Victoria, TX

The Courtyard Rehabilitation And Healthcare Center

3-star overall rating with 4-star inspections with $27,130 in total fines with 3 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle

3401 E Airline Dr, Victoria, TX

(361) 573-2467

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

1 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

56

Certified beds

Average residents

48

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

The Ensign Group

Operator or chain grouping

Approved since

1998-10-09

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

329 facilities

Chain averages 3 overall / 3 health / 3 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

0.24

Registered nurse staffing · state 0.44 · national 0.68

LPN hours / resident day

1.27

Licensed practical nurse staffing · state 0.95 · national 0.87

Aide hours / resident day

1.49

Nurse aide staffing · state 2.01 · national 2.35

Total nurse hours

3.00

All reported nurse hours · state 3.40 · national 3.89

Licensed hours

1.51

RN + LPN hours · state 1.38 · national 1.54

Weekend hours

2.55

Weekend nurse staffing · state 2.99 · national 3.43

Weekend RN hours

0.22

Weekend registered nurse coverage · state 0.34 · national 0.47

Physical therapist

0.05

Reported PT staffing · state 0.07 · national 0.07

Adjusted RN hours

0.25

CMS adjusted RN staffing hours

Adjusted total hours

3.14

CMS adjusted total nurse staffing hours

Case-mix index

1.31

Higher values indicate more complex resident acuity

RN turnover

0%

Annual RN turnover

Total nurse turnover

38%

Annual nurse turnover · state 52% · national 46%

SNF VBP

Value-based purchasing

Program rank

9,311

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

24.02

Composite VBP score used to determine payment impact.

Payment multiplier

0.9833

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Healthcare-associated infections

7.21

Baseline 10.40% · Performance 6.24% · Measure score 7.21 · Achievement 5.35 · Improvement 7.21

Total nurse turnover

0

Baseline 47.50% · Performance 71.74% · Measure score 0 · Achievement 0 · Improvement 0

Adjusted total nurse staffing

0

Baseline 3.16 hours · Performance 3.08 hours · Measure score 0 · Achievement 0 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.61%	10.72% 0.1 pts better	No Different than the National Rate · Eligible stays 46 · Observed rate 8.7% · Lower 95% interval 6.45%
Discharge to community	Not Available	50.57%	Not Available · Eligible stays 18 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Medicare spending per beneficiary	0.92	1.02 0.1 pts better
Drug regimen review with follow-up	84%	95.27% 11.3 pts worse	Numerator 21 · Denominator 25
Falls with major injury	4%	0.77% 3.2 pts worse	Numerator 1 · Denominator 25
Discharge self-care score	43.48%	53.69% 10.2 pts worse	Numerator 10 · Denominator 23
Discharge mobility score	60.87%	50.94% 9.9 pts better	Numerator 14 · Denominator 23
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 25 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	6.24%	7.12% 0.9 pts better	No Different than the National Rate · Eligible stays 26 · Observed rate 0% · Lower 95% interval 3.07%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 69
Staff flu vaccination coverage	40.86%	42% 1.1 pts worse	Numerator 38 · Denominator 93
Discharge function score	56.52%	56.45% 0.1 pts better	Numerator 13 · Denominator 23
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	3.0	2.1 0.9 pts worse	1.9 1.1 pts worse	Long Stay · 20240701-20250630 · Adjusted 3.0 · Observed 1.9 · Expected 1.2 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	2.4	2.1 0.3 pts worse	1.8 0.6 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 1.8 · Expected 1.3 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	97.6%	97.1% 0.5 pts better	93.4% 4.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 97.4% · Q3 100.0% · Q4 93.0% · 4Q avg 97.6%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	97.9% 2.1 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	2.4%	3.3% 0.9 pts better	3.3% 0.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 2.6% · Q3 2.3% · Q4 2.3% · 4Q avg 2.4% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	2.0%	2.7% 0.7 pts better	11.4% 9.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 2.9% · Q3 0.0% · Q4 2.6% · 4Q avg 2.0%
Percentage of long-stay residents who lose too much weight	6.7%	3.3% 3.4 pts worse	5.4% 1.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 5.6% · Q3 7.5% · Q4 5.1% · 4Q avg 6.7%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	15.2%	18.9% 3.7 pts better	19.6% 4.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 16.7% · Q3 15.0% · Q4 15.0% · 4Q avg 15.2%
Percentage of long-stay residents who received an antipsychotic medication	2.8%	10.8% 8 pts better	16.7% 13.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 4.0% · Q3 3.7% · Q4 0.0% · 4Q avg 2.8% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.0% About the same	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	37.5%	15.4% 22.1 pts worse	16.3% 21.2 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 37.5% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	12.9%	16.1% 3.2 pts better	14.9% 2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 20.0% · Q3 13.2% · Q4 14.3% · 4Q avg 12.9% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	0.5% 0.5 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	1.2%	0.8% 0.4 pts worse	1.7% 0.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.6% · Q3 2.3% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	19.4%	15.0% 4.4 pts worse	19.8% 0.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 20.4% · Q2 35.8% · Q3 5.5% · Q4 16.8% · 4Q avg 19.4%
Percentage of long-stay residents with pressure ulcers	1.8%	4.2% 2.4 pts better	5.1% 3.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.4% · Q3 1.6% · Q4 3.1% · 4Q avg 1.8% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	97.4%	89.7% 7.7 pts better	81.7% 15.7 pts better	Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.1% · Q3 95.6% · Q4 95.5% · 4Q avg 97.4%
Percentage of short-stay residents who had an outpatient emergency department visit	10.3%	12.0% 1.7 pts better	12.0% 1.7 pts better	Short Stay · 20240701-20250630 · Adjusted 10.3% · Observed 11.1% · Expected 12.0% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.9%	1.5% 0.6 pts better	1.6% 0.7 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 3.4% · 4Q avg 0.9% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	98.2%	88.0% 10.2 pts better	79.7% 18.5 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 98.2%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	37.8%	25.9% 11.9 pts worse	23.9% 13.9 pts worse	Short Stay · 20240701-20250630 · Adjusted 37.8% · Observed 33.3% · Expected 21.0% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-09-19 · Fire 2025-09-19

