Cycle 1
Health 2024-08-29 · Fire 2024-08-29
8 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
El Dorado, AR
Courtyard Rehabilitation And Health Center, LLC
4-star overall rating with 3-star inspections with 8 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
2415 W Hillsboro, El Dorado, AR
(870) 863-5034
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
76
Certified beds
Average residents
75
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Southern Administrative Services
Operator or chain grouping
Approved since
1991-12-12
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
35 facilities
Chain averages 4 overall / 3 health / 4 staffing / 4 quality stars
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
0.62
Registered nurse staffing · state 0.40 · national 0.68
LPN hours / resident day
0.95
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.35
Nurse aide staffing · state 2.72 · national 2.35
Total nurse hours
3.92
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.57
RN + LPN hours · state 1.35 · national 1.54
Weekend hours
3.11
Weekend nurse staffing · state 3.48 · national 3.43
Weekend RN hours
0.34
Weekend registered nurse coverage · state 0.27 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.03 · national 0.07
Adjusted RN hours
0.68
CMS adjusted RN staffing hours
Adjusted total hours
4.29
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
34%
Annual nurse turnover · state 51% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,771
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.09
Composite VBP score used to determine payment impact.
Payment multiplier
0.9888
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.69
Baseline 20.55% · Performance 19.26% · Measure score 4.69 · Achievement 4.69 · Improvement 3.17
Healthcare-associated infections
0
Baseline 6.82% · Performance 8.38% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
7.31
Baseline 33.33% · Performance 33.80% · Measure score 7.31 · Achievement 7.31 · Improvement 0
Adjusted total nurse staffing
2.04
Baseline 3.77 hours · Performance 3.66 hours · Measure score 2.04 · Achievement 2.04 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.65% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 79 · Observed rate 10.13% · Lower 95% interval 6.98% |
| Discharge to community | 58.67% |
50.57%
8.1 pts better
|
No Different than the National Rate · Eligible stays 78 · Observed rate 56.41% · Lower 95% interval 47.78% |
| Medicare spending per beneficiary | 1.12 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 72 · Denominator 72 |
| Falls with major injury | 1.39% |
0.77%
0.6 pts worse
|
Numerator 1 · Denominator 72 |
| Discharge self-care score | 58.93% |
53.69%
5.2 pts better
|
Numerator 33 · Denominator 56 |
| Discharge mobility score | 51.79% |
50.94%
0.9 pts better
|
Numerator 29 · Denominator 56 |
| Pressure ulcers or injuries, new or worsened | 1.39% |
2.29%
0.9 pts better
|
Numerator 1 · Denominator 72 · Adjusted rate 1.38% |
| Healthcare-associated infections requiring hospitalization | 8.39% |
7.12%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 55 · Observed rate 10.91% · Lower 95% interval 4.42% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 93 |
| Staff flu vaccination coverage | 97.35% |
42%
55.3 pts better
|
Numerator 110 · Denominator 113 |
| Discharge function score | 53.57% |
56.45%
2.9 pts worse
|
Numerator 30 · Denominator 56 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 33 · Denominator 33 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 13.16% |
25.2%
12 pts worse
|
Numerator 5 · Denominator 38 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
2.0
About the same
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 2.4 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.5 |
2.2
1.3 pts worse
|
1.8
1.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.5 · Observed 3.7 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
94.9%
4.7 pts better
|
93.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 98.4% · 4Q avg 99.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
96.1%
3.9 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 8.1% |
3.9%
4.2 pts worse
|
3.3%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 9.1% · Q3 7.9% · Q4 6.2% · 4Q avg 8.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.9% |
1.4%
0.5 pts better
|
11.4%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.7% · Q4 1.7% · 4Q avg 0.9% |
| Percentage of long-stay residents who lose too much weight | 3.4% |
4.9%
1.5 pts better
|
5.4%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 3.7% · Q3 5.1% · Q4 3.3% · 4Q avg 3.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.9% |
21.8%
6.9 pts better
|
19.6%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.6% · Q2 14.8% · Q3 11.3% · Q4 12.7% · 4Q avg 14.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 2.7% |
12.5%
9.8 pts better
|
16.7%
14 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 2.3% · Q3 2.0% · Q4 4.0% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 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 | 8.2% |
11.4%
3.2 pts better
|
16.3%
8.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.2% · Q2 15.6% · Q3 6.1% · Q4 2.9% · 4Q avg 8.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.0% |
10.4%
4.4 pts better
|
14.9%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.3% · Q2 8.3% · Q3 1.8% · Q4 1.8% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.7%
0.7 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.1%
1.1 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 6.0% |
14.6%
8.6 pts better
|
19.8%
