Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Courtyard Rehabilitation And Health Center, Llc during CMS and state inspections, most recent first.
A survey in an LTC facility revealed multiple food safety and hygiene deficiencies, including improper storage and handling of food, expired items not removed, and lapses in staff hygiene practices. Raw chicken was stored unsealed, and prepared foods were left uncovered. Staff failed to wash hands between tasks, and the dishwasher's sanitization process was compromised. These issues could potentially affect the health of 73 residents receiving meals from the facility's kitchen.
The facility failed to ensure call devices were within reach for two residents, both with memory problems and at risk for falls. One resident had the call device on the floor or wrapped around a feeding pump, while another had it clipped to a wall outlet. Staff acknowledged the devices were inaccessible, potentially contributing to falls and behaviors.
A resident with a PEG tube and severely impaired cognition required Enhanced Barrier Precautions (EBP) during care. However, CNAs failed to wear gowns while providing incontinence care, only using gloves, and subsequently contaminated clean items with dirty gloves. The DON confirmed this was an infection control issue, as per facility policy requiring gown and gloves for high-contact care activities.
A facility failed to provide a discharge notice to a cognitively intact Medicaid recipient needing specialized services for an intellectual disability. The resident was transferred to a behavioral facility and then admitted to a hospital due to unmanageable behaviors, but the required discharge notice was not given to the resident or their representative, as confirmed by the DON.
A facility failed to accurately code an MDS assessment for a resident with serious mental illness, resulting in a deficiency in documenting the need for a Level II PASARR. The resident had diagnoses of depression and bipolar disorder, but the MDS incorrectly indicated no need for specialized services. The error was acknowledged by the MDS Coordinator, and the facility's policy emphasized the importance of accurate assessments.
A resident with severely impaired cognition and a PEG tube was improperly cared for when CNAs lowered the head of the bed and turned the resident during continuous enteral feeding. The DON confirmed that such actions could lead to aspiration, violating the facility's policy on Accident Hazards Prevention.
A resident with severely impaired cognition and chronic renal failure, who was always incontinent, did not receive proper incontinence care. Two CNAs failed to clean the resident's genital area and buttock correctly, with one CNA citing the resident's contracted state as a reason. The DON confirmed that the care was not provided correctly.
The facility failed to securely lock medications and biologicals, as observed by a surveyor. An unattended and unlocked cart with medications and cleaning solutions was found. An LPN confirmed the cart should have been locked, and the DON admitted to leaving it unlocked, acknowledging the potential risk to residents. The facility's policy requires all drugs and biologicals to be stored in locked compartments.
Food Safety and Hygiene Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to proper food handling and storage practices, which could potentially lead to foodborne illnesses. During an inspection, surveyors observed several issues in the kitchen, including raw chicken stored in an unsealed bag, expired food items not removed from stock, and prepared foods left uncovered in the refrigerator. Additionally, frozen cookies and muffins were found unsealed in the freezer. These practices were not in line with the facility's policies on food storage and handling. The inspection also revealed lapses in hygiene practices among dietary staff. A staff member was observed cleaning the ice machine without washing hands or wearing gloves, contrary to the facility's handwashing policy. Furthermore, a meat slicer was found with remnants of ham from a previous meal, indicating it had not been cleaned after use. Utensils in the clean drawer were found with particles, and the dishwasher's sanitization process was not properly logged or functioning, as the sanitizer hose was incorrectly placed, preventing proper sanitization of dishes. Additional observations included improper thawing of frozen ground beef, with staff leaving it under running water, and improper handling of plates by staff, touching surfaces that come into contact with food. A staff member also failed to wash hands between tasks, moving from preparing pureed food to handling clean utensils. These deficiencies highlight significant non-compliance with food safety and hygiene protocols, potentially affecting the health and safety of the 73 residents receiving meals from the facility's kitchen.
Failure to Ensure Call Devices Within Reach for Residents
Penalty
Summary
The facility failed to ensure that the call devices were within reach for two residents, leading to a deficiency in accommodating their needs and preferences. Resident #8, who had memory problems and impairment on one side, was observed multiple times with the call device out of reach, either on the floor or wrapped around the feeding pump. This was despite the care plan indicating the need to keep the call light within reach due to the resident's risk for falls and non-ambulatory status. Similarly, Resident #63, who also had memory problems and was at risk for falls due to immobility, was observed with the call device clipped to the wall outlet, making it inaccessible. The Director of Nursing and a Licensed Practical Nurse acknowledged that the call devices were not within reach for these residents, which could contribute to falls and behaviors. These observations highlight the facility's failure to reasonably accommodate the residents' needs by ensuring the accessibility of call devices.
