Average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
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 The Courtyard Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
MDS Did Not Reflect Wound Infection A resident with a right hip abscess and IV antibiotic treatment had a quarterly MDS that did not list the wound infection as an active diagnosis. Records showed the resident had redness, swelling, tenderness, and drainage at the hip site, was receiving Ceftriaxone IV, and had documentation from the surgical consult, hospital discharge summary, and progress notes supporting the infection. The MDS nurse said the omission was due to human error, and the DON stated MDS accuracy was important because it reflected the resident’s care needs.
Food items in the kitchen were found stored without required labels or dates. A sealed bag of frozen ground beef in the freezer, a precooked meal in the refrigerator, and an opened carbonated beverage were all undated and unlabeled, and the Dietary Resource Manager stated she was unsure whether the refrigerator items belonged to a resident because there was no label.
Incontinent Care Not Completed for Uncircumcised Male Resident: A resident with severe cognitive impairment, total care needs, and bowel/bladder incontinence did not receive complete perineal care when a CNA failed to retract the foreskin and clean under the penis shaft and top of the scrotum during incontinent care. The CNA stated she knew the correct technique but forgot, and the DON confirmed the required care for an uncircumcised male resident.
Infection Control Glove Use During Incontinent Care: During incontinent care for a resident with severe cognitive impairment and total dependence, a CNA cleaned the resident but did not change soiled gloves or sanitize hands before touching the clean brief to fasten it. The resident had diagnoses including Alzheimer's disease, dementia, asthma, and HTN, and was always incontinent of bowel and bladder. The DON stated staff should change gloves after cleaning the resident and before touching the clean brief to avoid cross contamination and prevent infection.
The facility failed to ensure appropriate use of psychotropic medications for two residents. One resident continued to receive a higher dose of Cymbalta despite a recommendation for reduction, while another was prescribed Lexapro without a documented diagnosis of depression. The facility's policy requires that psychotropic drugs are only given when necessary and documented, but this was not followed, leading to unnecessary medication administration.
The facility failed to employ a qualified Director of Food and Nutrition Services, as the current DM lacked necessary certification and qualifications. Despite completing coursework, the DM had not taken the certifying exam. The HR Director confirmed the DM's promotion from a CNA/CMA role, and the Administrator was aware of the DM's lack of qualifications. The facility lacked a policy on DM position requirements.
A facility failed to maintain proper infection control practices, as an LVN did not sanitize hands between administering medications to residents, and a CNA did not wear gloves or wash hands after handling a meal tray from a resident on C-diff isolation. These actions were contrary to facility policies and could lead to infection spread.
A facility failed to obtain informed consent for the administration of Escitalopram Oxalate (Lexapro) to a resident with moderately intact cognition. The resident was not informed of the medication's risks and benefits, and the consent was not documented in the electronic health record until after administration. This oversight contradicts the facility's policy requiring informed consent prior to psychotropic medication use.
A facility failed to maintain resident dignity during dining assistance as a CNA stood while assisting two residents with meals, contrary to the facility's policy requiring staff to sit at eye level. The CNA was unaware of this requirement due to a lack of training, and the DON confirmed the expectation for staff to sit during feeding.
A facility failed to accurately document a resident's hospice care status in the MDS, despite existing physician orders and care plans indicating hospice admission. The MDS Nurse acknowledged the oversight, which could lead to inadequate care due to inaccurate assessments. The DON highlighted the importance of accurate MDS information for resident care and staffing needs.
A facility failed to include depression as a focus area in a resident's care plan, despite the resident having a diagnosis of major depressive disorder and moderately impaired cognition. The MDS LVN removed depression from the care plan after discontinuing the resident's anti-depressant, contrary to facility policy requiring comprehensive care plans to address all identified needs.
A resident's medical records were incomplete, missing several critical diagnoses, and supplemental oxygen was administered without a physician's order. The omissions in the resident's diagnoses were confirmed by the DON, who noted the responsibility of the admitting charge nurse to transcribe all pertinent information. Additionally, the resident received oxygen at 2L/min without documentation in the TAR or physician orders, with an LVN admitting to not transcribing the order despite verbal confirmation from the physician.
