Courtyards Comm Living Center

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

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.

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.

56.1% 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 122 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 46.7% 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 30 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 0.28 therapist hours per resident per day in 2026Q1 — more than 43% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 21% 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.

Staffing

How full it usually is: this home is certified for 66 beds and averages 59.1 residents a day — about 90% occupied, or roughly 7 beds typically open. It runs fairly full. 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 3.63 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.70 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.36 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 3.08 hrs/resident/day on weekends vs 3.85 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.83 to 0.37 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 51% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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 fewer than at the previous inspection — improving. 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.

42 citations, most serious first. The 21 most serious are shown; the remaining 21 are one tap away and print in full.

• Immediate jeopardy · Kcited before2024-02-20 · tag F0600 — failed to protect residents from abuse and neglect — pattern
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  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 observation, staff and resident interview, record review, and facility policy review, the facility failed to protect a residents right to be free from neglect for two (2) of three (3) residents sampled for abuse, Resident #13 and Resident #20 as evidence by: 1) neglected to recognize, communicate, evaluate, and address a resident's nutritional needs, which resulted in an unintended significant weight loss of 6.92% (percent) in one (1) month, which further led to a significant weight loss of 17.52% (percent) in four (4) months. Resident #13. The facility's failure to consult a Registered Dietician (RD), notify the attending physician of a significant change in condition, and act upon the residents' weight loss, placed the resident, and all other residents residing in the facility at risk for serious serious harm, serious injury, serious impairment, or possibly death. 2) neglected to identify, communicate, and address a resident at risk for malnutrition due to prolonged nausea and vomiting, and failure to…

  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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2024-02-20 · tag F0835 — failed to run the facility competently — pattern
  Administer the facility in a manner that enables it to use its resources effectively and efficiently.
  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 observation, resident and staff interview, record review, and job description review, the facility failed to be administered in a manner that ensured residents with significant weight loss would get the necessary nutritional support and services to ensure their well-being for two (2) of three (3) residents sampled for abuse/neglect as evidenced by: Resident #13 and Resident #20 1) failed to recognize, evaluate, and address a resident's nutritional needs, which resulted in an unintended significant weight loss of 6.92% (percent) in one (1) month, which further led to a significant weight loss of 17.52% (percent) in four (4) months. Resident #13. The facility's failure to consult a Registered Dietician (RD), notify the attending physician of a significant change in condition, and act upon the residents' weight loss, placed the resident, and all other residents residing in the facility at risk for serious harm, serious injury, serious impairment, and possibly death. 2) failed to identify and address a…

  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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2024-02-20 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  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 observation, staff and resident interview, record review and facility policy review, the facility failed to notify the physician for a significant change in condition for two (2) of six (6) residents sampled for nutrition Resident #20 and Resident #13 as evidenced by: 1) failed to recognize, evaluate, communicate, and address a resident's nutritional needs, which resulted in an unintended significant weight loss of 6.92% (percent) in one (1) month, which further led to a significant weight loss of 17.52% (percent) in four (4) months. Resident #13. The facility's failure to notify the attending physician of a significant change in condition, and act upon the residents' weight loss, placed the resident, and all other residents residing in the facility at risk for serious harm, serious injury, serious impairment, or possible death. 2) failed to identify, communicate, and address a resident at risk for malnutrition due to prolonged nausea and vomiting, and failure to identify a decrease in food intake due…

  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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2024-02-20 · tag F0656 — failed to write and follow a full care plan — isolated
  Develop 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interview, record review and facility policy review, the facility failed to implement a comprehensive care plan for five (5) of eighteen sampled residents as evidenced by: Resident #13, #15, #20, #26, and #54 1) failed to implement the nutritional care plan for Resident #13 which resulted in a significant weight loss which placed the resident at risk for dehydration, malnutrition, skin breakdown and placed the resident and all other residents residing in the facility at risk for serious harm, serious injury, serious impairment, and possibly death. 2) failed to implement a pain and nutritional care plan for Resident #20 which resulted in the resident experiencing prolonged nausea, vomiting, and an infrequent passage of stool (constipation), significant weight loss, with a potential outcome for fecal impaction, bowel obstruction (blockage), dehydration, malnutrition, skin breakdown and placed the resident and all other residents residing in the facility at risk for serious…

