Cycle 1
Health 2024-09-19 · Fire 2024-09-19
7 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Middletown, PA
Courtyard Gardens Nursing And Rehab Ctr
4-star overall rating with 4-star inspections with $12,315 in total fines with 5 recent health deficiencies
999 West Harrisburg Pike, Middletown, PA
(717) 944-3351
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
102
Certified beds
Average residents
89
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1982-04-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.58
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.90
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.45
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.94
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.49
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.44
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.31
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.57
CMS adjusted RN staffing hours
Adjusted total hours
3.87
CMS adjusted total nurse staffing hours
Case-mix index
1.39
Higher values indicate more complex resident acuity
RN turnover
39%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,454
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29.70
Composite VBP score used to determine payment impact.
Payment multiplier
0.9856
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
3.82
Baseline 7.11% · Performance 6.69% · Measure score 3.82 · Achievement 3.82 · Improvement 1.46
Total nurse turnover
2.80
Baseline 41.86% · Performance 52.25% · Measure score 2.80 · Achievement 2.80 · Improvement 0
Adjusted total nurse staffing
2.30
Baseline 3.44 hours · Performance 3.73 hours · Measure score 2.30 · Achievement 2.30 · Improvement 0.76
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.66% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 45 · Observed rate 8.89% · Lower 95% interval 6.51% |
| Discharge to community | 42.79% |
50.57%
7.8 pts worse
|
No Different than the National Rate · Eligible stays 44 · Observed rate 36.36% · Lower 95% interval 30.85% |
| Medicare spending per beneficiary | 0.72 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 29 · Denominator 29 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 29 |
| Discharge self-care score | 50% |
53.69%
3.7 pts worse
|
Numerator 13 · Denominator 26 |
| Discharge mobility score | 57.69% |
50.94%
6.8 pts better
|
Numerator 15 · Denominator 26 |
| Pressure ulcers or injuries, new or worsened | 6.9% |
2.29%
4.6 pts worse
|
Numerator 2 · Denominator 29 · Adjusted rate 5.99% |
| Healthcare-associated infections requiring hospitalization | 6.69% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 28 · Observed rate 3.57% · Lower 95% interval 3.26% |
| Staff COVID-19 vaccination coverage | 0.93% |
8.2%
7.3 pts worse
|
Numerator 2 · Denominator 214 |
| Staff flu vaccination coverage | 32.53% |
42%
9.5 pts worse
|
Numerator 81 · Denominator 249 |
| Discharge function score | 38.46% |
56.45%
18 pts worse
|
Numerator 10 · Denominator 26 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
1.7
0.5 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.5 · Expected 2.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0 |
1.2
1.2 pts better
|
1.8
1.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0 · Observed 0 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 88.4% |
86.9%
1.5 pts better
|
93.4%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 94.2% · Q2 92.6% · Q3 85.9% · Q4 81.0% · 4Q avg 88.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.7% |
93.5%
3.2 pts better
|
95.5%
1.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.9% |
3.2%
0.7 pts worse
|
3.3%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 3.7% · Q3 3.5% · Q4 3.6% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.6% |
6.5%
4.9 pts better
|
11.4%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 2.5% · Q4 2.4% · 4Q avg 1.6% |
| Percentage of long-stay residents who lose too much weight | 5.2% |
6.5%
1.3 pts better
|
5.4%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 3.9% · Q3 7.1% · Q4 4.9% · 4Q avg 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.8% |
19.9%
4.1 pts better
|
19.6%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.9% · Q2 17.5% · Q3 16.7% · Q4 17.1% · 4Q avg 15.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.5% |
18.7%
2.2 pts better
|
16.7%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 14.8% · Q3 17.4% · Q4 16.9% · 4Q avg 16.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 26.1% |
19.6%
6.5 pts worse
|
16.3%
9.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.1% · Q2 29.0% · Q3 26.6% · Q4 28.9% · 4Q avg 26.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.0% |
18.3%
0.7 pts worse
|
14.9%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.4% · Q2 22.1% · Q3 18.7% · Q4 18.9% · 4Q avg 19.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.0% |
0.9%
0.1 pts worse
|
1.0%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 2.0% · Q4 0.8% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.4% |