Inadequate Use of PPE During High-Contact Care
Penalty
Summary
The facility failed to ensure that staff used appropriate infection control measures and donned the proper Personal Protective Equipment (PPE) during high-contact care for a resident with severely impaired cognition, incontinence of bowel and bladder, and a feeding tube. The resident required Enhanced Barrier Precautions (EBP) due to the presence of a percutaneous endoscopic gastrostomy (PEG) tube. During an observation, two Certified Nursing Assistants (CNAs) were seen providing incontinence care to the resident without wearing gowns, which is a requirement under EBP. The CNAs only wore gloves and were observed touching clean items and surfaces with the same gloves that had been used to handle urine and feces. The CNAs acknowledged that the resident had a PEG tube and was on EBP, confirming that gown and gloves should have been worn during care. The Director of Nursing (DON) also confirmed that the failure to wear gowns and the contamination of clean items with dirty gloves constituted an infection control issue. The facility's policy on Enhanced Barrier Precautions, dated 2022, specifies the use of gown and gloves during high-contact resident care activities for residents with indwelling medical devices, such as feeding tubes, to prevent the spread of infections.
Failure to Provide Discharge Notice
Penalty
Summary
The facility failed to provide a notice of discharge to a resident or the resident's representative. The resident, who was cognitively intact and a Medicaid recipient, was identified as needing specialized services due to an intellectual disability. The resident was transferred to a behavioral facility and subsequently admitted to a hospital due to behaviors that the facility could not manage. Despite these actions, the facility did not provide the required discharge notice to the resident or their representative, as confirmed by the Director of Nursing.
MDS Assessment Coding Error for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure that an Annual Minimum Data Set (MDS) assessment was accurately coded for a resident with serious mental illness, leading to a deficiency in documenting the need for a Level II Preadmission Screening and Resident Review (PASARR). The resident in question had diagnoses of depression, bipolar depression, and seizure disorder, and scored 11 on the Brief Interview for Mental Status (BIMS), indicating moderate impairment. Despite these conditions, the MDS assessment incorrectly indicated that the resident was not considered to have a serious mental illness or intellectual disability requiring a Level II PASARR. The care plan for the resident, revised in July 2024, noted the use of antidepressant medication for major depression and bipolar disorder. However, the PASARR packet provided by the facility, dated May 2013, stated that the resident did not require specialized services beyond the capabilities of the nursing facility. During interviews, the MDS Coordinator acknowledged the coding error, and the Director of Nursing was questioned about the facility's policy on MDS assessment accuracy. The facility's policy emphasized the need for accurate and comprehensive assessments to inform care planning, but the deficiency highlighted a lapse in this process.
Improper Bed Positioning During Enteral Feeding
Penalty
Summary
The facility failed to ensure proper care for a resident with severely impaired cognition who was receiving continuous enteral feeding through a percutaneous endoscopic gastrostomy (PEG) tube. On the specified date, a Certified Nursing Assistant (CNA) was observed lowering the head of the bed while the resident was receiving enteral feeding. Additionally, two CNAs were seen turning the resident from side to side during the feeding process. This action was confirmed by one of the CNAs, who acknowledged that the head of the bed was indeed lowered while the feeding pump was running. The Director of Nursing (DON) later confirmed that staff should not lower the head of the bed during enteral feeding, as it could potentially cause aspiration. The facility's policy on Accident Hazards Prevention, although undated, indicates that care should be provided in a manner that promotes quality of life, which was not adhered to in this instance.
Improper Incontinence Care for a Resident
Penalty
Summary
The facility failed to provide proper incontinence care for a resident with severely impaired cognition and chronic renal failure, who was always incontinent of bowel and bladder. The resident required total care for Activities of Daily Living (ADLs) due to impaired mobility. During an observation, a surveyor noted that two CNAs did not clean the resident's genital area or buttock correctly after an episode of incontinence. One CNA admitted that a portion of the genital area was not cleaned because the resident was too contracted, acknowledging that improper cleaning could lead to a urinary tract infection or leave stool on the resident. The Director of Nursing confirmed that the incontinence care was not provided correctly if the genital area or buttock was not cleaned properly.
Failure to Securely Lock Medications and Biologicals
Penalty
Summary
The facility failed to ensure that medications and biologicals were securely locked away, as observed by a surveyor. On August 26, 2024, at 6:05 PM, an unattended and unlocked cart containing medications and cleaning solutions was observed. On August 28, 2024, at 6:21 PM, an LPN confirmed that the cart should have been locked. On August 29, 2024, at 8:34 AM, the DON admitted to leaving the treatment cart unlocked, acknowledging that a resident could have accessed potentially harmful items. The facility's Pharmaceutical Services Policy mandates that all drugs and biologicals be stored in locked compartments under proper temperature controls.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near El Dorado
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hudson Memorial Nursing Home | 1.5 mi | ★★★★★ | 1 | 0 |
| Timberlane Health & Rehabilitation | 1.9 mi | ★★★★★ | 1 | 0 |
| The Springs Of El Dorado | 3.1 mi | ★★★★★ | 2 | 0 |
| Oak Ridge Health And Rehabilitation | 3.2 mi | ★★★★★ | 2 | 0 |
| Silver Oaks Health And Rehabilitation | 25.6 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.