later kitchen observation, an opened half-full container of peanut butter was found in the dry storage room without date marking. Lead [NAME] observed the photograph of the peanut butter jar and removed it from the shelf, and stated that whoever opened items in the dry storage room was responsible for dating them. A Dietary Aide stated CNAs were responsible for cleaning nourishment rooms and discarding food, and that everyone was responsible for date marking in the kitchen. The facility policy stated the Dining Services Director or designee ensures storage is neat, arranged for easy identification, and date marked as appropriate.
Beneficiary notice records were inaccurate and incomplete
Penalty
Summary
The facility failed to provide documentation confirming that residents were informed before, at the time of admission, and periodically during their stay about services available in the facility and the charges for those services, including charges for services not covered under Medicare/Medicaid or by the facility’s per diem rate. The deficiency involved three residents whose Beneficiary Notice forms were reviewed, including Resident #49 and two other residents selected from the facility’s lists. Surveyors repeatedly requested the Beneficiary Notice Review forms and were given multiple versions that contained inaccurate or incomplete information. During the survey, the Administrator first provided a list of residents discharged within the last six months, but the list included residents who had been discharged to the hospital, transferred to other skilled nursing facilities, or had expired, despite instructions to exclude those residents. After the survey team identified errors, the facility provided corrected forms that remained inaccurate, then later provided another set that was incomplete and did not list residents who remained in the facility. The DON and BOM were involved in the process, but the BOM stated she was responsible for ABN forms and that the SSD handled NOMNC forms, and she did not recall completing the task during the last annual survey. When the three selected resident forms were finally provided, they still contained inaccurate information, including one resident who the facility said remained in the facility but had actually been discharged.
Infection control tracking was not maintained
Penalty
Summary
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 properly monitor and track infections between August 2025 and February 2026. During record review with the DON on 2/11/26, no infection control tracking was available for August 2025 through November 2025 or for January 2026. When asked about the missing data, the DON stated that since the previous Infection Preventionist left, she had been keeping up with it and had "like four binders" that she needed to find. On 2/12/26, review of the facility's infection control tracking information showed that antibiotic records generated from the electronic health record for August 2025 to present had been generated on 2/8/26 and 2/11/26 during the survey. During an interview that same day, the DON stated that she thought people were keeping track of it and that she ended up with all these papers. The facility policy titled Infection Prevention Control Program - Core Practices stated that routine monitoring through audits and surveillance would be conducted to determine compliance with infection prevention and control policies and procedures, and that surveillance tools would be used for recognizing infections, recording the number and frequency of infections, detecting outbreaks and epidemics, monitoring employee infections, and detecting unusual pathogens.
Failure to Complete and Document Admission Agreement
Penalty
Summary
The facility failed to implement its admissions policy for one resident reviewed for admission agreements. A review of the resident's record showed no admission agreement present for the initial admission or for the readmission following hospitalization. The record also 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 stated she did not start until November 2025, but she had spoken with the resident one time about the admission agreement and did not document that conversation anywhere. Review of the facility's Admissions Process - IDT policy showed the facility was to follow a consistent and complete admission process, and the Admissions Director position description stated the director was responsible for providing, reviewing, and explaining admission paperwork and policies to the resident and/or guardian.
Failure to Address Resident Vision Needs in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that reflected one resident’s individualized needs related to impaired vision. The resident had diagnoses including CVA, AFIB, urinary retention, HTN, and morbid obesity, and his annual MDS showed intact cognition with severely impaired vision and some depressed mood. His active care plan addressed mood and behavior changes, refusal of ADL assistance, anticoagulant therapy, and fall risk, but it did not address his impaired vision. Record review showed the resident was referred to an ophthalmologist for cataract surgery more than once in 2024, including in January and May, with documentation noting decreased vision and that nothing had been done, no glasses were ordered, and no readers were assigned. The resident was not seen again for cataract surgery referral until February 2025. Progress notes documented late entries that the resident was examined by an optometrist on the dates of the vision visits. Interviews with facility staff showed uncertainty about why the appointment was not scheduled and conflicting understanding of who was responsible for arranging transportation and follow-up. During interview, the resident became visibly upset and stated he was blind, that staff were not helping him, and that he had been supposed to have cataract surgery a year earlier but still had not received it. He stated he had insurance and other funds to pay for surgery, but the facility was not assisting with arranging it. He reported that his loss of vision affected his mood and made him feel trapped, and he said he did not feel staff cared about his wellbeing.
Failure to Assist Resident With Vision Services and Cataract Surgery Follow-Through
Penalty
Summary
The facility failed to ensure that a resident with severely impaired vision received proper treatment and assistance with arranging vision services and transportation to and from a practitioner specializing in vision impairment or vision assistive devices. The resident was admitted with diagnoses including CVA, AFIB, urinary retention, HTN, and morbid obesity. His annual MDS showed intact cognition with severely impaired vision, and his quarterly MDS later continued to note impaired vision. The resident told surveyors he was blind, had cataracts, had been supposed to have surgery a year earlier, and said the facility was not helping him arrange it even though he had insurance and other funds to pay for the surgery. He stated his loss of vision affected his mood and made him feel trapped. The resident’s care plan did not address his impaired vision. The record showed multiple vision service encounters with referrals for cataract surgery, including notes that he had age-related nuclear cataracts in both eyes and decreased vision. One consultation noted that he had been referred previously and that nothing had been done, with no glasses ordered and no readers assigned. Another later referral again recommended cataract surgery. Progress notes also documented that the resident was examined by an optometrist on those occasions. Staff interviews showed uncertainty and lack of documentation regarding follow-through on the resident’s eye care. An LPN stated the resident could not see and requested that medication cups be placed within reach so he could shake them to determine whether he was receiving the correct amount of medication. A CNA stated the resident complained that he could not see well and was supposed to have cataract surgery. The Unit Clerk stated she was responsible for scheduling dental and vision appointments and transportation, but she could not provide documentation showing that the resident’s eye appointment had been scheduled or that he had refused it. The SSD stated she was not sure why an appointment was not set up and could not verify the reason for the lack of follow-through.