1.7%
3.7 pts worse
|
1.7%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 4.9% · Q3 3.5% · Q4 3.6% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.9% |
26.4%
0.5 pts worse
|
19.8%
7.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.5% · Q2 27.2% · Q3 26.5% · Q4 20.2% · 4Q avg 26.9% |
| Percentage of long-stay residents with pressure ulcers | 5.2% |
5.3%
0.1 pts better
|
5.1%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 4.2% · Q3 5.1% · Q4 3.7% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 56.3% |
68.9%
12.6 pts worse
|
81.7%
25.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 58.1% · Q2 60.4% · Q3 56.1% · Q4 51.7% · 4Q avg 56.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 0.0% |
9.8%
9.8 pts better
|
12.0%
12 pts better
|
Short Stay · 20240701-20250630 · Adjusted 0.0% · Observed 0.0% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.1% |
1.5%
0.6 pts worse
|
1.6%
0.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q2 4.8% · Q3 0.0% · Q4 3.2% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 61.8% |
68.7%
6.9 pts worse
|
79.7%
17.9 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 61.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.4% |
23.1%
7.3 pts worse
|
23.9%
6.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.4% · Observed 27.3% · Expected 21.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-07 · Fire 2023-11-07
6 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Cycle 3
Health 2022-11-03 · Fire 2022-11-03
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
5 fire-safety deficiencies
Top issue: Construction (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2023-11-07
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2023-11-29
C · Minimal harm
2023-11-07
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2023-11-29
F · Potential for more than minimal harm
2022-11-03
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-12-17
E · Potential for more than minimal harm
2022-11-03
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2022-12-17
E · Potential for more than minimal harm
2022-11-03
K133 · Construction Deficiencies
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2022-12-17
E · Potential for more than minimal harm
2022-11-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-12-17
E · Potential for more than minimal harm
2022-11-03
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-12-17
Inspection history
Recent health citations
G · Actual harm
2026-01-27
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Not marked corrected
G · Actual harm
2026-01-27
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Not marked corrected
E · Potential for more than minimal harm
2026-01-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Not marked corrected
E · Potential for more than minimal harm
2026-01-27
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Not marked corrected
D · Potential for more than minimal harm
2024-09-19
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-10-18
D · Potential for more than minimal harm
2024-09-19
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-10-18
D · Potential for more than minimal harm
2024-09-19
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-10-18
F · Potential for more than minimal harm
2023-11-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-20
E · Potential for more than minimal harm
2023-11-07
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-12-20
D · Potential for more than minimal harm
2023-11-07
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-12-20
D · Potential for more than minimal harm
2023-11-07
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-12-20
D · Potential for more than minimal harm
2023-11-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-12-20
B · Minimal harm
2023-11-07
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-12-20
D · Potential for more than minimal harm
2022-11-03
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2022-11-30
D · Potential for more than minimal harm
2022-11-03
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-11-30
Penalties and ownership
What sits behind the stars
$8,469
2023-08-14
Fine
Fine · fine $8,469
Fine
$3,846
2023-06-05
Fine
Fine · fine $3,846
Fine
Ownership
Eaby, Douglas
Corporate Director · Individual
Vogel, Louis
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Oak Hill Center For Rehabilitation And Nursing
Middletown, PA
2-star overall rating with 1-star inspections with abuse icon flag with $85,005 in total fines with 14 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Spring Creek Rehabilitation And Nursing Center
Harrisburg, PA
2-star overall rating with 2-star inspections with $21,445 in total fines with 13 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
#3
River's Bend Health & Rehab Center
Harrisburg, PA
2-star overall rating with 2-star inspections with $19,841 in total fines with 13 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
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