Inspection visit
Health inspection
6 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 6 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room,
etc.) that affect the resident.
Based on record review, interview and facility policy review, the facility failed to notify one resident's (#30)
family of a change in condition and new physician orders related to the change in condition. This affected
one (Resident #30) of 18 sampled residents. The facility census was 88.
Findings Include:
Review of the medical record for Resident #30 revealed an initial admission date of 01/26/21 with the latest
admission date of 03/12/25 with the diagnoses including pneumonia, anemia, adjustment disorder with
anxiety and depressed mood, cerebrovascular accident with right sided hemiplegia, severe morbid obesity,
chronic obstructive pulmonary disease, hypercholesterolemia, obstructive sleep apnea, obstructive and
reflux uropathy, gout, dementia, congestive heart failure, osteoarthritis, metabolic encephalopathy, spinal
stenosis, atrial fibrillation, diabetes mellitus, major depressive disorder and insomnia.
Review of the plan of care dated 11/18/22, last revised 02/26/24 revealed the resident was at risk for
bleeding and bruising due to antiplatelet therapy. Interventions included daily skin inspections and report
abnormalities to nurse, monitor for adverse reactions bleeding/bruising and monitor for side effects of
medication.
Review of the resident's five day Minimum Data Set (MDS) assessment date 03/03/25 revealed the resident
had no cognitive deficit. The assessment indicated the resident had not received antiplatelet medications.
Review of the progress note dated 03/13/25 at 2:39 P.M. revealed the resident had complained of feeling
lethargic and dizzy. The nurse spoke with the Nurse Practitioner (NP) and new orders were obtained for a
STAT complete blood count (CBC) and basic metabolic panel (BMP). After reviewing the labs the resident's
hemoglobin was 7.0 grams per deciliter (g/L) and potassium was 5.4 milliequivalent per liter (mEq/L). The
NP was notified and a new order was received for iron daily, hold the medication Spironolactone, repeat
CBC/BMP in the am on 03/14/25 and occult for stool sample test with the resident's next bowel movement.
Review of the medical record revealed no documented evidence the resident and/or the resident
representative was notified of the change in condition and new orders.
Review of the NP progress note dated 03/13/25 at 11:59 P.M. revealed the resident STAT lab results
showed a hemoglobin of 7.0 mEq/L and potassium of 5.4 g/L. Orders were placed to hold spironolactone
due to the hyperkalemia and to get another CBC in the morning due to the local hospital would only
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 12
Event ID:
365928
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365928
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/26/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Court House Manor
555 North Glenn Ave
Washington Court Hou, OH 43160
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0580
Level of Harm - Minimal harm
or potential for actual harm
transfuse a hemoglobin of under 7.0 mEq/L. The NP documented the she was still waiting on the stool
guaiac test assessing for a gastrointestinal bleeding.
Review of the medical record revealed no documented evidence the resident and/or the resident
representative was notified of the change in condition and new orders.
Residents Affected - Few
On 03/24/25 at 3:30 P.M., interview with the Director of Nursing confirmed the facility had no documented
evidence the resident's family was notified of the change in condition and new physician orders.
Review of the facility policy titled, Notification of Change Policy, with the last review/revision date of 11/16
revealed the facility will inform the resident, the attending physician and the resident's representative or
interested family member of changes which affect the resident. The facility must inform the resident
immediately, the attending physician and the resident's representative or interested family member when
there is a significant change in the resident's physical, mental or psychosocial status, a need to alter
treatment significantly or a decision to transfer or discharge the resident from the facility.
This deficiency represents non-compliance investigated under Complaint Number OH00163883 and
OH00161161.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365928
If continuation sheet
Page 2 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365928
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/26/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Court House Manor
555 North Glenn Ave
Washington Court Hou, OH 43160
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interviews, observations, record reviews, and hospital discharge record review, the facility failed to ensure
Resident #188 had a dressing order in place and [NAME] hose ordered and failed to ensure Resident
#199's weekly wound assessments were documented along with daily treatments completed for a surgical
wound. Furthermore, the facility also failed to ensure a hospice certification was present for Resident #5.
