Above 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 Unique Rehabilitation And Health Center Llc during CMS and state inspections, most recent first.
Failure to care plan powered wheelchair use. A resident with morbid obesity, chronic bilateral LE lymphedema, and muscle weakness had a BIMS of 15 and was using a powered wheelchair that had been delivered to the facility. Records showed OT services and a wheelchair/seating assessment noting safe operation, but the care plan had no documented address of the resident's manual or electric wheelchair use. The RN/Unit Manager confirmed the omission during review.
Failure to document powered wheelchair education for a resident. A resident with morbid obesity, bilateral LE lymphedema, and muscle weakness received a powered wheelchair, but the chart lacked evidence that staff documented receipt of the equipment or education on safe use. Although the resident and an RN/unit manager stated education was provided, the record did not show when the wheelchair was delivered or that the teaching was documented.
A resident with dementia, psychosis, and severe cognitive impairment had discoloration under one eye that was not reported to the Administrator when first observed, and two residents were involved in an altercation after one stepped on the other’s foot and the second reacted by hitting at the first. Staff said they did not report the events because they did not witness clear injury or believed someone else would report it, and the Administrator was not notified in time to report the incident to outside authorities.
Facility staff did not develop care plans to address two residents' specific needs: one resident's ongoing refusal to allow staff to clean his room or change his linens, and another resident's requirement for a mechanical lift and two-person assistance for transfers due to total dependence and a stage 3 pressure ulcer. Staff interviews and care plan reviews confirmed that these issues were not addressed in the residents' care plans.
Staff failed to ensure a clean and comfortable environment for multiple residents, resulting in dirty floors, foul odors, clutter, flies, and missing bed linens. Some residents reported not receiving clean linens or assistance with cleaning, while staff cited linen shortages and uncertainty about when rooms could be cleaned.
A resident with multiple medical conditions reported being handled roughly by an aide during ADL care, which occurred while a respiratory therapist was present. Facility staff did not attempt to identify or interview the aide or the respiratory therapist involved, and did not conduct a thorough investigation as required by policy, instead providing only general reassurances and staff education.
Facility staff did not provide adequate supervision or timely intervention to prevent an aggressive resident, who had not received his prescribed PRN anxiety medication for several days, from striking another resident in the courtyard with a piece of plastic smoke equipment. This altercation resulted in the second resident sustaining a fractured left forearm. The staff member supervising the area was unable to intervene in time, and the aggressive resident's escalating behaviors had been previously documented.
Facility staff did not follow required timeframes for reporting incidents involving two residents in a physical altercation resulting in injury and another resident found unresponsive and treated with Naloxone for suspected overdose. In each case, notifications to the State Agency were delayed beyond policy requirements, and staff interviews confirmed the facility's reporting procedures were not followed.
Facility staff failed to timely report multiple incidents to the State Agency, including a resident-to-resident altercation with injuries, an unresponsive resident who was administered Naloxone, and a resident's allegation of being handled roughly by a CNA. In each case, required notifications and investigations were not completed within mandated timeframes, and staff did not always recognize or act on allegations as reportable abuse or neglect.
Staff did not consistently implement a care plan intervention to keep a resident's bed in the lowest position, despite the resident's high risk for falls and history of serious injuries. The bed was observed elevated, and the resident experienced multiple falls resulting in significant injuries.
A resident with a history of pain and cancer was prescribed Hydromorphone 2 mg, one tablet every four hours as needed. An LPN administered two tablets at once, contrary to the physician's order, and could not explain the deviation. The resident did not experience any harm from the incident.
A resident with dementia, aphasia, and seizure disorder alleged abuse by a CNA, leading to the CNA's suspension. Facility policy requires staff involved in abuse investigations to receive education on abuse before returning to work, but there was no documentation or staff recollection of such education being provided before the CNA resumed duties.
Failure to Care Plan Powered Wheelchair Use
Penalty
Summary
Facility staff failed to develop a care plan for one resident who used a powered wheelchair. The resident was admitted with multiple diagnoses including morbid obesity, chronic bilateral lower extremities lymphedema, and muscle weakness. An admission MDS documented a BIMS score of 15, indicating intact cognitive status, and noted lower extremity impairment, staff assistance with a manual wheelchair, and occupational therapy services. A delivery ticket from a local medical supply store documented that a power wheelchair was delivered to the facility for the resident on 04/17/25. A quarterly MDS also documented a BIMS score of 15, lower extremity impairment, independent use of a manual wheelchair, and occupational therapy services. A wheelchair and seating device assessment documented that the resident on an electric wheelchair demonstrated safe operation of the wheelchair. Review of the resident's care plans showed no documented evidence of a care plan addressing the resident's use of a manual or electric wheelchair. Multiple observations from 11/17/25 to 11/21/25 showed the resident in her room watching TV while sitting in a powered wheelchair, and during an observation on 11/17/25 the resident stated that staff helped her transfer from the bed to her wheelchair and that she could independently operate the electric wheelchair in her room, bathroom, around the facility, and outside the facility. During a face-to-face interview on 11/24/25, the RN/Unit Manager reviewed the care plans and stated that the resident's care plans did not have a care plan to address the resident's use of a powered wheelchair.