13.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.1% · Q2 1.8% · Q3 1.5% · Q4 5.8% · 4Q avg 6.0% |
| Percentage of long-stay residents with pressure ulcers | 7.8% |
4.6%
3.2 pts worse
|
5.1%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 9.0% · Q3 5.0% · Q4 7.6% · 4Q avg 7.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.9% |
81.8%
10.1 pts better
|
81.7%
10.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 94.5% · Q2 89.0% · Q3 91.2% · Q4 93.3% · 4Q avg 91.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.0% |
13.8%
3.2 pts worse
|
12.0%
5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 17.0% · Observed 18.0% · Expected 11.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.4%
1.4 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.2% |
77.9%
15.3 pts better
|
79.7%
13.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 12.7% |
25.2%
12.5 pts better
|
23.9%
11.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 12.7% · Observed 14.0% · Expected 26.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-22 · Fire 2023-09-22
7 health deficiencies
Top issue: Nutrition and Dietary (4 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-06-23 · Fire 2022-06-23
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-08-29
K344 · Smoke Deficiencies
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2024-09-26
F · Potential for more than minimal harm
2023-09-22
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-10-11
F · Potential for more than minimal harm
2023-09-22
K344 · Smoke Deficiencies
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2023-10-11
F · Potential for more than minimal harm
2022-06-23
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 2022-07-23
F · Potential for more than minimal harm
2022-06-23
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-07-23
F · Potential for more than minimal harm
2022-06-23
K344 · Smoke Deficiencies
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2022-07-23
F · Potential for more than minimal harm
2022-06-23
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2022-07-23
F · Potential for more than minimal harm
2022-06-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-07-23
F · Potential for more than minimal harm
2022-06-23
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-07-23
E · Potential for more than minimal harm
2022-06-23
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2022-07-23
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-08-29
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 2024-09-26
E · Potential for more than minimal harm
2024-08-29
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-09-26
E · Potential for more than minimal harm
2024-08-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-26
D · Potential for more than minimal harm
2024-08-29
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-09-26
D · Potential for more than minimal harm
2024-08-29
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-09-26
D · Potential for more than minimal harm
2024-08-29
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 2024-09-26
D · Potential for more than minimal harm
2024-08-29
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 2024-09-26
D · Potential for more than minimal harm
2024-08-29
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-09-26
F · Potential for more than minimal harm
2023-09-22
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 2023-10-10
E · Potential for more than minimal harm
2023-09-22
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-10-10
E · Potential for more than minimal harm
2023-09-22
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2023-10-10
E · Potential for more than minimal harm
2023-09-22
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-10-10
E · Potential for more than minimal harm
2023-09-22
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2023-10-10
D · Potential for more than minimal harm
2023-09-22
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 2023-10-09
D · Potential for more than minimal harm
2023-09-22
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 2023-10-10
F · Potential for more than minimal harm
2022-06-23
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 2022-07-23
E · Potential for more than minimal harm
2022-06-23
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2022-07-23
D · Potential for more than minimal harm
2022-06-23
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2022-07-23
D · Potential for more than minimal harm
2022-06-23
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 2022-07-23
Penalties and ownership
What sits behind the stars
Ownership
4p2t1 Ops Holding LP
5% Or Greater Direct Ownership Interest · Organization
Alexark1 LLC
General Partnership Interest · Organization
Jej Assets LP
5% Or Greater Indirect Ownership Interest · Organization
Jej Management, LLC
5% Or Greater Indirect Ownership Interest · Organization
Lewis, David
W-2 Managing Employee · Individual
Ponthie, John
General Partnership Interest · Individual
Ponthie, John
Limited Partnership Interest · Individual
Ponthie, John
Corporate Director · Individual
Ponthie, Sharlot
5% Or Greater Indirect Ownership Interest · Individual
Nearby options
Other facilities in reach
#1
Hudson Memorial Nursing Home
El Dorado, AR
2-star overall rating with 2-star inspections with 9 recent health deficiencies
#2
Timberlane Health & Rehabilitation
El Dorado, AR
3-star overall rating with 3-star inspections with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
The Springs Of El Dorado
El Dorado, AR
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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