Courtyard Health And Rehabilitation

Location & what’s nearby

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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.

43.5% 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 63 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 48.4% 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 62 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 0.24 therapist hours per resident per day in 2026Q1 — more than 33% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 14% 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 145 beds and averages 110.0 residents a day — about 76% occupied, or roughly 35 beds typically open. It usually has some room. 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 3.46 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.37 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.93 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 3.13 hrs/resident/day on weekends vs 3.60 on weekdays — 13% thinner on weekends. RN hours go from 0.45 to 0.16 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 45% 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.

30 citations, most serious first. The 20 most serious are shown; the remaining 10 are one tap away and print in full.

• Immediate jeopardy · Jcited before2025-10-20 · 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, interview, record review and facility policy review, the facility failed to ensure that residents were free from abuse, neglect, and intimidation when it admitted and retained a resident with known aggressive and violent behaviors (Resident #1) without implementing adequate supervision, behavioral interventions, or protective measures for other residents. The facility's failure to provide necessary psychiatric intervention or to relocate vulnerable roommates placed residents at risk for serious injury, harm, impairment, or death, resulting in an immediate jeopardy to resident health and safety. This deficient practice directly affected three (3) of four (4) sampled residents. Resident #2, Resident #3, and Resident #4.The facility failed to ensure that residents were free from abuse and neglect when it did not provide adequate supervision or implement effective interventions to prevent the ongoing aggressive and combative behaviors of Resident #1. This failure resulted in an unsafe environment and placed Resident #1 and other residents 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2025-10-20 · 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 observation, interview, and record review, the facility failed to ensure that residents were protected from a resident who was admitted with known aggressive behaviors and failed to provide adequate supervision and interventions for that resident. The facility admitted and continued to retain Resident #1 without ensuring appropriate psychiatric care, enhanced supervision, or reassignment of vulnerable roommates. This systemic failure directly affected three (3) of four (4) sampled residents. Resident #2, Resident #3, and Resident #4.The facility's failure to provide adequate supervision to prevent the exhibited aggressive and combative behaviors of Resident #1 placed this resident, and other residents at risk, in a situation that was likely to cause serious injury, harm, impairment, or death. The facility's failure to identify the need for adequate supervision and ensure a secure environment contributed to Resident #1's exhibited aggressive and combative behaviors and placed all residents who were…

  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 · Jcited before2025-08-13 · 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

  Based on observation, interview, record review, and facility policy review, the facility failed to provide supervision and implement effective elopement prevention strategies for one (1) of four (4) sampled residents (Resident #1), who had a known cognitive impairment and elopement risk, resulting in an incident of elopement.The facility's failure to ensure supervision and implement interventions-including failure to detect the resident's absence promptly, and failure to secure exit doors-resulted in Resident #1 exiting the facility through the front entrance without staff knowledge and being unsupervised in the community for approximately one (1) hour and twenty-nine (29) minutes. The resident was found approximately two (2) miles away at a local business after receiving a ride from an unknown individual. This failure placed Resident #1 in a situation that was likely to cause serious injury, serious harm, serious impairment, or death, given the resident's severe cognitive impairment, multiple medical diagnoses, and the environmental risks encountered during elopement (e.g.,…

  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 · Past Non-Compliance
• Immediate jeopardy · Kcited before2023-05-09 · 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, interviews, record review, and facility policy review, the facility neglected to provide physician ordered services that were necessary for five (5) of 24 sampled residents. This resulted in actual harm for Residents #31, #75, #87, and #254 and had the likelihood of serious harm for Resident # 34. The facility's failure to provide services necessary to avoid physical harm caused serious harm as Resident #31 experienced decreased range of motion and mobility, Resident #75 was hospitalized for Congestive Heart Failure (CHF), Resident #87 developed a infection of a vascular stent placement, and Resident #254 was hospitalized due to sepsis. There was likelihood of harm for Resident #34 due to a delay in follow-up appointment for a supra pubic catheter placement. This non-compliance put these residents and other residents in a situation that was likely to cause serious harm, injury, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) that began on 11/21/22 when…

  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 · K2023-05-09 · 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

  Based on interviews, record review, and job description review, the facility's administration failed to use its resources effectively to ensure residents received physician-ordered services for five (5) of 24 residents reviewed, with the likelihood to affected any resident who needed outside transportation. Resident #31, Resident #34, Resident #75, Resident #87, and Resident #254. Serious harm occurred as a result of the facility's Administration's failure to ensure residents received physician-ordered services which caused Resident #31 to have decreased mobility, Resident #75 to be hospitalized , Resident #87 to have a wound infection, and Resident #254 to have sepsis. There was a likelihood of harm for Resident #34 due to a delay in changing a newly placed supra pubic catheter. The failure placed these residents, and other residents who are at risk in a situation that was likely to cause serious harm, injury, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) that began on 11/21/22 when Resident #87 was referred to a vascular surgeon and 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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2023-05-09 · tag F0865 — failed to run a quality-improvement (QAPI) program — pattern
  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