Failure to Document Education for Powered Wheelchair Use
Penalty
Summary
Facility staff failed to maintain documented evidence that they followed the resident equipment policy by providing education for one resident who used a powered wheelchair. The facility policy required staff to document receipt of equipment, including the date and time received, equipment type, and who delivered it, and allowed education on use of the equipment to be provided for staff or the resident. Resident #2 was admitted with diagnoses including morbid obesity, chronic bilateral lower extremities lymphedema, and muscle weakness. A delivery ticket from a local medical supply store showed a powered wheelchair was delivered to the facility for the resident, but the resident’s medical record, including nursing, rehab, social services progress notes, and inventory sheets from the delivery date through early June, lacked documented evidence that the wheelchair was received by the resident. A wheelchair and seating device assessment documented that the resident on an electric wheelchair demonstrated safe operation of the wheelchair, but progress notes from early June through early July did not document that staff provided education on how to use the powered wheelchair. The resident was later discharged home and re-admitted. During observations in November, the resident was seen in her room sitting in the powered wheelchair and stated that the unit manager/RN and the technician who delivered the wheelchair provided education on the day it was delivered, though she could not recall the exact delivery date and said that was the first time she used an electric wheelchair. In a face-to-face interview, the unit manager/RN stated she provided education during the wheelchair assessment and acknowledged it was an oversight that the education was not documented in the resident’s medical record; she also stated she could not remember the delivery date and did not see documentation showing when nursing recorded the wheelchair delivery.
Failure to Report Injury of Unknown Origin and Resident Altercation
Penalty
Summary
Facility staff failed to report an injury of unknown origin involving one resident to the Administrator in accordance with the facility’s abuse policy. The resident had diagnoses including dementia, Alzheimer’s dementia, major depressive disorder, cognitive communication deficit, restlessness and agitation, and unspecified psychosis, and was documented as having severely impaired cognition and a history of physical and verbal behavioral symptoms toward others. The resident was also on a 1:1 order and was receiving psychotropic medications, including risperidone and divalproex, as well as clopidogrel with monitoring for bleeding, bruising, and discoloration. The resident’s representative observed discoloration below the resident’s left eye while visiting and asked staff whether anything had happened. The assigned CNA/1:1 monitor stated he did not know of any incident, and the charge nurse stated she was not aware of any incident and would let the unit manager know. The representative reported that she received no follow-up for several days and later reported the injury to the unit manager. The record contained no documented evidence that the charge nurse reported the injury to other facility staff, and the unit manager was first informed by the resident’s representative. Facility staff also failed to report a resident-to-resident altercation involving the same resident and another resident to the Administrator and to outside officials within the required timelines. Staff accounts described one resident stepping on the other resident’s foot, after which the second resident reacted by hitting at the first resident; staff intervened and separated them. The CNA assigned to the resident stated he did not report the incident because he did not see physical contact and believed the charge nurse would report it, while the charge nurse stated she did not report it because she did not see the actual incident and did not see injuries. The investigation record showed no evidence that the altercation was reported to the Administrator at the time it occurred, and the Administrator did not report it to the State Survey Agency, Adult Protective Services, and the Metropolitan Police Department until several days later.
Failure to Develop and Implement Comprehensive Care Plans for Resident Needs
Penalty
Summary
Facility staff failed to develop and implement comprehensive care plans for two residents with specific needs. One resident, admitted with diagnoses including major depression, substance abuse, and muscle weakness, consistently refused to allow nursing staff to clean his room, nightstand, or closet, and would not permit staff to make his bed or change his linen. Despite these ongoing refusals, there was no documented care plan outlining how staff should address or manage the resident's refusals regarding room cleanliness and personal space. Staff interviews confirmed that the resident's preferences were not addressed in the care plan, and the facility's protocol for daily cleaning was not followed for this resident due to his refusals. Another resident, admitted with a history of falls, muscle weakness, obesity, and a stage 3 sacral pressure ulcer, was totally dependent on staff for activities of daily living and mobility. This resident required the use of a mechanical lift and assistance from at least two staff members for transfers out of bed. However, a review of the care plan revealed that it did not address the use of a mechanical lift for transfers. Staff interviews confirmed that the mechanical lift was used for this resident, but this intervention was not documented in the care plan.