3 health deficiencies

Top issue: Infection Control (1 deficiency)

5 fire-safety deficiencies

Top issue: Egress (2 deficiencies)

Cycle 2 Health 2024-08-23 · Fire 2024-08-23

8 health deficiencies

Top issue: Resident Assessment and Care Planning (3 deficiencies)

3 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Cycle 3 Health 2023-06-30 · Fire 2023-06-30

8 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

3 fire-safety deficiencies

Top issue: Egress (2 deficiencies)

Fire safety

Fire-safety citations

K · Immediate jeopardy 2025-09-19

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2025-09-22

F · Potential for more than minimal harm 2025-09-19

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2025-09-22

F · Potential for more than minimal harm 2025-09-19

K916 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have a battery powered remote alarm panel in a location accessible by operating personnel.

Corrected 2025-10-02

E · Potential for more than minimal harm 2025-09-19

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2025-09-22

C · Minimal harm 2025-09-19

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Not marked corrected

E · Potential for more than minimal harm 2024-08-23

K741 · Miscellaneous Deficiencies

Fire Safety

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Corrected 2024-08-24

C · Minimal harm 2024-08-23

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2024-08-21

C · Minimal harm 2024-08-23

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2024-08-21

F · Potential for more than minimal harm 2023-06-30

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2023-07-27

E · Potential for more than minimal harm 2023-06-30

K200 · Egress Deficiencies

Fire Safety

Meet other general requirements.

Corrected 2023-08-12

C · Minimal harm 2023-06-30

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2023-07-27

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-09-19

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 2025-09-22

D · Potential for more than minimal harm 2025-09-19

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 2025-09-22

D · Potential for more than minimal harm 2025-09-19

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-09-22

E · Potential for more than minimal harm 2024-08-23

F758 · Pharmacy Service Deficiencies

Health

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Corrected 2024-09-03

E · Potential for more than minimal harm 2024-08-23

F801 · Nutrition and Dietary Deficiencies

Health

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

Corrected 2024-09-03

E · Potential for more than minimal harm 2024-08-23

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-09-03

D · Potential for more than minimal harm 2024-08-23

F552 · Resident Rights Deficiencies

Health

Ensure that residents are fully informed and understand their health status, care and treatments.

Corrected 2024-09-03

D · Potential for more than minimal harm 2024-08-23

F557 · Resident Rights Deficiencies

Health

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

Corrected 2024-09-03

D · Potential for more than minimal harm 2024-08-23

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2024-09-03

D · Potential for more than minimal harm 2024-08-23

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 2024-09-03

D · Potential for more than minimal harm 2024-08-23

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2024-09-03

E · Potential for more than minimal harm 2024-01-10