  Based on interviews, record review, and facility policy review, the facility failed to maintain an effective Quality Assurance Performance Improvement (QAPI) program to ensure transportation was provided for outside medical services for five (5) of 24 sampled residents, with the likelihood to affect any resident who required outside transportation. The facility's failure to maintain an effective QAPI program placed residents who require outside transportation at risk for serious injury, serious harm, serious impairment, or death. This caused Resident #31 to experience decreased mobility, Resident #75 to be hospitalized , Resident #87 to develop a wound infection, and Resident #254 to become septic. There was a likelihood of harm for Resident #34 due to the delay in changing a newly placed supra pubic catheter. The situation was determined to be an Immediate Jeopardy (IJ) that began on 11/21/22 when Resident #87 was referred to a vascular surgeon and the facility did not follow physician's orders. The Facility Administrator was notified of the IJ on 5/5/23 at 12:23 PM and provided 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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2023-05-09 · 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, interview, record review, and facility policy review, the facility failed to develop or implement a comprehensive care plan for residents with a Supra-Pubic Catheter, diagnoses of Chronic Obstructive Pulmonary Disease (COPD) and Congestive Heart Failure (CHF), Range-of-Motion (ROM) related to an Orthopedic Brace, Treatment related to a Vascular Implant, and Orthopedic, Wound and Vascular Appointments for five (5) of 24 care plans reviewed. Resident #31, Resident #34, Resident #75, Resident #87, and Resident #254. Serious harm occurred as a result of the facility's failure to develop or implement a Comprehensive Care Plan which resulted in decreased mobility for Resident #31, hospitalization for Resident #75, a wound infection for Resident #87, and sepsis for Resident #254. There was a likelihood of harm for Resident #34 due to a delay in changing a supra pubic catheter. The facility's failure to develop or implement care plan interventions placed these residents, and other residents who are…

  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 · J2023-05-09 · 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 interviews and record review, the facility failed to ensure two (2) of 24 sampled residents received outside medical services as ordered to prevent complications and maintain the highest practicable physical, mental, and/or psychosocial wellbeing. Residents #75 and #87. The facility's failure to provide required outside medical services led to the hospitalization of Resident #75 due to Congested Heart Failure (CHF) and Pneumonia and was admitted to the Intensive Care Unit (ICU) and wound infection for Resident #87 caused serious injury, serious harm, and serious impairment to Resident #75 and Resident #87 and placed other residents in a situation that was likely to cause serious injury, harm, impairment or death. The situation was determined to be an Immediate Jeopardy (IJ) that began on 11/21/22 when Resident #87 missed scheduled appointments with the vascular surgeon and developed two separate infections awaiting rescheduled appointments. The Facility Administrator was notified of the IJ on 5/5/23 at 12:23 PM and provided an IJ Template. The facility provided 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2023-05-09 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
  Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
  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 facility policy review, the facility failed to provide medical services to prevent an avoidable reduction in range-of-motion (ROM) and loss of mobility for one (1) of 24 sampled residents reviewed for ROM. Resident #31. The facility's failure to provide services to prevent the avoidable loss of ROM for Resident #31 resulted in serious injury, serious harm, and serious impairment and placed other residents in a situation that was likely to cause serious injury, harm, impairment, or death. The situation was determined to be Immediate Jeopardy (IJ) that began on 2/14/23 when Resident #31 missed the first post operative appointment with an orthopedic surgeon. The Facility Administrator was notified of the IJ on 5/5/23 at 12:23 PM and provided an IJ Template. The facility provided an acceptable Removal Plan on 5/7/23, in which the facility alleged all corrective actions to remove the IJ were completed and the IJ was removed on 5/8/23. The State Agency (SA) validated…

  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 · J2023-05-09 · tag F0919 — failed to provide a working call system — isolated
  Make sure that a working call system is available in each resident's bathroom and bathing area.
  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 facility policy review, the facility failed to ensure a functioning call light system was available for residents' bathrooms for 18 residents out of 107 residents that reside in the facility. (Residents #4, #5, #12, #21, #32, #37, #38, #44, #46, #49, #57, #60 #65, #69, #71, #81, #87, and #96) The facility's failure to ensure a functioning call light system was available for residents' bathrooms for 18 residents residing in the facility placed these residents, and other residents, in a situation that was likely to cause serious harm, injury, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) that began on 4/16/23 when a maintenance work order was completed for call light issues but was not acted upon. The facility Administrator was notified of the IJ on 5/2/23 at 5:38 PM and provided an IJ Template. The facility provided an acceptable Removal Plan on 5/2/23, in which they alleged all corrective actions to remove the IJ were…

  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.

