Above average — CMS composite of the measures below.
The next survey window likely opens around November 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 St Catherines Manor Of Washington Court House during CMS and state inspections, most recent first.
Food storage practices were deficient when surveyors found multiple opened and undated items in the walk-in refrigerator and freezer, including cheese, pepperoni, bacon, egg patties, and vegetables. One bag of egg patties was stored open, exposing it to air. An LPN confirmed opened perishable foods should be date marked, and the facility policy required perishable and leftover foods to be tightly covered, labeled, and dated.
Infection Prevention and Control Failures: The facility did not fully carry out its Legionella prevention program, with missing documentation for filter changes, flushing of unused areas, and monitoring of several water-related locations, and its policy did not define how monitoring or out-of-range temperatures should be handled. The facility also failed to maintain infection control during catheter care when a CNA performed Foley care for a resident with moderate cognitive impairment and then touched the bedside table and bed controls with soiled gloves.
Resident room temperature not maintained. A resident with a trach, ventilator dependence, impaired cognition, and multiple serious diagnoses was observed in a cool room; the HVAC unit was set to 60 degrees F and later adjusted to 70 degrees F. An RT and an LPN stated residents with trachs were kept colder than others, but neither could explain why, and the resident was unable to adjust the thermostat or request a change. Facility policy required room temperatures between 71 and 81 degrees.
A resident was placed on a secured memory care unit without a documented assessment of appropriateness. The record showed conflicting elopement and cognition information, including an elopement assessment showing no risk, a BIMS score of 15, and notes later amended after an AI error. The resident said she felt like a trapped prisoner and had been trying for months to see her PCP and obtain a psych eval, while the RN confirmed the facility lacked baseline info and did not complete an assessment before placement.
Failure to monitor behaviors with psychotropic medication use affected two residents. One resident with dementia and depression had a care plan calling for monitoring and documentation of signs and symptoms related to psychotropic use, but no behavior monitoring was documented. Another resident with major depressive disorder was ordered clonazepam for anxiety, and behavior monitoring was not completed or documented on several mornings despite a care plan directing staff to record behaviors every shift and monitor for side effects.
Delayed and Incomplete Care Conferences: The facility failed to complete timely care conferences for two residents. One resident with DM, HF, dementia, Parkinson's disease, and AFib had only two care conferences in the last year despite quarterly expectations, and another resident with chronic respiratory failure, DM, depression, and ventilator dependence had only two conferences, one of which appeared to be staff completing paperwork rather than holding an actual meeting. The resident with intact cognition stated she was not invited to regular care conferences, and the SSD confirmed the limited frequency of the meetings.
A resident who needed substantial to maximum staff assistance for bathing did not receive showers as scheduled. The care plan included staff help for bathing but no plan for shower refusals, and shower logs showed multiple missed showers over several months. The RD confirmed confusion between the electronic bathing schedule and the aide schedule, which led to showers not being offered on some scheduled days.
A resident with quadriplegia, anoxic brain injury, and multiple contractures did not receive timely implementation of a therapy-recommended palm protector splint and finger separators. Staff observed bilateral hand/wrist contractures, but only a thin fabric was in one hand, no intervention was present in the other, and ordered hand rolls and interdry were not consistently in place. Therapy had recommended the device for hand alignment and hygiene, but it had not yet been ordered due to pending facility approval.
An LPN administered medications through a resident’s g-tube without verifying placement or checking for residuals. The resident had severe cognitive impairment and diagnoses including CVA, COPD, and PVD. The LPN said she did not perform the checks because there was no order, and the RD of Clinical Services confirmed nurses should check gastric residual before giving meds through a g-tube.
An LPN administered medications to a resident with DM2, CKD, and a history of MI, then left the room before confirming the meds were swallowed. The resident had intact cognition and needed assistance with several ADLs. Facility policy required the resident to be observed after administration to ensure the dose was completely ingested.
