Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 House Manor during CMS and state inspections, most recent first.
The facility failed to document causative organisms for infections in its control log, affecting its ability to track and manage infections. Multiple residents were prescribed antibiotics for UTIs and wound infections without identifying the organisms, as confirmed by an RN. This oversight potentially impacted all 88 residents.
A resident with Type 2 Diabetes Mellitus received expired insulin due to the facility's failure to remove outdated medications from stock. Despite the facility's policy, staff RN administered insulin from an expired pen on three occasions. This incident highlights a lapse in medication management and storage practices.
A facility failed to notify a resident's family of a change in condition and new physician orders. The resident, with a complex medical history, experienced lethargy and dizziness, prompting a nurse to consult with an NP. New orders were issued based on lab results, but there was no documentation of family notification, contrary to facility policy.
The facility failed to ensure proper medical orders and documentation for three residents, leading to deficiencies in care. A resident did not have a dressing order for a surgical wound, nor were ted hose ordered as per discharge instructions. Another resident's care was compromised by the lack of documented wound assessments and missed treatments. Additionally, the facility did not have a hospice certification on-site for a resident receiving hospice services, indicating a lapse in maintaining necessary documentation.
A resident developed suspected deep tissue injuries on their heels due to the facility's failure to implement preventative measures such as turning, repositioning, and offloading. Despite being assessed as at mild risk for pressure ulcers, the resident's care plan initially lacked specific interventions, and staff interviews revealed a lack of awareness and documentation regarding care preferences. The facility's policy required preventative interventions, but these were not in place, leading to the development of pressure injuries.
A resident with dry eye syndrome did not receive prescribed Cyclosporine eye drops for several days due to the medication being out of stock. Despite a physician's order for twice-daily administration, the medication was not available, and the resident reported not receiving the drops unless requested. The facility's policy to reorder medications was not followed.
A resident on Eliquis was not properly monitored for decreasing hemoglobin levels, and a recommended CBC lab test was not completed. Despite a care plan to monitor for bleeding, the resident was hospitalized with a critically low hemoglobin level and required treatment for gastric ulcers. Interviews revealed a lack of clarity and documentation regarding the follow-up CBC order.
A resident with a pressure ulcer did not receive a scheduled dressing change as per physician's orders. The LPN responsible did not document the resident's refusal or attempt the change later. The DON confirmed the oversight, and the resident was unsure if the change occurred.
A resident with a pressure ulcer did not receive proper infection control during a dressing change. An LPN failed to change gloves after removing a soiled dressing, using the same gloves to clean the wound, contrary to the facility's aseptic technique guidelines. The DON confirmed the expectation to follow these guidelines.
Inadequate Infection Tracking in Facility
Penalty
Summary
The facility failed to ensure that both facility-acquired and community-acquired infections were properly identified and tracked in the infection control log. This deficiency was observed across multiple months, where residents were prescribed antibiotics for urinary tract infections (UTIs) and wound infections without the identification of the causative organisms. Specifically, the infection control logs from January 2024 to February 2025 showed that several residents were admitted from the hospital with antibiotic orders for UTIs, yet the organisms causing these infections were not documented. Additionally, a resident treated for a wound infection in February 2025 also lacked documentation of the causative organism. During an interview on March 24, 2025, a registered nurse confirmed that the infection control log did not document the organisms from wound cultures, nor did it identify incoming organisms from the hospital. This oversight in documentation had the potential to affect all 88 residents residing in the facility, as it hindered the facility's ability to effectively track and manage infections, potentially impacting the overall infection prevention and control program.
Outdated Medication Not Removed from Stock
Penalty
Summary
The facility failed to ensure that outdated medications were removed from stock, specifically affecting a resident with Type 2 Diabetes Mellitus. The resident, who had a slight cognitive deficit and required various levels of assistance for daily activities, was prescribed Humalog Kwik insulin pen-injector to be administered per sliding scale before meals. During an observation of Med Cart D2, it was found that an insulin pen had an open date and expiration date that indicated it was outdated. Staff RN #203 admitted to administering insulin from the expired pen on three separate occasions, despite the facility's policy requiring the removal of outdated medications. The facility's medication storage policy, revised in February 2021, mandates the removal of outdated, contaminated, or deteriorated medications from stock, which was not adhered to in this instance. This oversight led to the administration of expired insulin to the resident, highlighting a lapse in medication management and storage practices.
