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 Forest Hills Of Dc during CMS and state inspections, most recent first.
Facility staff did not provide required Notices of Medicare Non-Coverage (NOMNC) at least two days before the end of Medicare Part A services for two Medicare beneficiaries. In one case, the resident’s representative received the NOMNC by email only one day before rehab services ended. In the other case, a resident signed the NOMNC on the last covered day of Part A services. During interview, the social worker confirmed that NOMNCs for these residents were not issued 48 hours in advance of the termination of covered services.
Surveyors found that the facility did not ensure required monthly medication regimen reviews were consistently documented and that physician responses to pharmacist recommendations were obtained. For one resident with dementia, diabetes, hypertension, and chronic kidney disease who was receiving PRN oxycodone for severe pain, there was no documented monthly medication review for a specific month despite facility policy requiring monthly pharmacist review. For another resident with COPD, dementia with mood disturbance, depression, and multiple psychotropic and related medications, the consultant pharmacist documented concerns about psychotropic polypharmacy and recommended a psychiatric consult and consideration of gradual dose reductions, but the record contained no documented physician or prescriber response. The RN/Clinical Nurse Manager described a process for routing MRRs to physicians but could not locate a response for this resident’s review or explain how missed MRRs were prevented.
Staff failed to maintain sanitary conditions in food storage, preparation, and dishwashing areas, including undated opened shredded cheese, expired milk with settled contents, condensation leaking onto frozen food, and significant food residue on equipment and floors. A kitchen manager checked tuna salad temperature before handwashing, a dishwashing employee used a towel to dry sanitized kitchenware, and mold and limescale were present in the dishwashing area. Pest control reports had previously cited food debris and inadequate cleaning under and behind kitchen equipment and drains. During a follow-up visit, employee personal belongings were stored on racks in the dry storage room, creating potential cross contamination with food and food-contact surfaces.
Staff failed to document required nursing care and treatments for two residents, resulting in incomplete medical records. One resident with dementia, Parkinson's disease, and severe malnutrition had a standing order for aspiration precautions every shift, but the TAR lacked documentation that these precautions were provided on two shifts. Another resident with respiratory and pain-related diagnoses had orders for non-skid socks during the evening shift for fall risk and for heel elevation/floating on pillows for pressure relief every shift while in bed, yet the TAR showed no evidence these interventions were documented on multiple evening shifts. A CNM acknowledged the missing documentation and uncertainty about whether chart checks include verifying completion of ordered care.
Staff failed to maintain essential kitchen equipment when the condensation pipe carrying condensate wastewater from the air condenser in the walk-in freezer was found leaking during a kitchen tour. The issue was confirmed in an interview with the kitchen manager and the corporate chef, who acknowledged the ongoing leak in the freezer’s condensation piping.
Facility staff did not maintain an effective pest control program in the kitchen, as evidenced by surveyor observations of multiple live flies at the juice counter and dishwashing areas during a tour. Pest control reports from an external vendor months apart documented repeated needs for general cleaning under and behind cooking equipment, along walls, around floor drains in the dish room, and under the juice counter due to food debris and uncleaned areas. During an interview, the corporate chef and kitchen manager acknowledged the presence of flies and the observed conditions.
A resident with a history of Acute Pulmonary Embolism and Hypertension was inaccurately assessed due to a discrepancy in discharge location documentation. The resident was admitted with an intake form indicating discharge from a nursing home, but the MDS assessment recorded a discharge from a hospital. This error was due to the MDS Coordinator relying on a hospital discharge summary, despite being informed otherwise by the DON.
A resident with a history of acute pulmonary embolism and hypertension was administered incorrect dosages of Eliquis and the wrong form of Metoprolol due to transcription errors at the facility. The staff used hospital discharge orders instead of the nursing home discharge summary, leading to the administration of Eliquis 10 mg instead of 5 mg and Metoprolol Tartrate instead of Metoprolol Succinate. The errors were discovered when the resident's daughter questioned the medication being given, resulting in the resident's discharge from the facility.