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2026-06-18 · tag F0925 — failed to control pests — widespread
  Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, record review, facility policy review and interviews, the facility failed to maintain an effective pest control program so that the facility was free of pests for five (5) of seven (7) sampled residents, Resident #1, Resident #2, Resident #3, Resident #4 and Resident #6. Findings included:Record review of the facility policy titled, Safe and Homelike Environment with Revision Date 10/14/25, revealed the policy stated, In accordance with resident's rights, te facility will provide a safe, clean, comfortable and homelike environment.This includes ensuring that the resident can receive care and services safely and that the physical layout.does not pose a safety risk.Sanitary includes.preventing the spread of disease-causing organisms.Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment.On 6/17/26 at 1:38 PM, during a telephone interview the Resident Representative (RR) for Resident #1 reported that she complained that the facility did not provide a clean, sanitary environment and confirmed…

  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.

  Environmental Deficiencies · Deficient, Provider has plan of correction
• Potential for harm · D2026-06-18 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
  Reasonably accommodate the needs and preferences of each resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, record review, facility policy review, and interview, the facility failed to ensure that a Spanish-speaking resident had access to language assistance services to prevent cultural and language barriers to care and quality of life for one (1) of (1) Spanish-speaking resident reviewed for communication needs. Resident #1. Findings included:Record review of the facility policy titled, Non-Discrimination-Language Assistance Services with Revision Date 10/14/25 revealed, It is the policy of this facility to take reasonable steps to ensure that individuals with Limited English Proficiency (LEP) are not discriminated against and have access to language assistance services and meaningful communication involving their medical conditions, treatment, and other vital documents.Language assistance will be provided in-person or remotely by a qualified interpreter and/or the use of qualified bilingual or multilingual staff.The facility must not.Rely on staff other than qualified interpreters, qualified translators, or qualified bilingual/multilingual staff to communicate 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.

  Resident Rights Deficiencies · Deficient, Provider has plan of correction
• Potential for harm · Dcited before2026-06-18 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, record review, facility policy review and interviews the facility failed to ensure that staff followed standard and transmission-based precautions to prevent spread of infections, when an Registered Nurse (RN) did not follow Enhanced Barrier Precautions (EBP) during direct care/replacement of the resident's leaking catheter drainage and collection component for one (1) of two (2) sampled residents with indwelling catheters. Resident #6. Findings Included:Record review of the facility policy titled, Standard Precautions Infection Control with Revision Date 11/14/25 revealed the policy stated, All staff are to assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. Therefore, all staff shall adhere to Standard Precautions to prevent the spread of infection to residents, staff and visitors. Standard Precautions refer to the infection prevention practices that apply to all residents, regardless of suspected or confirmed diagnosis or presumed infection status.…

  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 plan of correction
• Potential for harm · Ecited before2025-01-09 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
  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

  Based on observation, staff interview, and facility policy review, the facility failed to securely safeguard hazardous chemicals in two unlocked janitor's closets for one (1) of four (4) days of survey. Findings Include: Review of the facility ' s policy, Overview of Proper Chemical Use, revised 6/2016, revealed, In order to help prevent accidents from occurring you must follow the following guidelines: 6. If you leave chemicals in the janitor's closet the door must be locked . An observation on 01/06/25 at 10:30 AM, revealed the Janitor Closet on the 200 hall was unlocked and there was a full bottle of 3M Concentrated Glass Cleaner in the closet. An observation on 01/06/25 at 11:19 AM, revealed the Janitor Closet on the Intermediate Care (IC) Hall was unlocked and unattended and there were containers of 3M Concentrated Glass Cleaner and 3M Quat Disinfectant. On 01/07/25 at 3:19 PM, during an interview, Housekeeping Supervisor #2 confirmed that the Janitor Closet's were unlocked. She also confirmed that these rooms were used to store housekeeping carts containing chemicals 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
• Potential for harm · E2025-01-09 · tag F0800 — pattern
  Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to ensure dietary staff supported and respected a resident's right to make choices about his or her meal preferences for one (1) of twenty-six (26) sampled residents. Resident #40. Findings Include: Record review of the facility policy Menus revised 10/2022, revealed, .Procedures .2. Menus will be periodically presented for resident review, including the resident council, menu review meetings, or other review board as indicated by the center. The menu will identify the primary meal, the alternate meal, and any always offered food and beverage items . An observation on 1/6/25 at 10:52 AM, revealed a menu hanging in both dining areas that did not include alternate options. An interview on 01/7/25 at 11:13 AM, with Resident #40 indicated that alternate meals are never posted or available for selection. She stated that this situation upsets her because she feels they have no choice but to eat what is provided. Resident #40 explained that, as a diabetic, she may not…