  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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2024-02-20 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  Provide enough food/fluids to maintain a resident's health.
  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 observation, staff and resident interview, record review, and facility policy review, the facility failed to maintain acceptable parameters of nutrition for two (2) of six (6) residents sampled for nutrition as evidence by: Resident #13 and Resident #20 1) failed to recognize, evaluate, and address a resident's nutritional needs, which resulted in an unintended significant weight loss of 6.92% (percent) in one (1) month, which further led to a significant weight loss of 17.52% in four (4) months. Resident #13. The facility's failure to consult a Registered Dietician (RD), notify the attending physician of a significant change in condition, and act upon the residents' weight loss, placed the resident, and all other residents residing in the facility at risk for serious harm, serious injury, serious impairment, and possibly death. 2) failed to identify and address a resident at risk for malnutrition due to prolonged nausea and vomiting, and failure to identify a decrease in food intake due to pain and…

  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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2024-02-20 · tag F0865 — failed to run a quality-improvement (QAPI) program — isolated
  Have a plan that describes the process for conducting QAPI and QAA activities.
  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 staff interview, record review, and facility policy review, the facility failed maintain an effective Quality Assurance and Performance Improvement (QAPI) program to identify, analyze, and address residents with weight loss for two (2) of six (6) residents reviewed for nutrition. Resident #13 and Resident #20. The facility's Quality Assurance and Performance Improvement (QAPI) review indicated the facility's failure resulted in a lack of action to identify and address weight loss, which placed Resident #13 and Resident #20, and all other residents residing in the facility at risk for serious harm, serious injury, serious impairment, and possibly death. The State Agency (SA) identified an Immediate Jeopardy (IJ) that began on 11/02/23 when the facility failed to recognize, evaluate, and address Resident #13's nutritional needs, which resulted in an unintended significant weight loss of 6.92% (percent) in one (1) month, which further led to a significant weight loss of 17.52% (percent) in four (4) months.…

  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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-08-14 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, staff and resident interviews, record review, and facility policy review, the facility failed to protect the resident ' s right to be free from physical, verbal, and mental abuse by staff for one (1) of three (3) residents reviewed for abuse. Resident #1 Findings include: Record review of facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated 10/2022, revealed, Policy Statement: Residents have the right to be free from abuse .This include but is not limited to verbal, mental, or physical abuse Policy Interpretation and Implementation .5. Establish and maintain a culture of compassion and caring for all residents . Record review of facility policy titled, Freedom from Abuse, Neglect, and/or Exploitation Prevention Plan Education, with revision date of 11/14/17, revealed, The resident has the right to be free from abuse .by anyone, including, but not limited to facility staff . Following are relevant definitions provided by CMS (Centers for Medicare and Medicaid Services): Abuse - The willful infliction of injury,…

  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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2024-08-14 · tag F0697 — failed to manage pain — isolated
  Provide safe, appropriate pain management for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on resident and staff interview, record review, and facility policy review, the facility failed to control pain for a resident who was experiencing moderate to intense pain for one (1) of three (3) residents reviewed for pain medication administration. Resident #3 Record review of facility policy titled Medication Administration - General Guidelines dated 8/25/14, revealed, .Medications are administered as prescribed in accordance with good nursing principles and practices .2. Administration . b. Medications are administered in accordance with written orders of the attending physician . During an interview on 8/13/24 at 9:10 AM, Resident #3 revealed she had Multiple sclerosis, Lupus, Arthritis, and Chronic pain and was on a pain medication regimen every four hours around the clock and this regimen kept her pain controlled, but if I miss even one dose, it sets me back for a week. She revealed that in June, her medication was not available, and the nurses gave her a different medication until hers was received from the pharmacy and even though it helped the pain, it did not help…