Delayed Follow-Up on Pharmacy Medication Review Recommendations: A resident with multiple chronic conditions including A-fib, dementia, diabetes, and a history of TIA had pharmacy recommendations for anticoagulant therapy acknowledged by the prescriber, but the MAR showed the prior anticoagulant continued for an extended period before the new Eliquis order was implemented. A later pharmacist review also identified an aspirin order with an incorrect diagnosis, and the DON confirmed the diagnosis had not been changed.
Pureed Diet Food Not Prepared to Required Texture: A staff member prepared chicken, broccoli, and rice casserole for residents on a pureed diet, but the food contained full pieces and grainy rice after blending. Another staff member agreed the casserole needed to be blended further to reach a smooth texture. The facility’s puree instructions and policy required a smooth, moist product that holds shape, and three residents had orders for the pureed casserole.
Food Storage Lacked Date Marking and Proper Covering
Penalty
Summary
Food was not stored in a manner to protect against potential contamination and spoilage. During observation on 12/15/25 at 8:57 A.M., four opened containers of food items in the walk-in refrigerator had no date marking, including one bag of yellow cheese slices, one bag of white cheese, one bag of pepperoni slices, and one package of bacon. At 8:59 A.M., two opened and undated bags of egg patties were observed in the walk-in freezer, and one of the bags was stored open, allowing exposure to air. The same observation also identified three opened and undated bags of vegetables in the freezer, including zucchini, corn, and sweet potato fries. During interview on 12/15/25 at 9:10 A.M., the staff member identified as #150 stated that opened containers of perishable food items should be date marked, and confirmed there were several undated food items in both the walk-in refrigerator and walk-in freezer. Review of the facility policy titled, Storage of Perishable Foods, revised 03/2025, stated that perishable goods are to be refrigerated at the appropriate temperature and stored in an orderly and sanitary manner, and that prepared or leftover foods should be tightly covered, clearly labeled, dated, and used within three days or discarded. The policy also stated that cheese and other dairy products may be served until the use-by date on the package, or the use-by date should be transferred to a label on the package.
Infection Prevention and Control Failures
Penalty
Summary
The facility failed to maintain and conduct its Legionella prevention and control measures as documented in its Legionella Policy - Environmental. The policy called for quarterly chlorine testing, weekly water temperature testing, monitoring and flushing of unused rooms and areas, monitoring of kitchen ice machines, eye wash stations, resident-room and central showers, circulation tubs, drinking fountains, and water filters changed bi-annually, but the plan did not define what “monitor” meant or how areas were to be checked or evaluated. Facility maintenance logs showed no evidence that water filters were changed bi-annually, with the only filter change documentation noted as 04/2025. Temperature logs showed weekly testing with a target range of 110 to 117 degrees Fahrenheit, but the plan did not explain how to respond when temperatures were outside that range; logs documented multiple low and high readings from January through November 2025. Flushing logs also showed no evidence of flushing vacant or infrequently used rooms from 01/01/25 to 06/30/25 and the last week in November 2025, and the facility provided no documentation for eye wash stations, resident-room and central showers, circulation tubs, or drinking fountains. The Project Manager confirmed the facility had no documentation defining monitoring, no additional documentation for missing flushing or filter-change dates, and no documentation related to those other areas. The facility also failed to maintain infection control during urinary catheter care for Resident #6. The resident was admitted on 08/21/25 with diagnoses including fracture of the right acetabulum, anxiety disorder, and history of malignant neoplasm, and had moderate cognitive impairment with a BIMS score of 12. The resident required substantial assistance with bathing, dressing, and transfers, was dependent for toileting, and had an indwelling catheter. The care plan and physician order required catheter care every shift. During observation on 12/17/25, a CNA completed urinary catheter care but did not remove gloves afterward and then touched the resident’s bedside table and bed controls with the same gloves. The CNA later confirmed she did not change her gloves after catheter care before touching those items.
