F0836

F

Failure to Meet State Minimum Direct Care Staffing Requirement

Washington, District Of Columbia Survey Completed on 03-03-2026

Penalty

Fine: $85,666

Summary

Facility staff failed to meet the State requirement of providing a minimum daily average of 4.1 hours of direct nursing care per resident per day on 02/22/26, when the census was 117 residents and the facility’s total direct care staffing level was 4.0 hours. On that same date, a facility reported incident documented that at approximately 3:00 AM, Resident #5 was found in the doorway of his room with his tracheostomy dislodged. An Immediate Jeopardy was identified at 42 CFR 483.24, F678, related to cardiopulmonary resuscitation on 02/25/26 at 3:40 PM. During a face-to-face interview on 03/03/26, the staffing coordinator calculated the total direct care staff, acknowledged that the 4.1-hour requirement was not met on 02/22/26, and stated that staffing had generally been good but that on some days replacements could not be obtained for staff who called out.

The deficiency centers on the facility’s failure to comply with State minimum direct care staffing requirements on 02/22/26, in the context of an incident where a resident with a tracheostomy was found with the trach dislodged during the early morning hours, and the subsequent identification of Immediate Jeopardy related to cardiopulmonary resuscitation requirements.