A resident with a history of Acute Pulmonary Embolism and Hypertension was administered an incorrect dosage of Apixaban (Eliquis) due to a transcription error. The staff transcribed the medication order from an outdated hospital discharge summary, leading to the resident receiving 10 mg instead of the prescribed 5 mg twice daily. The error was identified by the resident's daughter, and the medication order was subsequently corrected.
A medication cart on Unit 2 was found unlocked and accessible in a common area, with no staff in view. An RN confirmed the cart should have been locked, and an LPN admitted to leaving it unsecured.
A resident with a history of hypertension was prescribed Metoprolol Succinate (Toprol XL) but was incorrectly administered Metoprolol Tartrate (Lopressor) due to a documentation error in the MAR. The error was identified by the resident's daughter upon discharge, and the physician confirmed the intended prescription. The DON found that an LPN ordered the wrong medication from the pharmacy.
Staff failed to maintain sanitary conditions in food storage, preparation, and service areas, including undated and improperly stored food items, soiled cutting boards and kitchen equipment, incomplete food temperature logs, and unclean fire safety equipment. The Director of Dietary Services acknowledged these issues during the survey.
Facility staff failed to accurately code MDS assessments for two residents, omitting documentation of multiple unwitnessed falls for one resident and failing to record a diagnosis of depression for another, despite clear evidence in medical records and ongoing treatment for these conditions.
Facility staff did not create or document a care plan with goals and interventions for a resident receiving antibiotics for UTI prophylaxis, despite the resident's complex medical history and ongoing medication order. This omission was confirmed upon review and staff interview.
A resident with a history of falls and multiple diagnoses experienced two falls, including one resulting in a right elbow fracture. After the first fall, the care plan was updated with interventions such as rehab evaluation and safety rounding. However, following a subsequent fall, staff did not revise or update the care plan with new interventions, despite facility policy requiring such updates after each fall.
Facility staff did not document or monitor a resident's long-term antibiotic use and potential adverse reactions as required by the facility's antibiotic stewardship policy. The omission was discovered when the DON could not provide evidence of tracking, despite the resident's ongoing antibiotic regimen and multiple chronic conditions.
Failure to Provide Timely NOMNC Prior to End of Medicare-Covered Services
Penalty
Summary
Facility staff failed to provide required Notices of Medicare Non-Coverage (NOMNC), Form CMS-10123, at least two days before the end of Medicare-covered services for two Medicare beneficiaries. Record review on 03/24/2026 at approximately 4:35 PM showed that for one resident, the skilled services episode began on 09/04/2025 with the last covered day of Part A services on 09/25/2025. An email exchange in the clinical record dated 09/24/2025 at 10:14 AM between the social worker (Employee #5) and the resident’s representative included an attached notice stating that the resident’s rehab services were ending the next day under that version of Medicare. The NOMNC documentation showed the representative acknowledged the notice via email on 09/24/2025 at 12:52 PM, confirming that the notice was not provided at least two days before the end of covered services. For a second resident, record review showed a skilled services episode start date of 08/29/2025 and a last covered day of Part A services of 09/22/2025. The NOMNC form for this resident contained the resident’s printed full name and a date of 09/22/2025 on the signature line, indicating the notice was given on the last covered day rather than at least two days in advance. During a face-to-face interview on 03/24/2026 at approximately 4:35 PM, the social worker (Employee #5) confirmed that the NOMNCs for both residents were not sent 48 hours before the end of covered services, acknowledging that the facility did not provide timely notification of changes to Medicare-covered items and services for these residents.
