Citations in District Of Columbia
Statistics, citations and compliance trends for long-term care facilities in District Of Columbia.
Statistics for District Of Columbia (Last 12 Months)
Financial Impact (Last 12 Months)
Latest citations in District Of Columbia
Failure to Order Wound Consult and Treatment for New Buttock Blister: An RN observed an open blister on a resident’s right buttock during incontinent care and documented that the MD was notified and a wound consult and Xeroform treatment were obtained, but the orders were not found in the chart. Staff did not document use of the facility’s skin assessment tool or follow the pressure ulcer/injury policy, and within days the blister was documented as a Stage 3 pressure injury.
Incomplete investigation of missing controlled medication: Facility staff did not complete a thorough investigation of a missing Tramadol bubble pack belonging to a resident with a PEG tube, Stage 4 pressure ulcer, anoxic brain damage, epilepsy, and muscle weakness. The FRI and final report noted the nurse involved was interviewed, but there was no documented evidence that the nurse was off duty during the investigation period or that staff investigated inconsistencies between the controlled drug record and the physician’s order.
Care Plan Not Updated for New Skin Abrasions: A resident with a stage 3 sacral PI, surgical wound, and high Braden risk developed new right knee and left medial lower leg abrasions, but the care plan was not revised to include goals and interventions for those new skin issues. The record showed the abrasions were later noted as slowly improving, and the DON acknowledged that the care plan had not been updated.
A resident with cerebral infarction, muscle weakness, and Stage 3 and Stage 4 pressure ulcers was found with wet, stained gown and linens and dry stool on his thigh, while staff gave conflicting accounts of when care was last provided. The resident’s daughter said she often found him needing care, and a CNA said he was not repositioned when first seen in the morning and was only turned after ADL care began later, despite a care plan calling for repositioning at least every 2 hours.
A resident with a tracheostomy, chronic respiratory failure, aphasia, and severe ADL dependence was sent to a podiatry appointment without a nurse or trach supplies. Records, family report, and staff interview showed the resident traveled with transportation only, while the podiatry office was not notified and was unprepared to manage suctioning needs if needed.
A CNA provided wound care outside his scope for a resident with cerebral infarction, muscle weakness, and stage 3/4 pressure ulcers. The CNA reportedly used the same gloves to clean fecal matter and remove a soiled sacral dressing, then pulled on stuck packing without moistening it, sprayed wound cleanser on it, and caused bleeding. Staff stated wound care was not within CNA scope, and the complainant reported the CNA had changed the sacral dressing on multiple occasions.
Failure to Order Wound Consult and Treatment for New Buttock Blister
Penalty
Summary
Facility staff failed to order a wound consult and treatment for a resident who was observed with an open blister on the right buttock, and the area later progressed to a Stage 3 pressure ulcer. The resident had diagnoses including a pre-existing Stage 4 sacral pressure ulcer, type 2 diabetes mellitus, metabolic encephalopathy, generalized muscle weakness, and need for gastrostomy care. Physician orders included inspecting the skin of all admissions, evaluating and treating any wound that developed during the stay, and turning and repositioning every 2 hours. On 02/04/26, an RN documented during incontinent care that she noticed an open blister on the right gluteal area, cleansed the wound, applied Xeroform dressing, and obtained a wound consult, with the physician reportedly responding with the same instructions. However, review of the physician orders, MAR, and TAR for February 2026 showed no documented evidence that the Xeroform treatment or wound consult were actually ordered. Review of progress notes from 02/04/26 through 02/09/26 also showed no documented evidence that staff used the facility's pressure ulcer/injury assessment tool or followed the policy steps for assessing and documenting the skin alteration. A wound assessment on 02/09/26 documented the right buttock wound as a Stage 3 pressure ulcer, acquired in house, measuring 2.30 cm by 1.00 cm by 0.30 cm. The wound care nurse practitioner later stated that the resident was being seen weekly for multiple pressure injuries, including the sacral wound present on admission, a facility-acquired right buttock wound that started as a Stage 3, and a left heel Stage 2 injury. He stated he was not made aware of the right buttock blister before 02/09/26 and that a blister could progress to a Stage 3 or Stage 4 pressure ulcer within 5 days in a resident with fragile skin, moisture, lack of proper treatment, and shearing.
