St Catherines Manor of Washington Court House

In the surveyor’s words

From the most serious findings on record at St Catherines Manor of Washington Court House, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Dec 18, 2025

  Based on observation, staff interview, and policy review, the facility failed to ensure food was stored in a manner to protect against potential contamination and spoilage. This had the potential to affect all 43 residents in the facility that receive food from the kitchen. The facility identified three (#9, #36, and #55) residents with active orders for nothing by mouth. The facility census was 46. Findings include:Observation on 12/15/25 at 8:57 A.M. revealed four opened containers of food items with no date marking in the walk-in refrigerator including one bag of yellow cheese slices, one bag of white cheese, one bag of pepperoni slices, and one package of bacon. Observation on 12/15/25 at 8:59 A.M. […]

• No harm, potential for more than minimal, widespreadF880Dec 18, 2025

  Based on observation, review of a facility Legionella plan and testing and monitoring documents, medical record review, and staff interview, the facility failed to ensure measures to address and prevent Legionella growth within the facility were maintained and conducted as required and failed to ensure infection control measures were maintained following urinary catheter care for a resident (#6). This had the potential to affect all 46 residents residing in the facility. The census was 46. Findings include: 1. […]

• No harm, potential for more than minimal, isolatedF584Dec 18, 2025

  Based on observation, medical record review, staff interview, and policy review, facility failed to ensure a resident room was set to a comfortable temperature. This affected one (#9) of 16 residents reviewed for environmental issues during the initial sample. The facility census was 46. Findings include: Review of the medical record for Resident #9 revealed an admission date of 06/28/21. Diagnoses included quadriplegia, chronic respiratory failure, diabetes, heart embolism, tracheostomy, contracture of multiple sites, dependence on ventilator status, anoxic brain injury, epilepsy, and heart disease.Review of the plan of care dated 11/18/25 revealed Resident #9 had a tracheostomy (trach) with interventions to ensure trach ties were secured at all times, give humidified oxygen as… […]

• No harm, potential for more than minimal, isolatedF603Dec 18, 2025

  Based on medical record review, resident and staff interview, and policy review, the facility failed to ensure residents were properly assessed for appropriateness before being placed on the secured memory care unit. This affected one (#49) of one resident reviewed for restraints. The facility census was 46. Findings include: Review of the medical record for Resident #49 revealed an admission date of 07/15/25. Diagnoses included fibromyalgia, malnutrition, dementia with mood disturbance, and kidney disease.Review of hospital discharge paperwork dated 07/15/25 revealed Resident #49 had been living at home, was hospitalized , and found to have a urinary tract infection (UTI). […]

• No harm, potential for more than minimal, isolatedF605Dec 18, 2025

  Based on medical record review, staff interview, and policy review, the facility failed to monitor behaviors with psychotropic medication use. This affected two (#2 and #56) of five residents reviewed for psychotropic medications. The facility census was 46.Findings include:1. Review of the medical record for Resident #2 revealed an admission date of 09/04/18. Diagnoses included type II diabetes mellitus, heart failure, dementia, Parkinson's disease, and atrial fibrillation.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11. […]