Failure to Complete Monthly Medication Reviews and Obtain Physician Response to Pharmacist Recommendations
Penalty
Summary
The deficiency involves the facility’s failure to ensure that the consultant pharmacist completed and documented a monthly medication regimen review (MRR) for one resident and the failure of a physician or prescriber to respond to the pharmacist’s recommendations for another resident. Facility policy titled “Medication Review,” reviewed on 02/11/2026, required the consultant pharmacist to review each resident’s medication regimen monthly. One resident, admitted with diagnoses including Diabetes Mellitus, Dementia, Hypertension, and Chronic Kidney Disease, had an order for oxycodone 5 mg every six hours as needed for severe pain and an admission MDS showing a BIMS score of 03, indicating severe cognitive impairment. Review of this resident’s medical record from September 2025 through February 2026 showed no documented evidence of a monthly medication review for October 2025. During a telephone interview, the consultant pharmacist acknowledged that she should have made a note for every resident every month, confirmed that no note was present in the electronic health record for October, and stated it may have been an error on her part. For another resident, admitted with diagnoses including COPD, dementia with mood disturbance, Type 2 Diabetes Mellitus, depression, and generalized muscle weakness, the medical record contained multiple psychopharmacologic and related medications, including donepezil, trazodone, diazepam (in two different doses and schedules), Fetzima, Abilify, and Remeron. A Medication Regimen Review dated 12/08/2025 documented the pharmacist’s recommendation for a regular psychiatric consult to monitor therapy efficacy and side effects and to consider gradual dose reductions due to polypharmacy of psychopharmacological medications. The clinical record lacked documented evidence of any physician or prescriber response to this recommendation. In an interview, the RN/Clinical Nurse Manager described the process for handling MRR recommendations—receiving them by email, printing and flagging them in the paper chart for physician response, and then filing them in a binder—but was unable to locate the physician’s response to the 12/08/2025 MRR and did not explain how she ensured that no residents’ MRRs were missed.
Unsanitary Food Storage, Preparation, and Dishwashing Practices in Kitchen
Penalty
Summary
Facility staff failed to prepare and distribute food under sanitary conditions in the kitchen and dishwashing areas. During an initial kitchen survey, surveyors observed an undated opened bag of shredded cheese in the refrigerator and multiple half-gallon milk containers in a reach-in refrigerator that were past their sell-by dates, with contents appearing settled. In the walk-in freezer, condensation water was leaking onto packaged potato fries. A kitchen manager checked the temperature of tuna salad before washing hands. Surveyors also noted significant food residue buildup on cooking equipment and floors in both the cooking and dishwashing areas, as well as excessive limescale accumulation on the interior surfaces of the automatic dishwashing machine. A dishwashing employee used a towel to dry food-contact surfaces of washed and sanitized kitchenware, and mold was present on wall surfaces and caulk lines in the automatic dishwashing area. Pest control reports from an outside company documented prior findings that the kitchen floor areas along walls, under equipment on the cooking line, behind cooking equipment, under the three-compartment sink in the dish room, and under the juice counter contained food debris and needed cleaning, and that a small center drain on the cooking line needed to be cleaned. During a follow-up kitchen survey, employee personal belongings, including a jacket and backpack, were observed stored on racks in the dry storage room rather than in a designated locker area, creating a potential for cross contamination of food and food-contact surfaces stored there. These conditions and practices collectively demonstrate a failure to maintain food storage, preparation, and distribution in accordance with sanitary and professional standards.
Failure to Document Ordered Aspiration, Fall, and Pressure Injury Precautions
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records and to document nursing care and treatment as ordered for two residents. For one resident with dementia, Parkinson's disease, and severe protein-calorie malnutrition, a physician's order dated 01/23/26 required aspiration precautions every shift. The resident’s Significant Change MDS showed a BIMS score of 03, indicating severely impaired cognition. Review of the Treatment Administration Record (TAR) for March 1–31, 2026 showed no documented evidence that aspiration precautions were provided on the night shift of 03/07/26 and the evening shift of 03/18/26, despite the standing order. For another resident admitted with respiratory failure, pneumonia, asthma, and chronic back pain, a physician’s order dated 02/06/26 required non-skid socks during the evening shift for fall risk and elevation/floating of heels on pillows for pressure relief every shift while in bed. The admission MDS documented a BIMS score of 13, indicating the resident was cognitively intact and required supervision with ADLs. Review of the TAR for February 1–28, 2026 revealed no documented evidence that non-skid socks were applied during the evening shift, or that the resident’s heels were elevated/floated on pillows for pressure relief, on 02/07/26, 02/13/26, 02/21/26, and 02/22/26. In an interview, the Clinical Nurse Manager acknowledged the findings and stated that night shift normally performs 24-hour chart checks for new orders but was unsure if they verify that ordered care is documented as completed.