This affected three residents (#5, #188, and #199) of four residents reviewed. The facility census was 88.
Residents Affected - Few
Findings include:
1. Review of the medical record for Resident #188, revealed an admission date of 03/07/25. Diagnoses
included but were not limited to dementia, major depressive disorder, cerebral infarction due to unspecified
occlusion or stenosis of unspecified cerebral artery, and periprosthetic fracture around internal prosthetic
fracture around internal prosthetic right hip joint, subsequent encounter.
Review of the functional abilities assessment dated [DATE] for Resident #188 revealed assistance was
needed for toilet hygiene and shower/bathe self at substantial/maximal assistance and bed mobility,
transfers to be totally dependent.
Review of the admission skin assessment dated [DATE] for Resident #188 revealed a surgical wound on
the front right thigh to the front right knee with no description of the dressing.
Review of the hospital discharge instructions dated 03/07/25 for Resident #188 revealed the dressing from
the right thigh to right front knee was to remain in place for three days, to be replaced with a clean dry
gauze dressing and be kept dry and intact. Further review revealed the resident was also to wear ted hose
for clot prevention.
Review of the physician's orders dated 03/07/25 for Resident #188 revealed no order for ted hose and no
monitoring and changing of the dressing three days after admission for the right thigh to right front knee
surgical wound.
Review of the care plan dated 03/10/25 for Resident #188 revealed to be at risk for skin breakdown or
known to have area/s of skin breakdown with interventions including but not limited to administer
treatments/medications as ordered and monitor effectiveness, and staff will monitor, document and report
to provider changes in my skin status: appearance, color, signs and symptoms of infection, and wound size
(length, width, and depth).
Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief
Interview for Mental Status (BIMS) of 10 out of 15 suggested moderate cognitive impairment.
Review of the medical record for Resident #188 revealed for the dates of 03/07/25 through 03/15/25 no
documentation of the dressing from the right front thigh to the right front knee was completed and no order
to change the dressing three days after admission on [DATE].
Review of the physician's orders dated 03/15/25 for Resident #188 revealed to clean incision with normal
saline/wound cleanser, pat dry and cover with a dry clean dressing every three days.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365928
If continuation sheet
Page 3 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365928
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/26/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Court House Manor
555 North Glenn Ave
Washington Court Hou, OH 43160
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684
Observation on 03/18/25 at 10:40 A.M. of Resident #188 revealed no [NAME] hose in place.
Level of Harm - Minimal harm
or potential for actual harm
Interview on 03/20/25 at 11:02 A.M. with Registered Nurse (RN) #270 revealed if a resident has a surgical
or pressure wound, they are required to documents on the size and description of the wound when it is
assessed. If there is a dressing, they are to assess it and document the description.
Residents Affected - Few
Interview and observation on 03/20/25 at 11:15 A.M. with Certified Nursing Assistant (CNA) #219 verified
no [NAME] hose in place for Resident #188.
Interview on 03/20/25 at 12:25 P.M. with the Director of Nursing (DON) revealed Resident 188's dressing to
his surgical site from the front right thigh to the front right knee was to stay in place until his appointment
with the Orthopedic office but was unable to provide evidence of that. Reviewed the hospital Discharge
summary dated [DATE] revealed the dressing to the surgical site was to remain in place for three days then
be changed to a clean dry gauze dressing and keep clean and dry. Verified the facility did not do place the
order for the dressing change and to monitor the dressing.
Interview on 03/20/25 at 3:25 P.M. with the DON revealed for Resident #188 ted hose was never ordered
upon admission and through 03/20/25.
2. Review of the medical record for Resident #199, revealed an admission date of 02/10/25. Diagnoses
included but were not limited to displaced intertrochanteric fracture of right femur, subsequent encounter for
closed fracture with routine healing, type 2 diabetes mellitus, dementia, and anxiety disorder.