Failure to Notify Family of Resident's Condition Change
Penalty
Summary
The facility failed to notify a resident's family of a change in condition and new physician orders, affecting one resident out of 18 sampled. The resident, who had a complex medical history including pneumonia, anemia, and cerebrovascular accident, experienced a change in condition on 03/13/25, feeling lethargic and dizzy. The nurse consulted with the Nurse Practitioner (NP), who ordered a STAT complete blood count (CBC) and basic metabolic panel (BMP). The results showed a hemoglobin level of 7.0 g/L and potassium level of 5.4 mEq/L, leading to new orders for iron supplementation, holding spironolactone, and further testing. However, there was no documented evidence that the resident or their representative was informed of these changes. The facility's policy requires immediate notification of the resident, attending physician, and resident's representative or family member when there is a significant change in the resident's status or treatment plan. Despite this policy, the Director of Nursing confirmed that there was no documentation of family notification regarding the resident's condition change and new orders. This deficiency was investigated under Complaint Numbers OH00163883 and OH00161161, highlighting a lapse in communication and adherence to the facility's notification policy.
Deficiencies in Medical Orders and Documentation
Penalty
Summary
The facility failed to ensure proper medical orders and documentation for three residents, leading to deficiencies in care. Resident #188 did not have a dressing order in place for a surgical wound on the right thigh to knee, nor were ted hose ordered for clot prevention as per hospital discharge instructions. The dressing was not monitored or changed as required, and there was no documentation of the dressing from admission until a later date. Interviews with staff confirmed the lack of orders and documentation, and observations revealed the absence of ted hose. Resident #199's care was compromised by the lack of documented weekly wound assessments and missed daily treatments for a surgical wound on the right thigh and hip. The facility's records showed no description or measurements of the wound, and several treatment dates were missed. Interviews with the DON and nursing staff confirmed the absence of necessary documentation and missed treatments, highlighting a failure to adhere to care protocols for surgical wounds. For Resident #5, the facility did not have the hospice certification on-site, which is required to confirm the resident's eligibility for hospice services. The certification was only faxed upon request, indicating a lapse in maintaining necessary documentation. The DON confirmed the absence of the hospice certification, which was part of a complaint investigation. These deficiencies were identified during a survey, affecting the quality of care provided to the residents.
Failure to Prevent Pressure Ulcers on Resident's Heels
Penalty
Summary
The facility failed to prevent the development of suspected deep tissue injuries on the bilateral heels of Resident #188, who was admitted with no initial pressure areas on the heels. The resident, who had a history of dementia, major depressive disorder, and other significant health issues, was assessed as having a mild risk for developing pressure ulcers. Despite this, the facility did not implement adequate preventative measures such as turning, repositioning, and offloading the heels, as indicated by the lack of documentation of these interventions from the time of admission. The resident's care plan initially lacked specific skin care interventions, and it was not until several days after admission that interventions such as offloading devices were included. Observations and interviews with staff revealed that the resident was often found in bed without evidence of regular repositioning or heel elevation. Staff interviews indicated a lack of awareness and documentation regarding the resident's care preferences and refusals, contributing to the oversight in preventative care. The facility's policy stated that residents should not develop pressure ulcers unless clinically unavoidable, and appropriate preventative interventions should be in place. However, the absence of a baseline care plan for skin management and the failure to implement necessary preventative measures led to the development of pressure injuries on the resident's heels. The Director of Nursing confirmed that no preventative measures were in place for the resident's heels from admission until the injuries were identified.
Failure to Administer Prescribed Medication Due to Stock Issues
Penalty
Summary
The facility failed to ensure that a resident received their prescribed medication, specifically Cyclosporine, which was ordered to be administered twice daily for dry eyes due to inflammation. The resident, who was admitted with diagnoses including dry eye syndrome, Bell's palsy, and candidiasis, missed several doses of this medication over a three-day period. The medication administration record confirmed that the resident did not receive the medication on the morning and evening of two consecutive days and the morning of the third day. During an observation of medication administration, it was noted that the medication was out of stock. Interviews with the staff RN revealed that the medication was unavailable, and the physician had ordered to hold the medication until it was back in stock. The resident reported that she does not usually receive her eye drops unless she specifically asks for them. A review of the facility's medication storage policy indicated that medications should be reordered from the pharmacy if a current order exists, which was not adhered to in this case. This deficiency was investigated under a specific complaint number.