Failure to Maintain Walk-In Freezer Condensation System
Penalty
Summary
Facility staff failed to maintain essential kitchen equipment, specifically the walk-in freezer, in good working order. During the initial kitchen tour on 03/24/2026 at approximately 10:15 AM, surveyors observed that the condensation pipe conveying condensate wastewater from the air condenser in the walk-in freezer was leaking. In a face-to-face interview conducted shortly thereafter on 03/24/2026 at approximately 10:30 AM, the Kitchen Manager (Employee #6) and the Corporate Chef (Employee #7) acknowledged the observed leak from the condensation pipe in the walk-in freezer.
Failure to Maintain Effective Kitchen Pest Control and Sanitation
Penalty
Summary
Facility staff failed to maintain an effective pest control program to keep the kitchen free of pests, specifically flies. During an initial kitchen tour on 03/24/2026 at approximately 10:15 AM, surveyors observed multiple live flies at the juice counter and dishwashing areas. Review of a pest control report from Bay City Pest Management Co. Inc. dated 02/19/2026 documented that, although the kitchen was inspected, general cleaning was needed under equipment on the cooking line, along the wall and floor drain under the 3-compartment sink in the dish room, and in the corner area of the floor under the juice counter. A prior pest control report dated 07/18/2025 similarly noted that the floor area along the wall under counters and behind cooking equipment needed to be cleaned due to a lot of food debris, and that a small center drain on the cooking line needed cleaning. During a face-to-face interview on 03/24/2026 at approximately 10:15 AM, the Corporate Chef (Employee #7) and Kitchen Manager (Employee #6) acknowledged the observations of flies in the kitchen. No residents or their clinical conditions were mentioned in the report, and the deficiency centers on environmental sanitation and pest control practices in the kitchen area.
Inaccurate Resident Assessment Due to Discharge Location Error
Penalty
Summary
The facility's staff failed to ensure an accurate assessment for one of the sampled residents, leading to a discrepancy in the resident's documented discharge location. The resident, who had a history of Acute Pulmonary Embolism and Hypertension, was admitted to the facility with an admission intake form indicating discharge from an out-of-state nursing home. However, the Entry Minimum Data Set (MDS) assessment inaccurately documented the resident as being discharged from a short-term general hospital. This error occurred because the MDS Coordinator coded the resident's discharge based on a hospital discharge summary provided by the nursing staff, despite being informed by the Director of Nursing that the resident had been discharged from a nursing home.
Medication Administration Errors for a Resident
Penalty
Summary
The facility failed to administer medications according to the prescribed orders for a resident with a history of acute pulmonary embolism and hypertension. Upon admission, the resident was supposed to receive Eliquis 5 mg twice daily and Metoprolol Succinate Extended Release 50 mg at bedtime. However, due to a transcription error, the resident received Eliquis 10 mg twice daily for four occasions and Metoprolol Tartrate instead of the prescribed Metoprolol Succinate. The error occurred because the staff transcribed the hospital discharge orders instead of the nursing home discharge summary, which led to the incorrect administration of medications. The resident's daughter provided the facility with the correct medication list from the previous nursing home, but the staff failed to use this information accurately. The attending physician was not informed of the discrepancy in the Metoprolol prescription, and the error was only discovered when the resident's daughter questioned the dosage being administered. Interviews with staff revealed a lack of communication and verification of the correct medication orders. The Director of Nursing acknowledged the transcription error and the failure to administer the correct form of Metoprolol. The resident's daughter decided to discharge her mother from the facility due to these medication errors, highlighting the impact of the facility's failure to adhere to the prescribed medication regimen.