MDS Did Not Reflect Resident’s Wound Infection
Penalty
Summary
The facility failed to ensure Resident #1’s quarterly MDS assessment accurately reflected her status because it did not include her infected wound under Section I Active Diagnoses. Resident #1 was a [AGE]-year-old female admitted with a diagnosis of cutaneous abscess of the right lower limb, and her records showed she had an abscess of the right hip with redness, warmth, tenderness, swelling, and yellow fluid under the skin. Her active orders showed Ceftriaxone Sodium 2 GM IV daily for streptococcus anginose to the right hip wound, and the MAR showed she received the antibiotic throughout the MDS look-back period. The MDS also coded her as taking an antibiotic and IV medication, but did not identify the wound infection as an active diagnosis. Additional records supported the wound infection during the assessment period, including a surgical consult note documenting abscess of the hip, a hospital discharge summary showing she was discharged to the facility on antibiotics, and a progress note describing the right trochanter/hip skin issue and ongoing IV antibiotic treatment. During interview, the MDS nurse stated she missed the wound infection due to human error and acknowledged that MDS accuracy was important because it reflected the resident’s condition, care requirements, and needs. The DON stated MDS accuracy was important to show what the resident needed for care and that inaccuracy could lead to missed care.
Food Storage Items Found Undated and Unlabeled
Penalty
Summary
The facility failed to store food in accordance with professional standards for service safety in its only kitchen observed for sanitary conditions. During observation, a clear plastic bag of frozen uncooked ground beef was found in the freezer sealed but without a label or date. In the refrigerator, a precooked meal in a plastic container was not labeled or dated, and a 16-ounce carbonated beverage was opened and not dated or labeled. The Dietary Resource Manager stated she thought the precooked meal and beverage belonged to a resident, but with no label she was unsure. She later stated it was policy to label and date all incoming food. The facility's Refrigerators and Freezers Policy stated that all food shall be appropriately dated, received dates will be marked, and expiration or use-by dates will be observed.
Incontinent Care Not Completed for Uncircumcised Male Resident
Penalty
Summary
The facility failed to ensure appropriate incontinent care for a resident who was always incontinent of bowel and bladder and required total care. The resident had diagnoses including Parkinsonism, Alzheimer's disease, and hemiplegia, and the quarterly MDS indicated a BIMS score of 05, showing severe cognitive impairment. The care plan identified bowel/bladder incontinence related to dementia and immobility and included monitoring and documenting signs and symptoms of UTI. During observation on 09/18/2025 at 11:20 a.m., while CNA A was providing incontinent care, she did not pull back the resident's foreskin and did not clean under the shaft of the penis or the top of the scrotum. During interview, CNA A stated she knew the foreskin should be retracted for a male resident who was not circumcised and that she should clean under the penis shaft, but said she was nervous and forgot. The DON stated the foreskin must be pulled back and the underside of the shaft and top of the scrotum must be cleaned. The facility policy for perineal care also stated to retract the foreskin of the uncircumcised male and wash carefully to remove secretions, including the area under the scrotum.
Infection Control Glove Use During Incontinent Care
Penalty
Summary
Provide and implement an infection prevention and control program was cited after observation, interviews, and record review showed that CNA C did not maintain proper glove use during incontinent care for Resident #3. During care, the CNA cleaned the resident but did not change gloves or sanitize hands before touching the clean brief to fasten it, despite the gloves being soiled after cleaning the resident. The facility stated that staff should change gloves after cleaning the resident and before touching the clean brief to avoid cross contamination and prevent infection. Resident #3 had an admission date of 09/26/2024 and a readmission date of 02/10/2025, with diagnoses including Alzheimer's disease, dementia, asthma, and hypertension. The resident's quarterly MDS showed a BIMS score of 5, indicating severe cognitive impairment, and the resident required total assistance and was always incontinent of bowel and bladder. The care plan identified bowel/bladder incontinence related to activity intolerance, dementia, history of UTI, and impaired mobility, with interventions including checking for incontinence and washing, rinsing, and drying the perineum, changing clothing as needed after incontinence episodes.
