Courtyard Rehab: Wound Infection Missed on Assessment - TX
The resident, identified in inspection records only as Resident #1, is described as a woman admitted to The Courtyard Rehabilitation and Healthcare Center with a cutaneous abscess of her right lower limb. She scored 2 out of 15 on her cognitive assessment, a score that signals severe impairment. She spoke nonsense to aides. She could not speak for herself about what care she needed or whether she was getting it.
That made the paperwork matter more, not less.
A quarterly MDS assessment, the standardized federal form nursing homes use to document each resident's diagnoses, conditions, and care needs, did not list her wound infection under active diagnoses. This despite the fact that during the assessment's look-back period, she was receiving Ceftriaxone Sodium, a powerful intravenous antibiotic, at 2 grams per day, every day, to treat streptococcus anginose bacteria in her right hip wound. The medication administration record confirmed she received that injection each day throughout the period in question.
The paper trail was not subtle. A surgical consult from February 25 noted an abscess of the hip. A hospital discharge summary sent her back to the facility on antibiotics on February 27. A progress note written by LVN A on March 1 described the wound in clinical detail: red, warm, tender to the touch, with swelling, and an incision line with yellow fluid visible beneath the skin. The note named the antibiotic, the dose, the bacteria, and the location. The quarterly MDS, completed during that same window, recorded that she was taking an antibiotic and IV medication. It did not record why.
The MDS nurse, interviewed by inspectors on May 26, said she did not know how she missed it. "She stated she missed it due to human error," the inspection report reads, "and MDS accuracy was important because the MDS reflected a picture of the residents, their condition, care requirements and needs which could get missed."
The director of nursing, also interviewed that day, agreed that inaccuracy on the MDS could lead to missed care. She added that the facility did not have a specific policy and procedure for MDS accuracy, saying they followed the federal RAI manual instead.
What the MDS documents shapes what care a resident receives, what staff are assigned to monitor, and what the broader clinical team understands about a person's condition. For a resident who cannot tell anyone what hurts or what she needs, that record is the primary way her condition is communicated across shifts, across disciplines, and to outside reviewers. When it is wrong, the gap doesn't announce itself.
LVN A, interviewed on May 27, offered context for how the wound had developed. The resident's incision line had appeared healed on the surface, and staff did not know an abscess had formed underneath until LVN A noticed the area was red and swollen. She reported it immediately, the resident was sent to the hospital, and she returned on antibiotics. The clinical response, once the problem was visible, was prompt.
But the assessment completed during her treatment did not reflect what was happening inside that wound or what the facility was doing about it.
By the time inspectors observed the resident on May 27, more than two months after her hospital discharge, her right hip wound had healed. She was receiving incontinent care. She spoke nonsense to the aides providing it.
The inspection, a complaint survey completed May 28, cited the facility for failing to ensure assessments accurately reflected resident status. The finding was rated at the level of minimal harm or potential for actual harm, affecting few residents. One resident was reviewed for the assessment deficiency. That resident was her.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Courtyard Rehabilitation and Healthcare Center from 2026-05-28 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 8, 2026 · Our methodology
THE COURTYARD REHABILITATION AND HEALTHCARE CENTER in VICTORIA, TX was cited for violations during a health inspection on May 28, 2026.
She scored 2 out of 15 on her cognitive assessment, a score that signals severe impairment.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.