Failure to Monitor Anticoagulant Therapy Leads to Hospitalization
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice by not adequately monitoring a resident on Eliquis, an anticoagulant medication. The resident, who had a history of anemia and other significant health conditions, was not monitored for decreasing hemoglobin levels, and a physician-recommended complete blood count (CBC) lab test was not completed. This oversight occurred despite the resident's care plan, which included monitoring for signs of bruising or bleeding and conducting labs as ordered. The resident's hemoglobin levels were noted to be low in August, with a significant drop from 10.3 g/dl to 7.3 g/dl. A Nurse Practitioner (NP) recommended increasing the resident's ferrous sulfate dosage and planned to monitor CBC levels in a month. However, no order for a follow-up CBC was written or executed. The resident later presented with symptoms of gastrointestinal bleeding, including black tarry stools, and was admitted to the hospital with a critically low hemoglobin level of 4.5 g/dl, requiring blood transfusions and treatment for gastric ulcers. Interviews with facility staff, including the Director of Nursing and the NP, revealed a lack of clarity and documentation regarding the follow-up CBC order. The NP intended for the lab to be drawn, but it was unclear whether a verbal or written order was given. The Licensed Practical Nurse (LPN) involved could not recall the specifics of the order entry, and no documentation was found in the resident's medical record. This deficiency was investigated under a complaint number, indicating non-compliance with care standards.
Failure to Complete Pressure Ulcer Dressing Change
Penalty
Summary
The facility failed to adhere to a physician's order for a pressure ulcer dressing change for a resident, identified as Resident #79, who was admitted with multiple diagnoses including a pressure ulcer in the sacral region. The resident was cognitively intact, used a wheelchair, and was at risk for pressure ulcers. The physician's order specified that the dressing on the resident's right lateral foot should be changed three times a week on specific days and as needed. However, during an observation, it was found that the dressing had not been changed as scheduled on Saturday, 11/02/24, as the dressing was dated 10/31/24. Interviews with the LPN responsible for the dressing change and the Director of Nursing (DON) confirmed that the dressing change was not completed on the specified date. The LPN acknowledged the oversight, and the DON verified that the nurse on duty on 11/02/24 reported the resident refused the dressing change but failed to document the refusal or attempt to perform the change later. The resident was unsure if the dressing change occurred and did not recall refusing it. This deficiency was investigated under two complaint numbers, indicating non-compliance with the required care standards.
Infection Control Breach During Dressing Change
Penalty
Summary
The facility failed to maintain a sanitary environment to prevent the transmission of infections during a dressing change for a resident with multiple medical conditions, including sepsis and pressure ulcers. The resident, who was cognitively intact and used a wheelchair, required specific wound care for a pressure ulcer on the right lateral foot. The physician's orders detailed a precise procedure for wound care, including cleansing with wound cleanser or normal saline, applying medi-honey and calcium alginate, and covering with an abdominal pad, to be changed three times a week. During an observed dressing change, an LPN did not adhere to infection control procedures. After removing the soiled dressing from the resident's foot, the LPN failed to change her gloves before cleaning the wound, using the same gloves and gauze to clean all three wounds. This action was contrary to the facility's aseptic dressing technique competency form, which requires changing gloves and performing hand hygiene after removing soiled dressings. The LPN acknowledged the lapse in procedure during an interview, and the Director of Nursing confirmed the expectation to follow the aseptic technique, although no specific policy for dressing changes was in place.
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What surveyors actually found near you
We read the 125 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.
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Nursing homes near Washington Court Hou
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cedarvale Commons Rehabilitation And Healthcare Ce | 0.1 mi | ★★★★★ | 0 | 0 |
| St Catherines Manor Of Washington Court House | 0.3 mi | ★★★★★ | 18 | 0 |
| Copper Knoll Health & Rehab Llc | 3.1 mi | ★★★★★ | 13 | 0 |
| Autumn Years Nursing Center | 11.9 mi | — | 0 | 0 |
| Greenfield Skilled Nursing And Rehabilitation | 13.7 mi | ★★★★★ | 10 | 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.