  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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2024-08-14 · tag F0755 — failed to provide safe pharmacy services — isolated
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on resident and staff interview, record review, and facility policy review, the facility failed to have available and administer an ordered medication for pain control for one (1) of three (3) residents reviewed for pain medication administration. Resident #3 Findings include: Record review of facility policy titled Medication Administration - General Guidelines dated 8/25/14, revealed, Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. 2. Administration: . b. Medications are administered in accordance with written orders of the attending physician. During an interview on 8/13/24 at 9:10 AM, Resident #3 revealed there had been times in June 2024 and August 2024 that she did not receive her pain medication as ordered due to it not being available in the facility. She stated she had Multiple sclerosis, Lupus, Arthritis, and chronic pain and was on a pain medication regimen every four hours around the clock and this regimen kept her pain controlled, but if I miss even one dose, it…

  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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2024-08-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  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 staff interviews, record reviews, and facility policy review, the facility failed to ensure a resident was kept free from an accident resulting in an injury during facility transport for one (1) of (4) residents reviewed for accidents. Resident #1. Findings include: A record review of the facility's policy titled, Accidents and Incidents undated revealed, Policy: It is the policy of this facility that the resident environment remains as free of accidents and hazards as possible and those residents receive supervision and assistance devices to prevent accidents whenever possible. This is accomplished through the identification and evaluation of environmental hazards and individual risk factors, implementing interventions to reduce hazards and risks that are identified, and monitoring for the effectiveness of the interventions . A record review of Emergency Department Note date of service: 06/20/24 revealed, Resident #1 with a chief complaint of Extremity Laceration. (EMS states that facility told them…

  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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2024-02-20 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide 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

  Based on observation, resident and staff interview, record review, facility policy review, and job description review, the facility failed to recognize and assess risk factors for a resident receiving an opioid pain medication and failed to ensure that a resident received care in accordance with professional standards of practice, for one (1) of two (2) residents reviewed for pain management. Resident #20. Resident #20 experiencing prolonged nausea, vomiting, and an infrequent passage of stool (constipation) with a potential outcome for fecal impaction, and bowel obstruction (blockage). Findings Include: Record review of the facility policy titled Change in a Resident's Condition or Status with a review date of 7/24/23 revealed Policy Statement: Our facility notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status .Policy Interpretation and Implementation: 1. The nurse will notify the resident's attending physician or physician on call when there has been a (an): .d. significant change…

  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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-05-21 · tag F0656 — failed to write and follow a full care plan — pattern
  Develop 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, facility document review, and record review, the facility failed to ensure comprehensive Activities of Daily Living (ADL) care plans were developed and implemented for two (2) of eighteen (18) residents reviewed. Specifically, the facility failed to develop a comprehensive ADL care plan addressing nail care needs for Resident #8 and failed to implement established ADL care plan interventions related to nail care for Resident #45.The scope and severity for this deficiency were cited at an E due to previous citations of F656 on the last two annual recertification surveys completed on 2/20/24 and 5/22/25 representing a pattern of deficiency. Findings include:Review of facility policy titled Care Plan Policy and Procedure with no date revealed, .Each resident's care plan will remain current and inform staff of resident's needs, strengths, goals and approaches.Resident #8Record review of Resident #8's ADL care plan, dated 10/29/2024, revealed the comprehensive care plan was…