Resident Room Temperature Not Maintained
Penalty
Summary
Facility failed to ensure Resident #9’s room was maintained at a comfortable temperature. Resident #9 was admitted on 06/28/21 and had diagnoses including quadriplegia, chronic respiratory failure, diabetes, heart embolism, tracheostomy, contracture of multiple sites, dependence on ventilator status, anoxic brain injury, epilepsy, and heart disease. The care plan dated 11/18/25 included interventions for the tracheostomy, including securing trach ties, providing humidified oxygen as prescribed, elevating the head of the bed, oral care, monitoring for restlessness and agitation, suctioning as needed, and universal precautions. The MDS assessment dated [DATE] indicated impaired cognition. During observation on 12/15/25 at 10:02 A.M., Resident #9’s room was noted to be cool. On 12/17/25 at 9:45 A.M., the RT stated residents with tracheostomies have their rooms set colder than residents without, but could not explain why and said Resident #9 would sweat. The room’s heating and cooling unit was observed with the RT and was set to cold with cold air blowing at 60 degrees F; the RT confirmed it was cooler in the room and adjusted it to 70 degrees F. Resident #9 was observed covered with bedding sheets and blankets up to the neck. An LPN later stated residents with tracheostomies have their rooms set colder than residents without trachs, could not explain why, and confirmed Resident #9 was unable to adjust the thermostat, was not responsive, and could not request staff to change the temperature. Facility policy stated resident room temperatures shall be maintained from 71 to 81 degrees.
Improper Placement on Secured Memory Care Unit Without Assessment
Penalty
Summary
The facility failed to ensure Resident #49 was properly assessed for appropriateness before being placed on the secured memory care unit. The resident was admitted with diagnoses including fibromyalgia, malnutrition, dementia with mood disturbance, and kidney disease. Hospital discharge paperwork noted the resident had been living at home, was hospitalized for a UTI, and had wandered while in the hospital. However, the facility’s elopement assessment documented that the resident was not at risk for elopement, while the care plan later identified the resident as at risk for elopement and directed residence on the locked/secured unit. The medical record contained no evidence of any assessment prior to placement on the secured unit. Additional documentation showed inconsistent information about the resident’s cognitive status and need for psychiatric services. A progress note stated the resident had dementia with behavioral disturbances and was followed by psychiatry, but that note was later amended after surveyor intervention to state the psychiatry reference had been entered by AI in error. Another assessment showed a BIMS score of 15, indicating intact cognition, and a later note documented the resident had enough capacity to make decisions regarding code status. The resident told surveyors she had been placed in memory care improperly, felt like a trapped prisoner, and had been trying for months to see her regular PCP and obtain a psych evaluation. Regional Nurse #200 confirmed the facility did not have baseline information from before the hospital stay and did not complete an assessment for appropriateness before placing the resident on the locked/secured memory care unit.
Failure to Monitor Behaviors With Psychotropic Medication Use
Penalty
Summary
The facility failed to monitor behaviors associated with psychotropic medication use for two residents. One resident had diagnoses including type II diabetes mellitus, heart failure, dementia, Parkinson's disease, atrial fibrillation, and depression, with moderate cognitive impairment and dependence for several activities of daily living. The care plan identified the resident as at risk for complications related to psychotropic medication use and included interventions to educate on Zoloft and monitor, document, and report signs and symptoms of depression unaltered by medications, but the medical record contained no documentation of behavior monitoring. The Regional Director of Clinical Services verified that behaviors for psychotropic use should be monitored and confirmed the absence of documentation for this resident. A second resident was admitted with diagnoses including a periprosthetic fracture around an internal prosthetic right knee joint, fracture of the tibia, and major depressive disorder, and had intact cognition with a BIMS score of 15. The care plan directed staff to monitor behaviors and record them every shift, monitor for side effects, notify the physician of adverse effects, and use non-pharmacological interventions. The resident was ordered clonazepam 1 mg three times daily for anxiety, but behavior monitoring was not completed on several mornings, and the Regional Director of Clinical Services verified that no behaviors were monitored or documented on those dates.