Failure to Maintain Clean, Comfortable, and Homelike Resident Environments
Penalty
Summary
Facility staff failed to provide a safe, clean, and homelike environment for four residents, as evidenced by multiple observations of unsanitary and uncomfortable living conditions. In several rooms, floors were found dirty, covered with debris, sticky substances, and wheelchair tire marks. Some rooms had flies present, and there were instances of foul odors, particularly of urine, detectable from the doorway. Additionally, clutter such as boxes, bins, and personal belongings were piled around beds, creating tripping hazards, and some beds were observed without linens. One resident, who was cognitively intact and dependent on staff for most activities of daily living, reported issues with receiving clean linens and assistance with room cleaning. Another resident, with moderate cognitive impairment and significant physical limitations, was found in a room with a strong urine odor, flies, and a sticky, dirty floor. A third resident, also cognitively intact but physically limited, had a bare mattress, cluttered surroundings, and a dirty floor, with staff acknowledging a shortage of linens and uncertainty about when cleaning could occur. A fourth resident's room was observed with a sticky, dirt-stained floor, foul odor, and personal belongings scattered on and around the bed, including trash bags and an empty urinal on the floor. Staff interviews revealed a lack of awareness about the room's condition and indicated that cleaning was dependent on the resident's presence and willingness to allow environmental services staff to enter. These findings demonstrate a pattern of inaction and insufficient attention to maintaining a clean, comfortable, and homelike environment for residents.
Failure to Investigate Resident Grievance of Rough Handling During ADL Care
Penalty
Summary
Facility staff failed to properly investigate a grievance filed by a resident who reported being handled roughly by an aide during activities of daily living (ADL) care. The resident, who had chronic respiratory failure, malignant neoplasm of the lower gum and mouth, and dysphagia, was cognitively intact and able to communicate his concerns. The grievance form documented that the resident felt the aide was in a hurry and that the ADL care was performed simultaneously with trach care by a respiratory therapist, which the resident described as overwhelming. The facility's grievance policy required investigation and resolution of grievances within 72 hours, including steps to investigate, a summary of findings, and any corrective actions. Despite these requirements, there was no evidence that the facility attempted to identify or interview the aide involved or the respiratory therapist who was present during the incident. Staff interviews confirmed that no effort was made to determine which aide was involved or to gather statements from those present. Instead, the response was limited to reassuring the resident and providing general staff education, without a thorough investigation into the specific incident as required by policy.
Failure to Prevent Resident-to-Resident Altercation Resulting in Injury
Penalty
Summary
Facility staff failed to provide adequate supervision and intervention to prevent an altercation between two residents, resulting in one resident sustaining a fractured left forearm. One resident, who had a history of paranoid schizophrenia, severe cognitive impairment, and documented aggressive behaviors, was not administered his prescribed PRN anxiety medication for five days, including the day of the incident. During this period, the resident exhibited escalating physical and verbal aggression, including threats and attempts to harm staff and other residents, as documented in nursing notes. The incident occurred in the facility's courtyard, where the aggressive resident picked up a piece of plastic smoke equipment and struck another resident on the arm. The staff member assigned to supervise the courtyard, a smoking aide, reported that she was unable to reach the residents in time to prevent the altercation. The smoking aide's role was primarily to supervise safe smoking, and she indicated that unit managers or security were called for aggressive behaviors, but this intervention was not timely enough to prevent the incident. The resident who was struck had a medical history including COPD, HIV, chronic hepatitis C, and moderate cognitive impairment. Following the altercation, she reported pain in her left forearm, which was later diagnosed as a fracture of the distal ulna and radius. The incident report and medical records confirm that the injury was a direct result of the altercation, and that the lack of supervision and failure to administer prescribed medication contributed to the escalation of aggressive behavior leading to the injury.
Failure to Timely Report Abuse, Neglect, and Unusual Incidents
Penalty
Summary
Facility staff failed to implement their own written policies and procedures for timely reporting of abuse, neglect, or unusual incidents for three residents. The facility's policy requires immediate reporting of suspected abuse, neglect, exploitation, or misappropriation of resident property to the Administrator and appropriate agencies, with specific timeframes: within 2 hours for incidents involving abuse or serious bodily injury, and within 24 hours for other allegations. However, in three separate cases, staff did not notify the State Agency within the required timeframes. In the first case, two residents were involved in a resident-to-resident altercation. One resident, with a history of chronic heart failure, schizophrenia, dementia, and depression, attacked his roommate with a chair, resulting in the roommate sustaining facial bruises, lacerations, and contusions, and requiring hospital evaluation. The incident occurred late at night, and both residents' medical records documented the altercation and subsequent medical interventions. Despite the severity of the incident and resulting harm, the facility did not notify the State Agency within the mandated two-hour window. Staff interviews confirmed uncertainty about the delay, and the responsible supervisor was no longer employed at the facility. In the second case, a resident with multiple fractures, substance use history, and chronic pain was found unresponsive and administered Naloxone for a suspected drug overdose. The incident occurred on a weekend, and the report to the State Agency was not submitted until two days later, outside the required timeframe. The unit manager acknowledged that the facility's policy was not followed, attributing the delay to the incident occurring over the weekend and the report being sent on the next business day.