Review of the skilled evaluation on admission dated 02/10/25 for Resident #199 revealed a surgical wound
covered with a dressing to the right thigh and hip area with no description and measurements of the wound.
Review of the physician order dated 02/10/25 for Resident #199 revealed cleanse incision site with normal
saline, pat dry with a 4X4, and cover with a dry dressing and paper tape. Change daily and as needed.
Review of the care plan dated 02/10/25 for Resident #199 revealed at risk for skin breakdown or have a
known area/s of skin breakdown with interventions including but not limited to administer treatments as
ordered. No interventions to monitor wound sites were noted.
Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief
Interview for Mental Status (BIMS) of 08 out of 15 suggested moderate cognitive impairment. The resident
was assessed to require supervision or touching assistance with bed mobility, partial/moderate assistance
with transfers and total dependence on toilet hygiene and shower/bathe self. This resident was also
assessed to have a surgical wound.
Review of the skin check assessment dated [DATE] for Resident #199 revealed a right thigh and hip
surgical wound with no description and measurements of the wound.
Review of the skin check assessment dated [DATE] for Resident #199 revealed a right thigh and hip
surgical wound with no description and measurements of the wound.
Review of the Treatment Administration Record (TAR) dated February 2025 for Resident #199 revealed
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365928
If continuation sheet
Page 4 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365928
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/26/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Court House Manor
555 North Glenn Ave
Washington Court Hou, OH 43160
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684
missed treatments for the dates of: 02/14/25, 02/18/25, 02/23/25, and 02/28/25.
Level of Harm - Minimal harm
or potential for actual harm
Review of the skin check assessment dated [DATE] for Resident #199 revealed a right thigh and hip
surgical wound with no description and measurements of the wound.
Residents Affected - Few
Review of the skin check assessment dated [DATE] for Resident #199 revealed a right thigh and hip
surgical wound with no description and measurements of the wound.
Review of the TAR dated March 2025 for Resident #199 revealed missed treatments for the dates of
03/05/25 and 03/12/25.
Interview on 03/19/25 at 02:25 P.M. with the DON revealed when residents have surgical wounds the facility
should be documenting on the site weekly with descriptions and measurements.
Interview on 03/19/25 at 4:02 P.M. with the DON verified Resident #199's medical record no documentation
on the surgical wound which includes measurements and descriptions, and this resident had missed
treatments on 02/14/25, 02/18/25, 02/23/25, 02/28/25, 03/05/25 and 03/12/25.
Interview on 03/20/25 at 10:58 A.M. with Licensed Practical Nurse (LPN) #208 revealed if a resident has
any type of skin issues they are to be measured and assessed for drainage, redness and the description of
the wound.
Interview on 03/20/25 at 11:02 A.M. with RN #270 revealed if a resident has a surgical or pressure wound,
they are required to documents on the size and description of the wound when it is assessed.
3. Review of the medical record for Resident #5 revealed an initial admission date of 02/16/17 with the
latest readmission of 11/12/24 with the diagnoses including but not limited to chronic obstructive pulmonary
disease, severe morbid obesity, chronic respiratory failure, cirrhosis of liver, diabetes mellitus, chronic
pulmonary edema, hypertension, anxiety disorder, convulsions, primary adrenocortical insufficiency,
polyneuropathy, chronic pain, restless leg syndrome, retention of urine, congestive heart failure,
osteoarthritis, end stage renal failure, dependence on renal dialysis, atrial fibrillation, major depressive
disorder, insomnia, constipation, obstructive sleep apnea, gout and anemia.
Review of the plan of care dated 02/04/25 revealed the resident was receiving hospice services related to a
terminal prognosis chronic respiratory failure. Interventions included notify hospice with changes or
concern, observe resident closely for signs of pain, administer pain medications as ordered, and notify
physician immediately if there is breakthrough pain, work cooperatively with hospice team to ensure the
resident's spiritual, emotional, intellectual, physical and social needs are met and work with nursing staff to
provide maximum comfort for the resident.