Failure to Ensure Appropriate Use of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident was not given a psychotropic drug unless necessary to treat a specific condition as diagnosed and documented in the clinical record. Resident #17 was prescribed Cymbalta (Duloxetine) for depression, but the facility did not reduce the dosage from 60 mg to 40 mg as recommended by the consultant pharmacist and agreed upon by the physician. The Director of Nursing (DON) acknowledged that the process for medication regimen review was not followed correctly, resulting in the resident receiving an unnecessary dosage of the medication. Additionally, Resident #105 was prescribed a psychotropic drug, Escitalopram Oxalate (Lexapro), for depression without a documented diagnosis of depression in the clinical record. The resident's care plan included a focus area of antidepressant medication related to depression, but the diagnosis was not listed in the resident's record. The DON stated that the facility needed to review its procedures to ensure all residents' diagnoses were accurately transcribed from hospital documentation, and the oversight was attributed to nursing staff responsibilities. The facility's policy on psychotropic medications requires that residents are not given these drugs unless necessary to treat a specific condition as diagnosed and documented in the clinical record. The policy also mandates gradual dose reductions and behavioral interventions unless clinically contraindicated. However, the facility did not adhere to these guidelines, leading to the administration of unnecessary psychotropic medications to the residents involved.
Inadequate Qualifications for Director of Food and Nutrition Services
Penalty
Summary
The facility failed to employ staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service. The Director of Food and Nutrition Services (DM) did not possess the necessary certification, education, or qualifications for the role. During an interview, the DM admitted to not being a certified dietary manager or certified food service manager, lacking an associate's or higher degree in food service management or hospitality, and not having been a dietary manager in a long-term care facility for over two years. Although the DM was enrolled in a program and had completed all classes, she had not yet taken the certifying exam. The facility's HR Director confirmed that the DM was initially hired as a CNA/CMA and later promoted to the DM position despite not meeting the qualifications. The consultant RD, who also served as the course director for the DM's program, noted that the DM was missing a few preceptor hours and had not taken the certification exam. The facility's Administrator acknowledged the DM's lack of certification and qualifications but anticipated she would pass the exam soon. Additionally, the facility did not have a policy outlining the requirements for the DM position. This deficiency could potentially place residents at risk of foodborne illness and inadequate nutrition.
Infection Control Deficiencies in Medication Administration and Isolation Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of LVN-A and CNA-B. LVN-A did not wash or sanitize her hands between administering medications to three residents, despite acknowledging the protocol to do so. This lapse in hand hygiene occurred during medication administration to residents with various medical conditions, including dementia, Parkinsonism, and heart disease. LVN-A admitted to not sanitizing her hands consistently, which could lead to the spread of infection among residents. CNA-B also demonstrated a failure in infection control practices by not wearing gloves or washing hands with soap and water after handling a used meal tray from a resident on contact precautions for C-diff. Despite being aware of the resident's isolation status, CNA-B only sanitized her hands with alcohol, which is ineffective against C-diff spores. The CNA was unaware of the need for gloves or proper handwashing after contact with items used by the isolated resident, which could contribute to the transmission of infection. The facility's policies on infection prevention and control, as well as medication administration, require staff to follow proper hand hygiene and use personal protective equipment when necessary. Interviews with the DON confirmed the importance of these protocols to prevent the spread of germs. However, the observed practices of LVN-A and CNA-B did not align with these policies, highlighting deficiencies in the facility's infection control measures.
Failure to Obtain Consent for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident was informed and consented to the administration of an antipsychotic medication, Escitalopram Oxalate (Lexapro). This deficiency was identified during a review of records and interviews, where it was found that the resident, who had moderately intact cognition, was not informed of the risks and benefits of the medication, nor was a consent obtained prior to its administration. The resident, admitted with conditions including surgical aftercare and chronic systolic heart failure, was administered the medication from the start of her admission without her or her responsible party's knowledge or consent. Interviews with the Director of Nursing and the Director of Medical Records confirmed that the necessary consent was not present in the resident's electronic health record until after the medication had been administered. The facility's policy requires informed consent to be obtained prior to the use of psychotropic medications, which was not adhered to in this case. The lack of consent and information could place residents at risk of receiving medications without their knowledge, potentially leading to adverse reactions.