Failure to Timely Report Allegations of Abuse, Neglect, and Unusual Incidents
Penalty
Summary
Facility staff failed to notify the State Agency of allegations of abuse or neglect for four residents, as required by policy and regulation. In one incident, two residents were involved in a resident-to-resident altercation resulting in injuries, including bruising, lacerations, and a hospital transfer. Documentation showed that the incident was not reported to the State Agency within the required two-hour timeframe, despite clear evidence of physical harm and police involvement. Staff interviews revealed uncertainty about the reporting process and a lack of clarity regarding responsibility for timely notification. In another case, a resident was found unresponsive and was administered Naloxone by staff, indicating a possible drug overdose. The incident occurred on a weekend, but the report to the State Agency was not submitted until two days later, outside the required reporting window. Staff acknowledged that the facility policy was not followed, attributing the delay to the incident occurring over the weekend and the report being submitted when management returned. A further deficiency was identified when a resident alleged being handled roughly by a CNA during ADL care. The complaint was documented, and staff provided reassurance and education, but did not consider the allegation as abuse and therefore did not report it to the State Agency or conduct a full investigation. Staff interviews confirmed that they did not attempt to identify the aide involved or interview other witnesses, and did not view the resident's report as meeting the threshold for abuse reporting.
Failure to Implement Fall Prevention Care Plan Intervention
Penalty
Summary
Facility staff failed to implement a comprehensive, person-centered care plan for a resident with a history of repeated falls, muscle weakness, and significant medical conditions including a displaced femoral neck fracture and hemiplegia. The resident's care plan, initiated on 03/27/24, included specific interventions such as keeping the bed in the lowest position to mitigate fall risk. Despite this, observations revealed that the resident's bed was found elevated at its highest position during a survey, contrary to the care plan intervention. The resident experienced multiple falls during their stay, including incidents that resulted in a laceration requiring hospital transfer and a subsequent acute right femoral neck fracture. Documentation and staff interviews confirmed that the intervention to keep the bed in the lowest position was not consistently implemented, directly contributing to the resident's ongoing risk and actual occurrences of falls.
Failure to Follow Physician's Order for Narcotic Pain Medication
Penalty
Summary
Facility staff failed to follow a physician's order regarding the administration of narcotic pain medication for a resident with multiple diagnoses, including pain and malignant neoplasm of the left breast. The resident had an active physician's order for Hydromorphone 2 mg, to be given as one tablet by mouth every four hours as needed for chronic pain. During a narcotic count, it was discovered that the resident was administered two tablets of Hydromorphone 2 mg at one time, instead of the ordered one tablet. Review of the medication administration record and the resident's physician orders confirmed that there was no order for the administration of two tablets at once. When questioned, the LPN who administered the medication was unable to provide an explanation for the deviation from the physician's order. The resident did not experience any harm or adverse effects as a result of receiving the incorrect dosage.
Failure to Provide Required Abuse Education Following Allegation
Penalty
Summary
Facility staff failed to provide ongoing in-service training related to abuse, neglect, and exploitation for an employee involved in an allegation of abuse, as required by facility policy. The policy specifies that any employee suspended during an abuse investigation must receive education on abuse prior to returning to work. In this case, a CNA was suspended following an allegation by a resident with dementia, aphasia, and seizure disorder, who accused the CNA of abuse. Documentation review revealed no evidence that the CNA received the required education before returning to work. Interviews with the CNA and the facility educator confirmed that the CNA did not recall receiving any education on abuse prior to resuming duties. The educator acknowledged that education should be provided before the staff member returns to work after suspension during an investigation. The lack of documented evidence and staff recollection indicates that the facility did not follow its own policy for in-service training in response to an abuse allegation.
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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.
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Nursing homes near Washington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bridgepoint Subacute And Rehab Capitol Hill | 1.1 mi | ★★★★★ | 7 | 0 |
| Inspire Rehabilitation And Health Center Llc | 2 mi | ★★★★★ | 17 | 0 |
| Washington Ctr For Aging Svcs | 2.3 mi | ★★★★★ | 2 | 0 |
| Jeanne Jugan Residence | 2.6 mi | ★★★★★ | 0 | 0 |
| Stoddard Baptist Nursing Home | 2.8 mi | ★★★★★ | 2 | 0 |
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