  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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-01-09 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
  Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interviews, record review, and facility policy review, the facility failed to provide palatable, appropriately temperature-controlled foods for one (1) of (43) sampled residents. Resident #40 Findings included: A review of the facility's policy titled Food Quality and Palatability Policy (HCSG Policy 006), revised February 2023, revealed, Policy Statement: Food will be prepared by methods that conserve nutritive value, flavor, and appearance. Food will be palatable, attractive, and served at a safe and appetizing temperature. Food and liquids are prepared and served in a manner, form, and texture to meet the residents' needs . During an interview on 1/7/2025 at 11:19 AM, Resident #40 complained the food served was usually cold. An observation and interview on 1/7/2025 at 12:09 PM, a meal tray was provided, and temperatures were evaluated by the Dietary Manager. The temperatures were as follows: white rice, 122°F (Fahrenheit); spinach, 122°F; and egg noodles with gravy, 109°F. A sampling of the meal tray revealed that the food was bland and not served at 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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-01-09 · 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

  Based on observation, interviews, record review, and policy review, the facility failed to prevent the possibility of the spread of infection as evidenced by improper hand hygiene practices and wound care for three (3) of six (6) direct care observations. (Resident #3, Resident #64 and #66) Findings included: Record review of the facility's Handwashing Hand Hygiene policy, revised August 2019 revealed Policy Statement The facility considers hand hygiene the primary means to prevent the spread of infection. Policy Interpretation and Implementation . 2. All personnel shall follow the handwashing hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 3. Hand hygiene products and supplies (sink, soap, towels, alcohol-based hand rub, etc.) shall be readily accessible and convenient for staff use . Record review of the facility's policy titled Dressing, Dry Clean, revised September 2013, revealed, . Steps in the Procedure .15. Cleanse the wound with the ordered cleaner. If using gauze, use a clean gauze for each cleaning stroke. Clean…

  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 before2025-01-09 · 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

  Based on observations, staff interview and record review, the facility failed to ensure that the dignity and respect of residents are upheld when feeding during mealtimes for one (1) of 26 sample residents reviewed. Resident #3 Findings includes: An observation and interview on 1/06/25 at 1:30 PM, revealed Certified Nursing Assistant #1 (CNA) assisting Resident #3 with lunch. This observation revealed CNA #1 was standing up while feeding the resident. During an interview with CNA #1 stated that she did not know that she was not supposed to stand up when feeding residents. On 01/07/25 at 12:50 PM, Charge Nurse #1 stated during an interview that she was unaware that staff should sit down when feeding residents. She acknowledged that standing while assisting a resident with meals could raise dignity concerns. On 1/7/25, at 1:04 PM, during an interview with the Director of Nursing (DON) emphasized that CNAs should always sit at eye level when assisting residents with meals. She explained that sitting down prevents residents from feeling intimidated by staff who are standing over 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-01-09 · 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

  Based on observation, interviews, record review, and facility policy reviews, the facility failed to implement care plan interventions related to wound care when a nurse cleaned a resident's pressure ulcer wound without patting it dry for one (1) of 43 resident care plans reviewed (Resident #64) Findings included: Record review of the facility's policy titled Plans of Care, revised 9/25/2017, revealed, The Individualized Person-Centered plan of care may include .Services are provided to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . Record review of Resident #64's comprehensive care plan revealed . Interventions/Task .Cleanse Stage 4 sacrum with wound cleanser and 4 x 4 gauze. Pat dry with 4 x 4 gauze . During an observation on 1/8/2025 at 12:03 PM, Registered Nurse (RN) #2 did not pat the wound dry with gauze on the sacral region as described in Resident #64's care plan. On 1/8/2025 at 2:20 PM, during an interview, RN #2 admitted she did not pat the sacral region dry with gauze as per Resident #64's care plan. On 1/9/2025 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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2024-04-17 · 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 interviews, record reviews and facility policy reviews, the facility failed to ensure the comprehensive care plan was implemented, as evidenced by failure to provide oral care during Activities of Daily Living (ADLs) for two (2) of six (6) sampled residents. Resident #3 and Resident #6 Findings Include: Review of the facility's policy and procedure titled, Plans of Care, revised 9/25/17, revealed, .Procedure .The Individualized Person-Centered plan of care may include but is not limited to the following .Services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required by state and federal regulatory requirements . Individualized interventions that honor the resident's preferences and promote achievement of the resident's goals . Resident #3 Record review of the Care Plan for Resident #3 revealed (Proper name of Resident has an ADL self-care performance deficit r/t (related to) Activity Intolerance, Disease Process, Impaired balance…

  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

“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

$26,939 in federal fines across 2 penalties.

• $14,511 — penalty dated 2025-10-20
• $12,428 — penalty dated 2025-08-13

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 AVARDIS HEALTH — 38 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 20 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.

4 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 79% 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 $439K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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 MS