Incomplete investigation of missing controlled medication
Penalty
Summary
Facility staff failed to complete a thorough investigation of a facility-reported incident involving the missing Tramadol HCl oral tablet 50 mg bubble pack belonging to Resident #38. Resident #38 was admitted with diagnoses including Stage 4 pressure ulcer of the sacral region, anoxic brain damage, epilepsy, and muscle weakness, and had a physician’s order for Tramadol 50 mg via PEG tube every 8 hours for moderate to severe pain. The resident’s MARs for August and September 2025 showed the medication was documented as administered at 2:00 AM, 10:00 AM, and 6:00 PM from 08/21/25 through 09/09/25. The facility’s initial FRI stated that the Tramadol bubble pack was missing and that the investigation was ongoing, and the final report later stated that the nurse involved was interviewed and could not explain the missing narcotics. However, review of the investigation documents showed no documented evidence that Employee #30 did not work at the facility during the investigation period, and no documented evidence that staff investigated why the times and dosages on the Controlled Drug Receipt/Record Disposition Form were inconsistent with the physician’s order. The DON acknowledged the findings during interview.
Care Plan Not Updated for New Skin Abrasions
Penalty
Summary
Facility staff failed to revise and update Resident #112’s care plan after she developed new right knee and left medial lower leg abrasions. The resident was admitted with multiple diagnoses including pressure ulcer of the sacral region, encephalopathy, chronic respiratory failure with hypoxia, and iron deficiency anemia. On admission, she was documented as high risk for pressure injury with a Braden Scale score of 11, and her record also showed a stage 3 sacral pressure injury and a midline abdominal surgical wound present on admission. Care plan focus areas were initiated for the sacral pressure ulcer and the abdominal wound, but no updated care plan focus area was documented for the new abrasions identified later. The medical record showed that the right knee and left medial lower leg abrasions were first documented as new skin findings, and later notes described them as slowly improving in epithelium. Despite these new wounds and ongoing skin changes, the care plan was not updated to include goals and interventions for the abrasions. During interview, the DON reviewed the care plan and acknowledged the findings, stating that updating the care plan was up to the unit managers, supervisors, and the interdisciplinary team.
Incontinent Care and Repositioning Not Provided Timely
Penalty
Summary
Resident 43, who had a history of cerebral infarction, muscle weakness, and Stage 3 and Stage 4 pressure ulcers, was found lying in bed with light red wet spots on his gown and bed linen and dry, brown stool on his left thigh. The resident was dependent on staff for activities of daily living, always incontinent of bowel, had a urinary catheter, and had one Stage 3 and one Stage 4 pressure wound. During the observation, the resident’s daughter stated she often found her father needing care. An assigned RN stated the wetness and staining may have been caused by spilled medication, while an assigned CNA stated he had made rounds at 7:00 AM and the bed was clean at that time, then said he was there to provide care. The resident also had a care plan directing assistance with turning and repositioning at least every 2 hours or more often as needed because of pressure ulcers related to chronic respiratory failure, chronic kidney disease, diabetes, and immobility. The daughter reported that staff did not turn and reposition her father for hours and that she sometimes turned him herself if staff had not done so within 3 hours. Multiple observations showed the resident lying supine at 4:50 AM, 8:50 AM, 9:55 AM, and 10:20 AM, and an assigned night-shift CNA stated he had just completed care, including a bed bath. An assigned dayshift CNA stated he first observed the resident around 7:00 AM but did not reposition him, and that he repositioned the resident only after providing ADL care beginning around 10:30 AM.
Resident With Tracheostomy Sent to Appointment Without Nursing Accompaniment
Penalty
Summary
The facility failed to ensure that a resident with a tracheostomy was accompanied by nursing staff during a podiatry appointment. Resident #43 was admitted with diagnoses including aphasia, chronic respiratory failure, tracheostomy, and muscle weakness. A physician order directed trach collar oxygen at 28% and trach and suction care by a respiratory therapist and a nurse every shift. The quarterly MDS coded the resident as requiring maximum staff assistance with all ADLs, tracheostomy care, suctioning, and respiratory services. A nursing note documented that the resident went to the podiatry appointment and returned by transportation. A complaint submitted to the State Agency stated that the resident was transported without accompanying supervision or support from facility staff, and that the podiatry office was not prepared to manage a potential airway emergency because there was no prior notification or suction equipment available. During interview, the unit manager stated the resident was sent without a nurse or tracheotomy supplies and that this was an oversight because staff thought the transportation company would provide supervision during the appointment. The complainant also reported that the podiatry office called to express concern that the resident had been sent without facility staff or tracheostomy supplies.
