Cycle 1
Health 2025-01-09 · Fire 2025-01-09
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Mccomb, MS
Courtyard Health And Rehabilitation
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $148,196 in total fines with 9 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
501 South Locust Street, Mccomb, MS
(601) 684-8111
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
145
Certified beds
Average residents
111
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Avardis Health
Operator or chain grouping
Approved since
1991-12-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.45
Registered nurse staffing
LPN hours / resident day
1.12
Licensed practical nurse staffing
Aide hours / resident day
1.88
Nurse aide staffing
Weekend hours
3.16
Weekend nurse staffing
RN turnover
47%
Annual RN turnover
Total nurse turnover
45%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.6 |
2.4
0.2 pts worse
|
1.9
0.7 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.3 |
2.9
0.6 pts better
|
1.8
0.5 pts worse
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 92.2% |
95.7%
3.5 pts worse
|
93.4%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.4% |
97.0%
1.4 pts better
|
95.5%
2.9 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.7% |
3.2%
0.5 pts better
|
3.3%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 4.4% |
1.6%
2.8 pts worse
|
11.4%
7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 10.8% |
6.1%
4.7 pts worse
|
5.4%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 37.0% |
24.4%
12.6 pts worse
|
19.6%
17.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 44.3% |
23.4%
20.9 pts worse
|
16.7%
27.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 25.4% |
22.8%
2.6 pts worse
|
16.3%
9.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.5% |
20.6%
2.9 pts worse
|
14.9%
8.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
1.5%
0.6 pts better
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 2.8% |
2.5%
0.3 pts worse
|
1.7%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.3% |
21.4%
1.9 pts worse
|
19.8%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 7.0% |
6.9%
0.1 pts worse
|
5.1%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 73.1% |
87.9%
14.8 pts worse
|
81.7%
8.6 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.5% |
15.3%
3.8 pts better
|
12.0%
0.5 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 5.4% |
2.6%
2.8 pts worse
|
1.6%
3.8 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.2% |
84.6%
3.6 pts better
|
79.7%
8.5 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 42.3% |
27.9%
14.4 pts worse
|
23.9%
18.4 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-05-09 · Fire 2023-05-09
10 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2019-10-24 · Fire 2019-10-24
13 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-09
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-02-19
F · Potential for more than minimal harm
2023-05-09
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-06-02
F · Potential for more than minimal harm
2019-10-24
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-12-03
F · Potential for more than minimal harm
2019-10-24
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2019-12-20
D · Potential for more than minimal harm
2019-10-24
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2019-12-03
D · Potential for more than minimal harm
2019-10-24
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-12-03
Inspection history
Recent health citations
J · Immediate jeopardy
2025-10-20
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-11-07
J · Immediate jeopardy
2025-10-20
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.
Corrected 2025-11-07
J · Immediate jeopardy
2025-08-13
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
E · Potential for more than minimal harm
2025-01-09
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.
Corrected 2025-02-19
E · Potential for more than minimal harm
2025-01-09
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2025-02-19
E · Potential for more than minimal harm
2025-01-09
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-02-19
E · Potential for more than minimal harm
2025-01-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-19
D · Potential for more than minimal harm
2025-01-09
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-02-19
D · Potential for more than minimal harm
2025-01-09
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-02-19
E · Potential for more than minimal harm
2024-04-17
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-05-22
D · Potential for more than minimal harm
2024-04-17
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-05-22
D · Potential for more than minimal harm
2024-04-17
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-05-22
D · Potential for more than minimal harm
2023-10-20
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-11-28
E · Potential for more than minimal harm
2023-06-27
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2023-07-17
E · Potential for more than minimal harm
2023-06-27
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-07-17
D · Potential for more than minimal harm
2023-06-27
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-07-17
K · Immediate jeopardy
2023-05-09
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-06-27
K · Immediate jeopardy
2023-05-09
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2023-06-27
K · Immediate jeopardy
2023-05-09
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2023-06-27
J · Immediate jeopardy
2023-05-09
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-06-27
J · Immediate jeopardy
2023-05-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-27
J · Immediate jeopardy
2023-05-09
F688 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2023-06-27
J · Immediate jeopardy
2023-05-09
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2023-06-27
G · Actual harm
2023-05-09
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-06-27
D · Potential for more than minimal harm
2023-05-09
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-06-27
E · Potential for more than minimal harm
2019-10-24
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2019-12-03
E · Potential for more than minimal harm
2019-10-24
F926 · Environmental Deficiencies
Health
Have policies on smoking.
Corrected 2019-12-03
D · Potential for more than minimal harm
2019-10-24
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-12-03
D · Potential for more than minimal harm
2019-10-24
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2019-12-03
D · Potential for more than minimal harm
2019-10-24
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2019-12-03
D · Potential for more than minimal harm
2019-10-24
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2019-12-03
D · Potential for more than minimal harm
2019-10-24
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2019-12-03
Penalties and ownership
What sits behind the stars
$12,428
2025-08-13
Fine
Fine · fine $12,428
Fine
$135,768
2023-05-09
Fine
Fine · fine $135,768
Fine
$0
2023-05-09
Payment Denial
Payment Denial · denial start 2023-06-03 · 44 days
44 day denial
Ownership
Mccomb Parentco LLC
5% Or Greater Direct Ownership Interest · Organization
Fc Encore Mccomb LLC
5% Or Greater Security Interest · Organization
Hoback, Tiffany
Operational/Managerial Control · Individual
Jenkins, Patricia
Operational/Managerial Control · Individual
Jones, Tequilla
Operational/Managerial Control · Individual
Lampton, Lucius
Operational/Managerial Control · Individual
Mize, Gary
Operational/Managerial Control · Individual
Msop Holdco LLC
5% Or Greater Indirect Ownership Interest · Organization
Nu C Ii Irrevocable Trust
5% Or Greater Indirect Ownership Interest · Organization
Nu C Irrevocable Trust
5% Or Greater Indirect Ownership Interest · Organization
Pike Holdco LLC
5% Or Greater Indirect Ownership Interest · Organization
Snf Care Centers LLC
5% Or Greater Indirect Ownership Interest · Organization
Snf Mgr LLC
Operational/Managerial Control · Organization
Thomas, John
Operational/Managerial Control · Individual
Zenith Holdco Ii LLC
5% Or Greater Indirect Ownership Interest · Organization
Zenith Holdco LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Mccomb Community Care Center
Mccomb, MS
2-star overall rating with 3-star inspections with 9 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Camellia Estates
Mccomb, MS
4-star overall rating with 4-star inspections with $7,066 in total fines with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Diversicare Of Tylertown
Tylertown, MS
5-star overall rating with 4-star inspections with 4 recent health deficiencies
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