Average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Court Manor Health Services during CMS and state inspections, most recent first.
A resident with a tracheostomy experienced repeated respiratory distress and multiple ER visits due to the facility's failure to provide necessary tracheal/stoma suctioning and appropriate respiratory care. Despite clear indications and medical recommendations, staff were not trained or equipped to perform suctioning, and there was no suctioning equipment at the bedside. The resident was unable to self-suction and expressed anxiety about delays in care, while staff interviews revealed a lack of understanding of tracheostomy care requirements.
Staff failed to follow infection control protocols for two residents on Enhanced Barrier Precautions. One resident with a tracheostomy did not have staff consistently using required PPE, such as N95 masks and eye protection, during nebulizer or humidified air use. Another resident with an indwelling urinary catheter was observed with their uncovered catheter bag lying on the floor multiple times, contrary to facility policy. These lapses were confirmed by interviews and observations, showing noncompliance with established infection prevention procedures.
Failure to Provide Appropriate Tracheostomy Suctioning and Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident with a tracheostomy following a laryngectomy, resulting in repeated episodes of respiratory distress and multiple emergency room (ER) visits. The resident had a history of mucous plugs and required frequent suctioning to maintain a patent airway, as documented by both facility and hospital records. Despite clear indications for suctioning in the facility's own policies and recommendations from medical specialists, the facility did not ensure that staff performed tracheal/stoma suctioning when needed. There was no suctioning equipment at the resident's bedside, and staff were not trained or prepared to perform suctioning beyond superficial or oral cavity suctioning. The resident's medical record showed several ER visits due to respiratory distress, with documentation from EMS and ER staff indicating that mucous plugs were removed during these visits, and that the care provided in the ER was within the scope of practice for facility nursing staff. Facility staff interviews revealed a lack of understanding and training regarding tracheostomy care and suctioning, with staff stating they did not perform deep suctioning and did not consider suctioning part of trach care. The resident was unable to self-suction and expressed anxiety about waiting for emergency services when experiencing respiratory distress. There was also a lack of documentation and education provided to the resident regarding prevention of mucous plugs and the importance of humidification. Physician orders for suctioning were discontinued for a period without documented rationale, and there was no evidence of suctioning being performed or documented by facility staff during critical periods. The facility's inaction and lack of appropriate interventions, including failure to provide necessary equipment and staff training, led to repeated episodes of respiratory compromise for the resident. The surveyor found that the facility did not follow professional standards of practice for tracheostomy care, resulting in a finding of Immediate Jeopardy.
Failure to Adhere to Infection Control Protocols for Residents on Precautions
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple lapses in staff adherence to established protocols for residents on Enhanced Barrier Precautions (EBP) and droplet precautions. For one resident with a tracheostomy and a history of laryngeal cancer, hemiplegia, COPD, and other conditions, staff did not consistently use the required personal protective equipment (PPE) when entering the room during the use of a nebulizer or humidified air. Observations showed that an LPN entered the resident's room wearing only a gown and gloves, omitting the N95 mask and eye protection required by both facility policy and the droplet precautions signage. Similarly, a CNA was observed wearing a regular mask without eye or face protection. Both the Infection Preventionist and the Director of Nursing confirmed that the expectation was for staff to wear N95 masks and eye protection under these circumstances. In another instance, a resident with an indwelling urinary catheter and a history of urinary infection was observed with their uncovered catheter bag lying directly on the floor on more than one occasion. The resident's care plan specified the use of enhanced barrier precautions during high-contact activities, including device care. Despite this, the catheter bag was seen on the floor both in a covered and uncovered state, and staff interviews revealed that this was a recurring issue due to the bed frame configuration. The Infection Preventionist and Director of Nursing acknowledged that the catheter bag should not be uncovered or in contact with the floor. These deficiencies were identified through direct observation, staff interviews, and review of facility policies and resident records. The facility's failure to ensure proper PPE use and maintain sanitary conditions for medical devices did not align with their own infection control policies and placed residents at increased risk for the development and transmission of communicable diseases and infections.
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Illustrative
What surveyors actually found near you
We read the 6 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Ashland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ashland Health Services | 0.8 mi | ★★★★★ | 0 | 0 |
| Northern Lights Hcc | 6.6 mi | ★★★★★ | 6 | 0 |
| Villa Maria Health And Rehab Ctr | 35 mi | ★★★★★ | 2 | 0 |
| Sky View Nursing Center | 35 mi | ★★★★★ | 5 | 0 |
| Westgate Nursing & Rehabilitation Community | 35.2 mi | ★★★★★ | 5 | 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 July 2026) and official state health department websites.