CNA Performed Wound Care Outside Scope and Used Improper Dressing Removal Technique
Penalty
Summary
The facility failed to ensure that Employee #22, a CNA, stayed within scope of practice and used proper wound care technique for Resident #43, who had a history of cerebral infarction, muscle weakness, chronic respiratory failure, chronic kidney disease, diabetes, and stage 3 and stage 4 pressure ulcers. The resident’s care plan directed staff to administer ordered treatments and monitor effectiveness, and a physician order required the sacral wound to be cleansed, packed with collagen and hydrogel-moistened rolled gauze, and covered with a bordered dressing daily and as needed. A wound assessment documented a stage 4 sacral wound measuring 4.00 cm by 6.00 cm by 2.90 cm. A complaint alleged that during personal care, the CNA used the same gloves to clean fecal matter and then remove the resident’s old wound dressing, attempted to pull out stuck packing without moistening it, sprayed wound-cleaning solution on the dressing, and immediately pulled again, causing the resident’s skin to bleed. During interviews, staff stated that wound care was not within the CNA’s scope of practice and that the CNA should only notify the nurse if a wound was soiled or came off during bathing. The complainant and the DON reported that the CNA had changed the sacral dressing on several occasions, removed a stool-soiled dressing, cleaned the area, replaced it with clean gauze, and secured it with tape.
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Compliance trends in District Of Columbia
Data through Apr 2026Comparisons below measure the most recent period May 2025 – Apr 2026 against the prior period May 2024 – Apr 2025 (two equal 12-month windows). The most recent 1 months are excluded because CMS is still publishing them.
Top tags by month · last 24 months
dashed = still reportingMonthly citation counts for the 5 most-cited tags. The dashed tail is the 1-month reporting lag.
Care domain movers
Citations grouped into CFR care domains — F-tags by their §483 regulatory section (CMS State Operations Manual, Appendix PP) — measured as a rate per 100 inspections: May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025. Share is the domain's portion of citations this period; avg severity is the mean scope/severity letter and immediate jeopardy the percentage cited at J–L, both over the current period. Domains with at least 20 citations in both periods are shown; the sparkline tracks the last 12 months (left = oldest).
Immediate jeopardies · this period
Citations at the most serious scope/severity — J–L, immediate jeopardy, residents placed at risk of serious harm or death — over May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025. "Surveys with an IJ" counts distinct health inspections that had at least one.
Survey activity · by month
faded/dashed = still reportingCitations each month split into complaint-driven (unscheduled, triggered by grievances) vs standard surveys — bars, left axis — with the number of inspections as a line on the right axis. Rising inspections signal more scrutiny; a rising complaint share means more off-cycle surveys. The most recent 1 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025; the most recent 1 months are still being reported (dashed).
Penalties · by month
faded = still reportingTotal civil money penalty dollars imposed on the state's facilities each month — how hard the state is enforcing. The most recent 1 months are still being reported, and penalties often lag citations by several months.
Emerging tags
Tags that weren't established last period but surged — an early warning, distinct from movers (which track already-common tags). Criteria: fewer than 20 citations in the prior period, but at least 10 this period and 2.5× their prior volume. The sparkline shows monthly counts over the last 12 months (left = oldest).
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release July 29, 2026) and official state health department websites — never guesswork.
Some of the Latest Corrective Actions taken by Facilities in District Of Columbia
- Revised the resident’s care plan to increase monitoring of location/whereabouts to every 30 minutes (J - F0689 - DC)
- Implemented a systemic change to increase monitoring for residents at risk for elopement/exit-seeking from every 1 hour to every 30 minutes (J - F0689 - DC)
- Applied wanderguards for residents identified as elopement risk and established orders to check placement and functioning every shift (J - F0689 - DC)
- Installed keypads on pantry doors so they could not be opened unless the code was entered (J - F0689 - DC)
- Re-educated dining staff on locking the pantry door when no one was in the pantry (J - F0689 - DC)
- Re-educated employees on ensuring doors that should not be left open/unlocked were properly closed and locked after entry/exit (J - F0689 - DC)
- Educated charge nurses on checking wanderguard placement and functioning (including methods to verify function) and documenting the wanderguard location during checks (J - F0689 - DC)
- Educated nursing staff on increasing monitoring for residents at risk for elopement from every hour to every 30 minutes (J - F0689 - DC)
Elopement from Memory Care Unit Due to Inadequate Supervision and Open Pantry Door
Penalty
Summary