Delayed and Incomplete Care Conferences
Penalty
Summary
The facility failed to ensure care conferences were completed in a timely manner for two residents reviewed. Resident #2 was admitted on 09/04/18 and had diagnoses including type II diabetes mellitus, heart failure, dementia, Parkinson's disease, and atrial fibrillation. A quarterly MDS assessment showed moderate cognitive impairment with a BIMS score of 11, and the resident required supervision with eating and was dependent for toileting, bathing, dressing, and transfers. Review of the record showed care conferences were only completed twice in the last 12 months, on 04/21/25 and 09/19/25, rather than quarterly as expected. Resident #35 was admitted on 08/19/21 and had diagnoses including chronic respiratory failure with hypoxia, diabetes, depression, and dependence on ventilator status. The MDS assessment showed intact cognition with a BIMS score of 15. Review of interdisciplinary meeting notes showed a care conference on 04/10/25 with several interdisciplinary team members and another on 09/30/25 documented only the resident in attendance. The resident stated she was not invited to regular care conferences, and the Social Service Director confirmed there was evidence of only two care conferences in the last year and that the later meeting appeared to be staff completing the form rather than holding an actual care conference, with the two conferences occurring more than five and a half months apart.
Missed showers due to unclear bathing schedule and lack of refusal plan
Penalty
Summary
The facility failed to provide showers to a resident who was dependent on staff for assistance with activities of daily living. Resident #8 was admitted with diagnoses including osteoarthritis, atrial fibrillation, acute respiratory failure with hypoxia, chronic kidney disease stage II, candidiasis, deep vein thrombosis, hypo-osmolality and hyponatremia, congestive heart failure, hypertension, and traumatic brain injury. The resident’s MDS assessment dated 11/06/25 indicated mild cognitive impairment, and Section GG showed the resident needed substantial to maximum physical assistance from staff for showers and bathing. The resident’s care plan identified an ADL self-care performance deficit and included an intervention for one to two staff to assist with bathing, but it did not include a care plan or interventions for shower refusals or a plan to implement if refusals occurred. Shower logs from September through November 2025 showed multiple missed showers, including three in September, seven in October, and eight in November, with four refusals in November. The resident’s representative stated the resident was not offered baths/showers as often as expected. The Regional Director confirmed there was confusion about the shower schedule, with the electronic record showing showers on Mondays, Wednesdays, and Fridays while the aide schedule listed Tuesdays and Fridays, and multiple days passed when a shower was not offered because of that confusion.
Failure to Implement Splint and Follow Contracture Orders
Penalty
Summary
The facility failed to ensure timely implementation of a therapy-recommended splint and failed to follow orders related to contractures for a resident with quadriplegia, chronic respiratory failure, diabetes, heart embolism, tracheostomy, contracture of multiple sites, ventilator dependence, anoxic brain injury, epilepsy, and heart disease. The resident’s care plan identified altered musculoskeletal status related to extremity contractures, with interventions including supportive devices, a hand roll or equivalent in the right palm as ordered, and treatment to the fingers, elbows, and wrists. The resident was also documented as unable to make needs known due to brain injury and did not speak, with staff expected to anticipate needs. The resident’s physician orders included washing and drying both hands between all fingers, applying antifungal powder, and weaving interdry between the fingers daily and as needed. Occupational therapy assessed the resident and found hand function was limited by the need for a right hand finger/digit splint, recommending a palm protector type splint and finger separator to support hand alignment and hygiene. During observation, the resident had bilateral hand and wrist contractures, with a thin fabric in the right hand and no material in the left hand. Staff confirmed the resident did not have a splint in place, the left hand had no intervention present, and the interdry was only in place on the right hand. Therapy staff stated they had recommended a splint and were waiting for facility approval before ordering it, and facility staff confirmed the ordered hand rolls were not in place and the interdry was only present on one hand.
Failure to Verify G-Tube Placement Before Medication Administration
Penalty
Summary
The facility failed to verify placement of a gastrostomy tube before administering medications through the tube for one resident reviewed for medication administration. Resident #36 was admitted on 03/27/25 with diagnoses including cerebral infarction, COPD, and PVD, and the quarterly MDS showed severe cognitive impairment with a BIMS score of zero and substantial assistance needed for toileting, bathing, dressing, and transfers. During observation on 12/16/25 at 7:58 A.M., an LPN administered medications through the resident’s g-tube without checking tube placement or checking for residual tube feeding. When interviewed shortly afterward, the LPN stated she did not check placement or residual because there was no order. The Regional Director of Clinical Services later verified that nurses should check for gastric residual prior to administering medications through a g-tube. The facility policy stated that medications should be administered in accordance with good nursing principles and practices and that if the resident was tube-fed, medications were to be crushed finely to prevent clogging the tube.