Review of the resident's significant change MDS assessment dated [DATE] revealed the resident had no
cognitive deficit. The assessment indicated the resident received hospice services.
The facility had the hospice certification signed by the physician the resident had six months or less life
expectancy faxed to the facility from the hospice company once requested.
On 03/20/25 at 2:35 P.M., interview with the Director of Nursing confirmed the hospice physician
certification was not onsite and the hospice company faxed the hospice resident's certificate to the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365928
If continuation sheet
Page 5 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365928
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/26/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Court House Manor
555 North Glenn Ave
Washington Court Hou, OH 43160
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684
facility when requested.
Level of Harm - Minimal harm
or potential for actual harm
This deficiency represents non-compliance investigated under Complaint Number OH00163888 and
OH00163883.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365928
If continuation sheet
Page 6 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365928
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/26/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Court House Manor
555 North Glenn Ave
Washington Court Hou, OH 43160
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0686
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review, staff interview, review of wound notes and facility policy review, the facility failed
to prevent facility acquired suspected deep tissue injury (a type of pressure-induced damage to underlying
tissues, such as muscle and subcutaneous layers, that appears as a localized area of discolored intact skin
(purple or maroon) or a blood filled blister, without a visible open wound) to bilateral heels. This affected
one (Resident #188) of three residents reviewed for pressure ulcers. Facility census was 88.
Residents Affected - Few
Findings include:
Review of the medical record for Resident #188, revealed an admission date of 03/07/25. Diagnoses
included but were not limited to dementia, major depressive disorder, cerebral infarction due to unspecified
occlusion or stenosis of unspecified cerebral artery, and periprosthetic fracture around internal prosthetic
fracture around internal prosthetic right hip joint, subsequent encounter.
Review of the functional abilities assessment dated [DATE] for Resident #188 revealed assistance was
needed for toilet, hygiene, and shower/bathe self at substantial/maximal assistance and bed mobility and
transfers totally dependent.
Review of the admission skin assessment dated [DATE] for Resident #188 revealed no pressure areas to
the left and right heel.
Review of the Braden Scale for Predicting Pressure ulcer Risk Evaluation dated 03/07/25 for Resident #188
revealed the resident is very limited: Makes occasional slight changes in body or extremity position but
unable to make frequent or significant changes independently with a score of 15 out of 23 indicating mild
risk for developing a pressure ulcer or injury.
Review of the physician's orders dated 03/07/25 revealed for Resident #188 a pressure reducing mattress
to bed, but no orders to turn and reposition and offload and or elevate heels.
Review of the Physical Therapy evaluation dated 03/08/25 for Resident #188 revealed bed mobility training
to be dependent.
Review of the baseline care plan on admission dated 03/09/25 for Resident #188 revealed no skin care
interventions selected which included but were not limited to pillows for offloading.
Review of the care plan dated 03/10/25 for Resident #188 revealed to be at risk for skin breakdown or
known to have area(s) of skin breakdown with interventions including but not limited to requiring using
offloading devices such as pillows for offloading.
Review of the medical record for Resident #188 revealed from 03/07/25 through 03/11/25 no
documentation of turning and repositioning as well as offloading and or elevating heels while in bed.
Additionally, no documentation to support this resident met clinical conditions to demonstrate the pressure
ulcers were unavoidable was found.
Review of skin issues assessment dated [DATE] for Resident #188 revealed two acquired in-house
pressure injuries, one on the left heel measuring 2 centimeters (cm) by 1.6 cm by no depth and a right
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365928
If continuation sheet
Page 7 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365928
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/26/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Court House Manor
555 North Glenn Ave
Washington Court Hou, OH 43160
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0686
heel measuring 0.8 cm by 1 cm by no depth. No staging and description documented for either injury.