  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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-05-21 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
  Provide 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, resident and staff interviews, record reviews, and facility policy review, the facility failed to provide activities of daily living (ADL) care necessary to maintain personal hygiene for two (2) of sixty (60) residents observed. (Residents #8 and #45)The scope and severity for this deficiency were cited at an E due to previous citations of F677 on the last two annual recertification surveys completed on 2/20/24 and 5/22/25 representing a pattern of deficiency. Findings include:Review of the facility policy titled ADL Care of a Resident Policy and Procedure, undated, revealed, .Resident ADL care will be provided to the resident according to the individualized resident needs.Resident #8During an observation on 5/18/2026 at 11:46 AM, Resident #8's fingernails were observed to be approximately three-fourths (3/4) inch in length with jagged edges.During an observation and interview on 5/19/2026 at 1:26 PM, Licensed Practical Nurse (LPN) #1 confirmed Resident #8's fingernails were long with…

  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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-05-21 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  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 observation, staff interviews, record review and facility policy review the facility failed to maintain infection control practices by failing to ensure respiratory equipment was stored in a sanitary manner to prevent contamination (Resident #30) and by failing to ensure soiled items were properly discarded (Resident #55) for two (2) of eighteen sampled residents.The scope and severity for this deficiency were cited at an E due to previous citations of F880 on the last two annual recertification surveys completed on 2/20/24 and 5/22/25 representing a pattern of deficiency. Findings Include: Review of the facility policy titled, Infection Control Policy and Procedure, undated, revealed Purpose: To establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Review of a statement typed on facility letterhead dated 5/21/26 and signed by 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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-05-21 · tag F0550 — failed to protect resident dignity and rights — isolated
  Honor 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 observation, staff interview, record review, and facility policy review the facility failed to ensure the residents were treated with dignity and respect by failing to maintain privacy during the provision of care for one (1) of 18 sampled residents. Resident #55 Findings include:Review of the facility policy titled, Residents Rights and Quality of Life Policy and Procedure undated, revealed All residents have the right to a dignified existence.An observation from the main hallway on 5/19/2026 at 1:59 PM revealed Resident #55 lying in bed, uncovered, with her incontinent brief and legs exposed. The privacy curtain was not drawn, and the room door remained open to the hallway. During the observation, hospice personnel and maintenance staff passed by the resident's room while the resident remained exposed, and the door remained open.An observation and interview on 5/19/2026 at 2:04 PM, Certified Nurse Aide (CNA) #1 entered Resident #55's room carrying a disposable blue pad. CNA #1 stated, I had to run and…

  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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-05-21 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
  Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, resident interview, staff interview, record review, and facility policy review, the facility failed to ensure a clean homelike environment for one (1) of 38 resident rooms. Resident #2Findings Include: Record review of facility policy titled Cleaning and Disinfection of Environmental Services revised August 2009 revealed, .14. Horizontal surfaces will be wet dusted regularly (e.g., daily, three times per week) using clean cloths moistened with an EPA-registered hospital disinfectant (or detergent). The disinfectant (or detergent) will be prepared as recommended by the manufacturer . In an interview on 5/18/2026 at 12:30 PM, Resident #2 stated that her room was dusty and she needed to clean it herself. Resident #2 stated she also needed to clean the bathroom. When asked if housekeeping staff cleaned her room, Resident #2 stated they only removed the trash. Resident #2 stated that she does not like her room to be dusty. Observations made on 5/18/2026 at 12:35 PM and again on 5/19/2026 at 3:50 PM of Resident #2's room revealed, heavy accumulations of dust on chest…

  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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-05-21 · tag F0641 — isolated
  Ensure each resident receives an accurate assessment.
  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 staff interviews, record review, and facility policy review, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the resident's status for one (1) of eighteen (18) residents reviewed. (Resident #21)Findings include:Review of the facility policy titled Resident Assessment Policy and Procedure, undated, revealed, .The facility shall complete residents' assessments via MDS 3.0 according to the Resident Assessment Instrument (RAI) guidelines.Record review of Resident #21's Significant Change MDS assessment, with an Assessment Reference Date (ARD) of 7/21/2025, revealed under Section J1900C (Number of Falls Since Admission/Entry or Reentry or Prior Assessment - Major Injury), the assessment was coded to indicate the resident experienced a fall with major injury during the look-back period.Record review of Resident #21's progress notes and the facility Incident Log revealed no record of a fall with major injury for Resident #21. During an interview on 5/19/2026 at 3:00 PM,…