Medication Administration Not Observed to Completion
Penalty
Summary
The facility failed to ensure medications were ingested during medication administration before leaving the resident's room. Resident #14 was admitted on 05/02/24 and had diagnoses including type II diabetes mellitus, chronic kidney disease, and myocardial infarction. The quarterly MDS assessment showed intact cognition with a BIMS score of 14, and the resident required setup with eating, supervision with toileting and bathing, and substantial assistance with dressing and transfers. During observation on 12/16/25 at 8:26 A.M., LPN #133 administered medications to Resident #14 and left the room before the resident took the medications. During interview on 12/16/25 at 8:29 A.M., LPN #133 stated she thought Resident #14 took the medications before she left but confirmed she did not see the resident ingest them. The facility policy titled, Medication Administration - General Guidelines, dated 10/17/07, stated the resident was always observed after administration to ensure the dose was completely ingested.
Delayed Follow-Up on Pharmacy Medication Review Recommendations
Penalty
Summary
The facility failed to ensure timely follow-up on pharmacy recommendations during monthly medication regimen reviews for Resident #24, who had diagnoses including heart failure, dementia with behavioral disturbances, type II diabetes, A-fib, major depressive disorder, anxiety disorder, psychosis, hypertension, insomnia, and a history of TIA. A pharmacy note dated 01/16/25 documented that rivaroxaban (Xarelto) 15 mg daily was continued on readmission, but the pharmacist recommended Eliquis 5 mg twice daily if feasible. The physician/prescriber response on the same date directed Eliquis 2.5 mg twice daily due to falls. Review of the MAR showed rivaroxaban 15 mg daily remained ordered from 01/14/25 through 02/04/25, then again from 02/04/25 through 02/27/25 after the resident returned from a hospital stay, with Eliquis 2.5 mg not started until 02/27/25. The DON confirmed the recommendation to start Eliquis 2.5 mg twice daily had been acknowledged and signed on 01/16/25, and stated the facility usually had 30 days to enact pharmacy recommendations. A later pharmacist review on 03/19/25 recommended removing the pain level from the aspirin order and changing the diagnosis to A-fib and history of TIA, but the current aspirin 81 mg order still listed a diagnosis of a right ulna fracture; the DON confirmed the diagnosis had not been changed and was unsure why.
Pureed Diet Food Not Prepared to Required Texture
Penalty
Summary
The facility failed to prepare pureed food in a form that was safe and appropriate for residents with pureed diet orders. During observation of food preparation, a staff member placed cooked chicken, broccoli, and rice casserole into a blending canister to be pureed, then transferred the food into a clean pan. The surveyor observed two full pieces of rice in the puree, and after a second batch was blended and added to the pan, small grains of rice were still present in the food. The staff member stated that pureed food should be smooth and able to hold its form, and another staff member agreed the casserole needed to be blended further to be more smooth. Review of the facility’s chicken, broccoli, and rice casserole puree instructions stated the food should be blended until smooth using small amounts of chicken broth. Medical record review confirmed that three residents had pureed texture diet orders that included the chicken, broccoli, and rice casserole. The facility’s regular pureed diet policy stated that pureed food should be smooth, thick, and moist, hold shape, require little or no chewing, and be easy to swallow.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 101 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | 0.2 mi | ★★★★★ | 0 | 0 |
| Court House Manor | 0.3 mi | ★★★★★ | 0 | 0 |
| Copper Knoll Health & Rehab Llc | 3 mi | ★★★★★ | 13 | 0 |
| Autumn Years Nursing Center | 11.7 mi | — | 0 | 0 |
| Greenfield Skilled Nursing And Rehabilitation | 14 mi | ★★★★★ | 10 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for St Catherines Manor Of Washington Court House.
100% money-back within 48 hours.
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.