Level of Harm - Minimal harm
or potential for actual harm
Review of the physician orders dated 03/12/25 for Resident #188 revealed heel/ankle protectors to be
applied to bilateral heels with a discontinue date of 03/13/25.
Residents Affected - Few
Review of the Wound Consultation dated 03/13/25 for Resident #188 revealed a left heel suspected deep
tissue injury measuring 3.8 cm by 3.5 cm by no depth being dark purplish maroon in color and a right heel
suspected deep tissue injury measuring 1.9 cm by 1.5 cm by no depth being a dark purplish maroon in
color, both being acquired in house at the facility. Interventions to include float heels, offload heels, and to
turn and reposition per facility protocol. Additional risk factors for this resident revealed a healed ulcer is
more likely to break down again, impaired decreased mobility, cognitive impairment and decreased
functional ability. Treatment order for skin preparation (prep) to bilateral heels twice a day and as needed.
Review of the physician's orders dated 03/13/25 for Resident #188 revealed bilateral heels cleanse
heels/pat dry and apply skin prep and to offload heels while in bed as the resident allows every shift.
Review of the care plan updated on 03/13/25 for Resident #188 revealed at risk for skin breakdown or
known to have area(s) of skin breakdown with an added intervention to offload heels as tolerated.
Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief
Interview for Mental Status (BIMS) of 10 out of 15 suggesting moderate cognitive impairment.
Review of the care plan updated on 03/15/25 for Resident #188 revealed at risk for skin breakdown or
known to have area(s) of skin breakdown with an added intervention of encourage resident to get up every
day as the resident refuses to get out of bed.
Observation on 03/17/25 at 9:18 A.M. revealed Resident #188 to be in bed.
Interview and observation on 03/18/25 at 10:35 A.M. with Resident #188 revealed the resident was in bed.
He doesn't recall his heels being elevated on pillows when he first got here and he was not turned in bed
stated, I know when I first was here, I just laid here and now they keep putting pillows under my feet and
making me move back and forth in bed, but I can't lay on my right side still it hurts too much. The resident
also expressed that he enjoys lying in bed in the mornings and relaxing before therapy.
Observation on 03/19/25 at 9:12 A.M. revealed Resident #188 to be in bed.
Observation on 03/20/25 at 10:57 A.M. revealed Resident #188 to be in bed.
Interview on 03/20/25 at 10:58 A.M. with Licensed Practical Nurse (LPN) #208 revealed if a resident is
totally dependent on assistance with movements in the bed, the staff are to make sure they are turned to
prevent pressure ulcers. LPN #208 was not aware of Resident #188 refusing care and if he was it would be
documented, but the resident wanted to stay in bed this morning.
Interview on 03/20/25 at 11:02 A.M. with Registered Nurse (RN) #270 revealed if a resident is totally
dependent then the staff is to assist them when in bed, elevate their heels, and the aides
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365928
If continuation sheet
Page 8 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365928
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/26/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Court House Manor
555 North Glenn Ave
Washington Court Hou, OH 43160
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0686
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
usually turn them with their two-hour check and change and document it in their charting. RN #270 stated it
is the aide staff who are responsible for taking preventative measures to keep them from getting pressure
ulcers. If a resident refuses care, it is documented.
Interview on 03/20/25 at 11:08 A.M. with Certified Nurse Assistant #274 revealed when caring for residents,
the [NAME] is where the aides gather the information to care for the residents and it comes from the care
plans. If they are new, they ask the nurses for information. Residents are checked and changed every two
hours and that is when they are turned and are to be documented in their charting. Also revealed Resident
#188 does not like to be turned onto his right side, so he is only turned on his back and left side and the
only care he has refused for her was to get out of bed in the mornings, but by the afternoon he is wanting to
get up.
