Court Manor Health Services

In the surveyor’s words

From the most serious findings on record at Court Manor Health Services, in the surveyor’s own words.

• Immediate jeopardy, isolatedF695May 28, 2025

  Based on observation, record review, and interviews, the facility did not ensure that a resident (R) received tracheal/stoma (soft tissue opening in tracheal airway) suctioning of respiratory secretions to maintain adequate respiratory care in accordance with professional standards of practice for 1 of 1 resident (R17) with a tracheostomy/stoma. R17 has tracheostomy from a laryngectomy. R17 has a build-up of secretions and a history of mucous plugs in R17's airway, which have required emergency room (ER) visits on 7 occasions from 1/13/25 - 4/28/25. […]

• No harm, potential for more than minimal, patternF553Oct 19, 2021

  Based on record review and interview, the facility did not provide the opportunity for residents and/or their representatives to participate in the care planning process when changes were made in their plan affecting 4 of 4 residents reviewed (R1, R2, R3, R4). Example #1: Since the facility recertification survey on 03/03/21, R1's Minimum Data Set (MDS) assessments were completed on 4/01/21, 5/11/21, 6/04/21 and 9/04/21 with care plan revisions based on the assessments. Record shows the facility conducted a care conference review with R1's daughters on 10/12/21. There is no evidence R1 was invited or involved in the care conference. R1 and her involved family were not invited or involved in care plan revisions after MDS assessments on 4/01/21, 5/11/21, 6/04/21 and 9/04/21. […]

• No harm, potential for more than minimal, isolatedF880Jul 22, 2026

  Based on observation, interview, and record review, the facility did not ensure 2 of 12 residents (R22, R3) out of a total sample of 15 had appropriate Transmission Based Precautions (TBP) in place.-R22 had a stage 2 pressure injury (PI). No Enhanced Barrier Protection (EBP) were implemented. Staff did not use appropriate Personal Protective Equipment (PPE) when providing direct care. ~R3 had a pressure injury and required EBP. Observations were made of no signage or PPE available for R3.Findings include: Facility policy titled, Enhanced Barrier Precautions revised 08/08/2024, states, Enhanced barrier precautions (EBP) refers to an infection control intervention designed to reduce transmission of multi-resistant organisms that employs targeted gown and glove use during high contact… […]

• No harm, potential for more than minimal, isolatedF880May 28, 2025

  Based on observation, interview and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable disease and infection, for 2 out of 2 residents (R), (R33, R17) observed on Enhanced Barrier Precautions (EBP). Staff did not wear required Personal Protective Equipment (PPE) for R17 who is on droplet precautions. Facility staff did not ensure R33's uncovered urinary catheter bag stayed off the floor and allowed the uncovered urinary catheter to lie directly on the floor. […]

• No harm, potential for more than minimal, isolatedF758Mar 22, 2023

  Based on interview and record review, the facility did not comprehensively assess resident sleep disturbance or monitor the effectiveness of psychoactive medications used to promote sleep for 1 of 5 residents reviewed for unnecessary medications (R21). R21's orders include Trazodone (antidepressant) 25 mg tablet at bedtime for insomnia. The facility did not comprehensively assess R21's sleep disturbance or have a system in place to monitor the medication's effectiveness. This is evidenced by: Surveyor reviewed R21's record and noted R21's diagnosis includes primary insomnia. […]