Failure to Maintain Resident Dignity During Dining Assistance
Penalty
Summary
The facility failed to ensure the residents' right to respect and dignity by not providing proper assistance during dining for two residents. CNA B was observed standing while assisting two residents, one with moderate cognitive impairment and the other with Down Syndrome and dementia, during their meals. This action was contrary to the facility's policy, which requires staff to sit at eye level with residents when assisting them with dining. CNA B admitted to standing while assisting residents to be ready to assist others quickly and stated that she had not received specific training on whether to sit or stand during feeding. The Director of Nursing (DON) confirmed that the expectation is for staff to sit while assisting residents with dining, aligning with the facility's policy revised in 2007. This oversight in training and adherence to policy led to the deficiency in maintaining the residents' dignity during meals.
Inaccurate MDS Documentation for Hospice Care
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) accurately reflected the status of a resident, specifically regarding hospice care services. Resident #6's Quarterly MDS did not document that the resident was receiving hospice services, despite the resident's face sheet and physician orders indicating admission to hospice care due to respiratory failure. The MDS Nurse confirmed that the oversight occurred because hospice care was not carried over onto the most recent Quarterly MDS, even though a Significant Change MDS had been completed earlier in the year to reflect the resident's change of status to hospice care. The deficiency was identified during interviews and record reviews, where it was noted that the inaccurate MDS could result in the resident not receiving the necessary care. The Director of Nursing (DON) emphasized the importance of accurate MDS information for ensuring residents receive appropriate care and for determining staffing needs. This oversight in documentation could potentially place residents at risk for inadequate care and services due to inaccurate assessments.
Failure to Include Depression in Resident's Care Plan
Penalty
Summary
The facility failed to complete an accurate assessment of a resident's functional capacity, specifically neglecting to include the diagnosis of depression as a focus area in the resident's comprehensive care plan. The resident, a female with chronic kidney disease, type II diabetes mellitus, and major depressive disorder, was admitted and readmitted to the facility with these diagnoses. Her quarterly MDS indicated moderately impaired cognition and active depression, yet the care plan did not reflect depression as a focus area. This oversight occurred despite the resident's psychological progress notes highlighting depression as a top target symptom, with a goal for therapy being symptom reduction. The MDS LVN removed depression from the care plan when the resident's anti-depressant medication was discontinued, as the care plan template was based on medication. However, the facility's policy requires that a comprehensive person-centered care plan should address all medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment, regardless of medication status. The DON confirmed that depression should have remained a focus area in the care plan to ensure a holistic approach to the resident's care needs.
Incomplete Medical Records and Unauthorized Oxygen Administration
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, identified as Resident #105, which could lead to improper or potentially life-threatening treatment. The resident's face sheet and list of diagnoses were missing several critical diagnoses, including chronic kidney disease stage IIIB with anemia, anxiety, cerebrovascular accident, atrial fibrillation, gastroesophageal reflux disease, mood disorder, and hypertensive disorder. These omissions were discovered during a record review and confirmed by the Director of Nursing (DON), who acknowledged that the admitting charge nurse was responsible for transcribing all pertinent diagnoses from the hospital discharge paperwork into the resident's electronic health record (EHR). Additionally, the facility administered supplemental oxygen to Resident #105 without a physician's order. The resident was observed receiving oxygen at a rate of 2L/min via nasal cannula, but this treatment was not documented in the Treatment Administration Record (TAR) or the consolidated physician orders. The DON confirmed the absence of a physician's order for the oxygen, and a Licensed Vocational Nurse (LVN) admitted to failing to transcribe the order into the resident's records, despite having received verbal confirmation from the resident's physician to continue the order from the hospital stay.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 62 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Victoria
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Riverside Oaks | 0.2 mi | ★★★★★ | 19 | 0 |
| Twin Pines Nursing And Rehabilitation | 1.6 mi | ★★★★★ | 20 | 0 |
| Twin Pines North Nursing And Rehabilitation Center | 3.9 mi | ★★★★★ | 4 | 0 |
| Southbrooke Manor Nursing And Rehabilitation Cente | 20.3 mi | ★★★★★ | 2 | 0 |
| Lavaca Bay Nursing And Rehabilitation Center | 24 mi | ★★★★★ | 17 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for The Courtyard Rehabilitation And Healthcare Center.
100% money-back within 48 hours.
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.