Observation on 03/20/25 at 11:55 A.M. of Resident #188's wound care with Certified Nurse Practitioner
(CNP) #340 and RN #317 to the left and right heel revealed no concerns. Resident #188 tolerated well, and
wounds are improving with measurements showing the right heel suspected deep tissue injury to be 0.9 cm
by 1 cm by no depth being a dark purplish maroon color and the left heel suspected deep tissue injury to
be 3.5 cm by 2.9 cm by no depth being a dark purplish maroon color. Interventions included to float heels,
offload heels and to turn and reposition per facility protocol with additional risk factors for this resident
continuing to be a healed ulcer is more likely to break down again, impaired decreased mobility, cognitive
impairment and decreased functional ability. Treatment order continued as skin prep to bilateral heels twice
a day and as needed.
Interview on 03/20/25 at 12:05 P.M. with CNP #340 revealed if a resident is totally dependent on
movements in bed at the facility, the resident should be turned every two hours and have elevated heels to
prevent pressure ulcers.
Interview on 03/20/25 at 12:10 P.M. with RN #317 revealed residents that are dependent on the staff for
movement in bed should have elevated heels and be turned every two hours for pressure ulcer prevention.
Interview on 03/20/25 at 2:20 P.M. with the Director of Nursing revealed for Resident #188 no preventative
measures were in place for his bilateral heels and no baseline care plan for skin management for Resident
#188 from admission on [DATE] through 03/10/25.
Review of the facility policy titled Pressure Ulcer Policy revision date 04/2016 revealed a resident who
enters the Manor without a pressure ulcer will not develop a pressure ulcer unless the individual's clinical
condition demonstrates they are unavoidable. Appropriate preventative interventions will be implemented
(i.e. offloading heels, etc.) and all residents will be placed on a pressure-reducing mattress upon entering
the Manor.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365928
If continuation sheet
Page 9 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365928
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/26/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Court House Manor
555 North Glenn Ave
Washington Court Hou, OH 43160
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review,interview, and facility policy review, the facility failed to ensure a resident received medication.
This affected one (Resident #10) of five residents reviewed for medication administration. The facility
census is 88.
Findings Include:
Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses
of dry eye syndrome of bilateral lacrimal glands, bell's palsy, and candidiasis of skin and nails.
Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #10 had
mild cognitive deficit and was frequently incontinent of bowel and always incontinent of bladder. The
resident required supervision or touching assistance with eating, partial/moderate assistance with oral
hygiene and bed mobility, substantial/maximal assistance for toileting and transfers, substantial/maximal
assistance for bathing, partial/moderate assistance for personal hygiene and substantial/maximal
assistance for dressing.
Review of physician orders revealed Resident #10 had an order dated 04/12/24 for Cyclosporine to be
administered two times a day for dry eyes due to inflammation.
Review of the medication administration record confirmed Resident #10 has missed her medication on
3/16/25 and 03/17/25 for both the A.M. and P.M. administration times and on 03/18/25 for the A.M.
administration.
Observation of medication administration on 03/18/25 at 09:13 A.M. with staff Registered Nurse (RN) #334
for Resident #10 revealed that the cyclosporine medication was out of stock.
Interview on 03/18/25 at 09:15 A.M. with staff RN #334 revealed the medication was not available and that
she will have to contact the doctor.
Interview on 03/18/25 at 4:02 P.M. with staff RN #334 stated that the doctor had put an order to hold the
medication until the medication is back in stock.
Interview on 03/19/25 at 12:15 P.M. with Resident #10 stated that she doesn't usually get her eye drops and
that the nurses won't give her the eye drops unless she asks.
Review of the facility policy titled Medication Storage in the Facility dated March 1996 and revised on
February 11, 2025 revealed the facility is to reorder medications from the pharmacy if the current order
exists.
This deficiency represents non-compliance investigated under Complaint Number OH00161161.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365928
If continuation sheet
Page 10 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365928
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/26/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Court House Manor
555 North Glenn Ave
Washington Court Hou, OH 43160
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and facility medication storage policy, the facility failed to ensure outdated
medications were removed from stock. This affected one (Resident #53) out of 11 resident's insulin
reviewed. Facility census is 88.