Failure to Post Daily Staffing Information
Penalty
Summary
The facility failed to ensure that daily nurse staffing information was posted at the beginning of each shift on 2 of 5 days reviewed during the recertification survey. During a tour on 2/8/26 from 11:00 AM to 12:00 PM, no staffing information was posted at the reception desk area, and a clear frame that should have contained staffing information was empty. A whiteboard near the south wing that did have staffing information was dated 2/6/26. During the same tour, resident room whiteboards intended to show the current date, current shift, and assigned nurse and CNA were observed with outdated or missing information; seven boards had not been updated with the current date, including boards dated 1/18/26, 1/28/26, 2/2/26, and 2/6/26, and one board was undated and did not list the assigned nurse or CNA. On 2/9/26 at 9:01 AM, the Daily Staffing posting at the entrance near the nurses' station was still dated Sunday, 2/8/26. During an interview on 2/11/26 at 4:21 PM, the DON stated the staffing coordinator had previously been responsible for posting staffing, but that person was no longer employed and the DON had been filling in since 2/6/26. He acknowledged that staffing had not been posted and that the resident room boards had incorrect or missing dates. He stated nurses were responsible for updating staffing on the unit and CNAs were responsible for updating the boards in resident rooms at the beginning of each shift, and the Administrator stated the information should have been corrected by the nurses and/or CNAs.
Failure to Clean Dryer Lint Traps After Each Load
Penalty
Summary
The facility failed to maintain equipment in safe operating condition by not ensuring lint was promptly removed from the dryers. During an observation in the laundry room, the lint removal log had not been completed for the 7:00 AM or 9:00 AM entries, and the lint trap in the first dryer was observed to be covered with a thick layer of white fluffy material. When interviewed, the Laundry Assistant stated that lint is cleaned out after every load and nodded yes when asked if it had been cleaned that morning, but then could not explain why lint remained in the dryer trap. The interim Housekeeping Director stated she did not know and identified herself as the Maintenance Director, and the Administrator stated that if the policy says after every load, then she expected staff to do it after every load and document it. The facility policy titled Dryers/Lint Catcher stated that lint catchers should be cleaned after each load.
Failure to Conduct Required Level 2 PASRR Evaluation
Penalty
Summary
The facility failed to ensure that a resident identified with a mental disorder or intellectual disability was re-evaluated to determine if specialized care and services were required. Resident #29 had a Level 1 PASRR indicating a serious mental illness and the need for a Level 2 PASRR evaluation, which was not found in the resident's medical records. The resident was admitted and readmitted to the facility with diagnoses including cognitive/communication deficit, epilepsy, schizophrenia, major depression, and a history of suicidal ideations. Despite these conditions, the necessary Level 2 PASRR evaluation was not conducted. The Social Services Director (SSD) acknowledged that the facility's interdisciplinary team (IDT) reviews PASRR screenings to ensure appropriate admissions. However, SSD B admitted that a Level 2 PASRR should have been triggered for Resident #29 but could not explain why the referral was not made. The resident's care plan included focus areas for tactile hallucinations, elopement risk, and the use of psychotropic medications, indicating ongoing mental health concerns that required specialized attention. The failure to conduct the Level 2 PASRR evaluation represents a significant oversight in the resident's care management.
Failure to Provide Timely Nail Care and Grooming
Penalty
Summary
The facility failed to provide necessary services to maintain appropriate grooming and personal hygiene for Resident #25, as evidenced by observations of elongated fingernails with brown matter underneath and an untrimmed mustache covering his lips. Despite the resident's alert and oriented state, and his expressed consent for nail trimming, the care was not provided in a timely manner. Interviews with staff revealed that CNAs were primarily responsible for ADL care, including nail trimming on shower days, but this was not consistently executed. The resident's care plan included specific interventions for nail care, especially considering his anticoagulant therapy, but these were not followed through as required. Resident #25, who was admitted with multiple diagnoses including heart failure, chronic pulmonary edema, and cerebral infarction, had a BIMS score indicating intact cognition and required moderate assistance with personal hygiene. Despite the care plan's directives to check and trim nails on bath days and as necessary, the resident's nails were observed to be neglected. The facility's policy on ADL care emphasized the importance of providing appropriate support and assistance with personal care, but this was not adhered to, leading to the observed deficiency.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 245 citations issued within 25 miles in the last 12 months — including the 7 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Jacksonville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| First Coast Health And Rehabilitation Center | 2.2 mi | ★★★★★ | 12 | 0 |
| Fleet Landing | 2.2 mi | ★★★★★ | 0 | 0 |
| Dolphin Pointe Health Care Center | 2.3 mi | ★★★★★ | 13 | 0 |
| University Crossing | 4.3 mi | ★★★★★ | 0 | 0 |
| Vivo Healthcare University | 4.6 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Fountains Rehabilitation At Mill Cove.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.