Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of June 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.
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.
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.
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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 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 | — | 2 | 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 |
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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 August 2026) and official state health department websites.