Medication Dosage Error Due to Transcription Mistake
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, resulting in the administration of an incorrect dosage of Apixaban (Eliquis). The resident, who had a history of Acute Pulmonary Embolism and Hypertension, was admitted to the facility with a prescription for Eliquis 5 mg twice daily. However, due to a transcription error, the resident received Eliquis 10 mg twice daily for four occasions. This error occurred because staff transcribed the medication order from an outdated hospital discharge summary instead of the most recent nursing home discharge summary. The error was discovered when the resident's daughter noticed the incorrect dosage being administered and brought it to the staff's attention. The attending physician was notified, and the medication order was corrected. The resident was assessed and monitored for any adverse effects, and no negative outcomes were reported. The primary care physician acknowledged the oversight, stating that the discharge summary from the discharging nursing home was not seen in the resident's record at the time of admission.
Medication Cart Security Breach
Penalty
Summary
The facility staff failed to ensure a medication cart was locked and secure from residents, visitors, and other personnel. This deficiency was observed on Unit 2, where an unlocked medication cart was parked in a common area with its drawers facing forward, making it visible and accessible to anyone passing by. At the time of the observation, there were no staff members in view of the medication cart, and residents and staff were gathered in a nearby dining area. During interviews, an RN acknowledged that the cart should have been locked, and an LPN admitted to leaving the cart unlocked, stating she should have locked it before leaving.
Medication Administration Error Due to Incorrect Formulary
Penalty
Summary
The facility failed to ensure that a resident's Medication Administration Record (MAR) included the correct formulary for a medication used to treat elevated blood pressure. A resident with a history of Acute Pulmonary Embolism and Hypertension was admitted to the facility and was supposed to receive Metoprolol Succinate (Toprol XL) Extended Release 50 mg at bedtime. However, the MAR incorrectly documented an order for Metoprolol Tartrate (Lopressor) 50 mg, which was administered on five occasions. The error was discovered when the resident's daughter, who is also the Power of Attorney, noticed the discrepancy upon the resident's discharge. The physician confirmed that Metoprolol Succinate was the intended prescription and was not informed of the administration of Metoprolol Tartrate. The Director of Nursing identified that the error occurred when an LPN mistakenly ordered the incorrect medication from the pharmacy.
Food Service Sanitation and Documentation Deficiencies
Penalty
Summary
Facility staff failed to distribute and serve food under sanitary conditions, as evidenced by several observations during the survey. An open pack of provolone cheese and a pan with chunks of grapefruit were found undated in a refrigerator in the kitchen on Healthcare 1. In the main kitchen, two of fourteen white cutting boards and two of fourteen green cutting boards were soiled and discolored. Food temperature logs from the main kitchen and kitchens on Healthcare 1 and 2 were missing multiple entries for the month of October 2024. Additionally, one of two convection ovens in the main kitchen was soiled, and two of eight fire suppression nozzles above the grease fryer and gas stove were soiled with grease deposits, with one nozzle also found to be corroded. One of two fire sprinkler heads in the walk-in refrigerator was soiled and rusty. These findings were acknowledged by the Director of Dietary Services during an interview.