Findings include:
Review of the medical record revealed Resident #53 was admitted to the facility on [DATE] with diagnoses
of Type 2 Diabetes Mellitus with hyperglycemia.
Review of the Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #53 had a
slight cognitive deficit and was always incontinent of bowel and frequently incontinent of bladder. The
resident required independent with eating, set up or clean up assistance with oral hygiene and bed mobility,
dependent for toileting and transfers, substantial/maximal assistance for bathing, setup or clean-up
assistance for personal hygiene and dependent assistance for dressing.
Review of physician orders revealed Resident #53 had an order dated [DATE] to be administered Humalog
Kwik insulin pen-injector 100 UNIT/ML, inject per sliding scale subcutaneously before meals for diabetes
mellitus type 2.
Observation of Med Cart D2 on [DATE] at 4:02 P.M. with staff RN #203 revealed one insulin pen had an
open date of [DATE] and expiration date of [DATE].
Interview on [DATE] with staff RN #203 revealed the insulin was supposed to be removed on [DATE] and
not to be used. Staff RN #203 stated she administered 2 units of insulin on [DATE] at 11:13 AM, 2 units of
insulin on [DATE] at 5:00 PM, and 2 units of on [DATE] at 11:24 AM with the expired insulin.
Review of the facility policy titled Medication Storage in the Facility dated [DATE] and revised on February
11, 2021 revealed the facility should remove outdated, contaminated, or deteriorated medications from
stock.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365928
If continuation sheet
Page 11 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365928
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/26/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Court House Manor
555 North Glenn Ave
Washington Court Hou, OH 43160
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
Based on infection control log review and interview, the facility failed to ensure facility and community
acquired organism was identified and tracked in the facility's infection control log. This had the potential to
affected all 88 residents residing in the facility.
Residents Affected - Many
Findings Include:
Review of the January 2024 infection control log, the urinary tract infection (UTI) no catheter flow tracking
sheet revealed Resident #143 was prescribed the antibiotic Augmentin for a UTI with no identification of the
organism causing the UTI.
Review of the February 2024 infection control log, the UTI no catheter flow tracking sheet revealed
Resident #12, #144 and #145 were admitted from the hospital with antibiotic orders with no identifying
organism causing the UTI.
Review of the March 2024 infection control log, the UTI no catheter flow tracking sheet revealed Resident
#38, #144 and #146 were admitted from the hospital with antibiotic orders with no identifying organism
causing the UTI.
Review of the July 2024 infection control log, the UTI no catheter flow tracking sheet revealed Resident
#52, #148 and #149 were admitted from the hospital with antibiotic orders with no identifying organism
causing the UTI.
Review of the December 2024 infection control log, the UTI no catheter flow tracking sheet revealed
Resident #150 were admitted from the hospital with antibiotic orders with no identifying organism causing
the UTI.
Review of the January 2025 infection control log, the UTI no catheter flow tracking sheet revealed Resident
#38 and #78 were admitted from the hospital with antibiotic orders with no identifying organism causing the
UTI.
Review of the February 2025 infection control log, skin and soft tissue infection revealed Resident #151
was treated with antibiotics for a wound infection with no identifying organism causing the infection.
On 03/24/25 at 11:15 A.M., interview with Registered Nurse (RN) #288 confirmed the multiple organisms
were not documented on the infection control log from the wound culture and in coming organisms from the
hospital were not identified.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365928
If continuation sheet
Page 12 of 12
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Back to topCitations
6 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F580 - Notification of Changes
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
FAQ · About this visit
Common questions about this visit
What happened during the March 26, 2025 survey of COURT HOUSE MANOR?
This was a inspection survey of COURT HOUSE MANOR on March 26, 2025. The surveyor cited 6 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at COURT HOUSE MANOR on March 26, 2025?
Yes, 6 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.