Facility staff failed to ensure adequate supervision and adherence to a person-centered care plan for a resident identified as an elopement risk, resulting in the resident eloping from a secure Memory Care unit. The resident had multiple diagnoses including dementia, congestive heart failure, hypertension, and age-related macular degeneration, and had physician orders for behavioral monitoring related to elopement and for use of a wander guard (code alert) with checks for placement and functioning every shift. An elopement risk screening showed a high-risk score, and the care plan documented that the resident was at risk for elopement related to poor safety awareness, hoovered around the main exit door with a friend waiting for someone to allow them to leave, and was on high alert for elopement. Care plan interventions included following the community elopement evaluation and monitoring process, keeping the resident safe on the locked unit, replacing the wander guard bracelet as soon as it was known the resident had removed it, and that nursing would check and know the whereabouts of the resident at all times. On the day of the incident, documentation showed that the wander guard system had been checked and passed, and a safety checklist entry indicated that the resident was observed in her room at 11:00 AM. However, video recordings later showed that at approximately 11:40 AM, a food service manager entered the first-floor pantry near the Memory Care unit entry/exit doors and left the pantry door wide open. Shortly thereafter, the resident approached the dining room doors near the main entry/exit doors of the unit and hovered there while a food pantry worker was inside the pantry. The pantry worker exited through the dining room side pantry door, and the resident then opened the dining room doors, entered the dining room, and proceeded into the pantry. The video further showed that the resident exited the still-open pantry door located outside of the Memory Care unit, pushing her rolling walker, without staff knowledge. The resident then walked past two security officers in the main lobby, now without a walker and holding a jacket and a bag, and proceeded outside the facility’s main entry/exit doors. A nurse supervisor was later called by security to identify a person outside with a bag and recognized the individual as the resident from the Memory Care unit. The resident was resisting returning inside and was brought back with assistance from nursing staff, after which a head-to-toe assessment was completed with no abnormalities noted. Interviews revealed that an LPN had previously placed and tested a wander guard bracelet on the resident, but after the incident staff discovered that the resident had obtained scissors and used them to cut off the bracelet, hiding the scissors and cut bracelet in her pocketbook. The DON acknowledged that the care plan intervention stating that nursing would check and know the whereabouts of the resident at all times had been interpreted as hourly checks, and could not clearly explain what “at all times” meant beyond stating that staff frequently had eyes on the resident. The evidence showed that staff did not check and know the resident’s whereabouts at all times, and that the resident was able to elope from the secured unit without staff awareness, leading to identification of an Immediate Jeopardy at F689. An Immediate Jeopardy (IJ-J) to resident health and safety was identified at 42 CFR 483.25, F689, on 03/18/26 at 1:12 PM based on these failures in supervision and implementation of the care plan, including failure to ensure the resident’s whereabouts were known at all times and failure to prevent elopement from a secure area.
Removal Plan
- Resident #1 was brought safely back into the facility by the Supervisor and first floor staff after being observed outside unsupervised.
- Upon re-entering the first floor, Resident #1 received a head-to-toe assessment by the charge nurse and supervisor and no abnormalities were noted.
- Resident #1's care plan was revised to increase monitoring of her location/whereabouts to every 30 minutes.
- Resident #1 is utilizing a wanderguard bracelet that will trigger both doors to the memory care unit.
- Resident #1 no longer has access to scissors used to remove the wanderguard; scissors were removed.
- The charge nurse notified Resident #1's legal guardian about the incident and that the resident cannot have access to scissors.
- Dining staff were educated by the Dining Manager on the importance of locking the pantry door when no one is in the pantry.
- Maintenance made the pantry door used for elopement inoperable so no one could enter/exit through that door; pantry access remained available via the dining room door for emergencies.
- Keypads were installed on both pantry doors so they cannot be opened unless the code is entered.
- A 100% audit of all residents at risk for elopement was conducted to ensure behavior monitoring for wandering/exit-seeking was in place.
- All residents identified as elopement risk and exit-seeking were to have care plans updated to reflect increased monitoring every 30 minutes.
- All residents identified as elopement risk were to have a wanderguard applied with an order to check placement and functioning every shift.
- All residents identified as elopement risk were to have a care plan identifying elopement risk and person-centered interventions to prevent unaccompanied leaving.
- All residents identified as elopement risk were to have orders in place to check wanderguards for placement and functioning every shift.
- All employees were to be re-educated on ensuring doors that should not be left open/unlocked are properly closed and locked after entry/exit.
- All charge nurses were to be re-educated on checking wanderguard placement and functioning, including methods to verify function.
- All nursing staff were to be educated on increasing monitoring for residents at risk for elopement from every hour to every 30 minutes.
- All charge nurses were to be educated on documenting the location of the resident's wanderguard when checking placement and functioning.
- Facility implemented a systemic change to increase monitoring for residents at risk for elopement and exit-seeking from every 1 hour to every 30 minutes.
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