Failure to Accurately Code MDS Assessments for Falls and Depression
Penalty
Summary
Facility staff failed to accurately code Minimum Data Set (MDS) assessments for two residents, resulting in incomplete and inaccurate documentation of their clinical status. For one resident with diagnoses including dementia, vertebral and femoral fractures, and glaucoma, the admission MDS indicated severe cognitive impairment and a history of falls prior to admission. Despite multiple documented unwitnessed falls during the resident's stay, these incidents were not recorded on the discharge MDS assessment, as confirmed by staff interview. The omission included leaving blank the section regarding the number of falls since admission, despite clear evidence in the medical record of at least three falls. For another resident with chronic conditions such as COPD, diabetes, hypothyroidism, and documented depression, the facility failed to code depression as an active diagnosis on the Quarterly MDS assessment. This occurred despite multiple physician orders for antidepressant medications, psychiatric notes confirming depression and behavioral disturbances, and psychosocial documentation of ongoing depressive symptoms. Staff interview revealed that the depression diagnosis was accidentally deleted from the resident's diagnoses page, resulting in the omission from the MDS.
Failure to Develop Care Plan for Antibiotic Use
Penalty
Summary
Facility staff failed to develop and implement a care plan with measurable goals and interventions to address a resident's use of antibiotics for urinary tract infection (UTI) prophylaxis. The resident, who had multiple diagnoses including COPD, Type 2 Diabetes Mellitus, and Hypothyroidism, was admitted with a physician's order for Trimethoprim 100 mg to be administered at bedtime for UTI prevention. Despite this ongoing antibiotic therapy, review of the comprehensive care plan revealed no documentation of a care plan specific to the antibiotic use. The absence of this care plan was confirmed during a staff interview, where the DON acknowledged the omission.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
Facility staff failed to update and revise the care plan with resident-centered goals for one resident following a fall that occurred on 07/13/24. The resident, who had a history of repeated falls and multiple diagnoses including difficulty walking, lack of coordination, and cognitive communication deficit, experienced a fall resulting in a right elbow fracture on 07/12/24. After returning from the hospital, the care plan was updated to include interventions such as rehabilitation evaluation, safety rounding, use of a sling and soft cast, and scheduled toileting. However, after a subsequent fall on 07/13/24, there was no documented evidence that the care plan was further updated or revised to address this new incident. Staff interviews confirmed that the facility's policy requires care plan updates after each fall, and the clinical manager acknowledged that the care plan should have been revised following the second fall. Despite the resident's continued risk and the occurrence of another fall, the care plan did not reflect any new or additional interventions after the incident on 07/13/24, as required by facility policy and regulatory standards.
Failure to Document and Monitor Antibiotic Use per Stewardship Policy
Penalty
Summary
Facility staff failed to implement their antibiotic stewardship system for one resident who had been prescribed Trimethoprim for urinary tract infection (UTI) prophylaxis. According to the facility's policy, all antibiotic usage and outcomes are to be documented using an approved surveillance tracking form, and the Infection Preventionist or designee is responsible for reviewing antibiotic utilization. However, a review of the antibiotic surveillance tracking forms revealed that the resident's antibiotic regimen was not documented, despite the resident being on the medication for approximately nine months. The resident in question was admitted with multiple diagnoses, including Chronic Obstructive Pulmonary Disease (COPD), Type 2 Diabetes Mellitus, and Hypothyroidism, and had a moderately impaired cognitive status as indicated by a BIMS score of 11. During the survey, the Director of Nursing was unable to provide documentation that the resident's antibiotic use and monitoring for adverse reactions were being tracked, acknowledging the omission as an oversight. This failure resulted in the facility not following its own antibiotic stewardship policy for monitoring and documenting antibiotic use and adverse reactions for this resident.
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What surveyors actually found near you
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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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Washington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ingleside At Rock Creek | 0.7 mi | ★★★★★ | 0 | 0 |
| Lisner Louise Dickson Hurthome | 1 mi | ★★★★★ | 2 | 0 |
| Knollwood Hsc | 1.5 mi | ★★★★★ | 0 | 0 |
| Stoddard Baptist Nursing Home | 2 mi | ★★★★★ | 2 | 0 |
| Sibley Mem Hosp Renaissance | 2.5 mi | ★★★★★ | 0 | 0 |
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