  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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-05-22 · tag F0656 — failed to write and follow a full care plan — pattern
  Develop 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, record review, and facility policy review, the facility failed to implement comprehensive care plans for two (2) of the twenty-four resident care plans reviewed. (Resident #8 and Resident #53). The scope for F 656 was increased to E due to a prior citation on the last annual recertification survey on 2/20/24, which represents a pattern of deficiency. Findings include: Review of facility policy titled Care Plans, Comprehensive Person-Centered, reviewed on 10/22, revealed: Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . 7. Policy Interpretation and Implementation .The comprehensive, person-centered care plan: b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . Resident #8 Record review of the care plan date…

  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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-05-22 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
  Provide 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 observation, resident and staff interviews, record review, and facility policy review the facility failed to provide Activities of Daily Living (ADL) care for two (2) of 24 residents (Residents #8 and #53) observed during the initial tour. Specifically, the facility failed to ensure nail care was provided for Resident #8, failed to provide shaving for Resident #53, and failed to provide showers for both Residents #8 and #53 in accordance with their scheduled care routines and facility policy. The scope for F 677 was increased to E due to a prior citation on the last annual recertification survey on 2/20/24, which represents a pattern of deficiency. Cross reference F725 Findings include: Review of facility policy titled, Bath, Shower/Tub revised 8/25/14 revealed, .Purpose: The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin . Review of facility policy titled, Fingernails/Toenails, Care of revised date 2/18…

  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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-05-22 · tag F0725 — failed to have enough nursing staff — pattern
  Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
  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 observation, interview, record review, and policy review, the facility failed to ensure sufficient nursing staff were available to meet the Activities of Daily Living (ADL) needs of dependent residents, as required by the residents' care plans and the facility's staffing policy. This failure resulted in two (2) of 61 sampled residents (Resident #8 and Resident #53) not receiving scheduled showers, hygiene care, and nail care. Findings include: Review of facility's policy titled, Staffing with review date 10/22 revealed, Policy Statement Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment . Record review of the Payroll Based Journal Staffing Data Report for Fiscal Year Quarter 1 2025 (October 1 - December 31), revealed, Excessively Low Weekend Staffing Triggered = Weekend Staffing data is excessively low. During an observation and interview on 5/19/25 at…

  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.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-05-22 · tag F0565 — failed to support the resident council — isolated
  Honor the resident's right to organize and participate in resident/family groups in the facility.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on staff and resident interviews, record review, and facility policy review, the facility failed to make prompt efforts to resolve a grievance from resident Council meetings and communicate steps towards a resolution of a grievance concerning sheets not being changed on shower days for three (3) of six (6) meeting minutes reviewed. Meeting dates of 3/11/25, 4/7/25, and 5/6/25 Findings include: Record review of facility's policy titled, Grievances and Complaints, dated 2/14/23, revealed, Process - Social Services will act as the grievance officer for the facility and oversee the grievance process. Upon receipt of a grievance, Social Services will complete a written report within 5 (five) working days of the filed grievance and determine what corrective actions, if any, should be taken . Social Services must notify the person who filed the grievance, within 10 working days of the filed grievance, in the form of a report. Copies of this report will be available to the person filing the grievance at any time. If filer is not satisfied with the results of the investigation, 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

$132,468 in federal fines across 3 penalties. 1 Medicare payment denial on record.

• $17,780 — penalty dated 2024-08-01
• $52,809 — penalty dated 2024-08-01
• $61,879 — penalty dated 2024-02-20
• Medicare payment denial — starting 2024-08-24 for 16 days

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to COMMUNITY ELDERCARE SERVICES — 17 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 10 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

2 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.

About 78% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $701K paid to related parties — landlords or management companies under common ownership — equal to about 12% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. 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, FY2024). 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 MS