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
A facility failed to keep resident rooms within the required temperature range after the HVAC system was shut off for repair. Four residents with respiratory conditions and/or O2 therapy were found in rooms measuring 85 to 90 degrees, and each stated that the rooms were hot or uncomfortable. Maintenance staff said contractors were working on the HVAC, and the admin said she was unaware the system had been turned off or that rooms were excessively warm.
Failure to prevent and manage pressure ulcers: Two residents developed pressure injuries that were first identified at advanced stages. One resident with multiple mobility and nutrition-related diagnoses had conflicting admission skin documentation and later was found with an unstageable left buttock pressure ulcer, while staff and the wound physician stated the wound was first assessed later and not clearly documented earlier. Another resident with dementia, DM2, HTN, incontinence, and limited mobility was admitted with intact skin but later developed a sacral opening that progressed to a stage 3 pressure wound.
A resident with pain orders and moderately impaired cognition had an oxycodone blister pack found tampered with, taped closed, and partially replaced with loratadine tablets. Staff who completed the narcotic count did not inspect the pack for tampering when signing off the count, and another LPN failed to sign the narcotic logbook with the outgoing nurse during a controlled substance count.
An LPN involved in a missing narcotics incident returned from suspension and worked a shift without documented education on drug diversion and narcotics reconciliation. The incident involved an Oxycodone IR 5 mg pack that appeared tampered with, with Loratadine tablets substituted for Oxycodone and five tablets missing. The DON and Staff Development/Educator acknowledged the education should have been completed before the LPN resumed work.
Failure to provide required discharge notification: A resident with arthritis, osteoporosis, DVT, UTI, and a hx of falls was discharged without written notice to the resident and rep at least 30 days in advance. Staff interviews showed the nursing team was not aware of the discharge until the day it occurred, the social worker did not follow the usual discharge process, and there was no documented MD discharge order in the record.
A resident admitted with psychosis, anxiety, and major depressive disorder had an incomplete PASARR I that failed to identify a history of serious mental illness or document whether a PASARR II referral was needed. The care plan stated Level II PASARR was not needed, and the DSW later acknowledged the PASARR I was completed incorrectly and that a new PASARR I and PASARR II referral would be submitted because of the resident's mental health diagnoses.
Excessive resident room temperatures during HVAC outage
Penalty
Summary
The facility failed to maintain a safe and comfortable environment by allowing resident room temperatures to rise above the regulatory range of 71 to 81 degrees Fahrenheit after the HVAC system was turned off for repair. Surveyors observed that the ambient temperatures in the rooms of four residents with respiratory diagnoses and/or oxygen therapy ranged from 85 to 90 degrees Fahrenheit during the day, while the weather in the District of Columbia was also hot, ranging between 73 and 90 degrees Fahrenheit. One resident with a history of pulmonary embolism and oxygen use was observed lying in bed and stated that her room was hot; her room temperature was measured at 90 degrees Fahrenheit. Another resident with COPD, cardiac defibrillator, and generalized weakness was also observed in bed and stated that she was not comfortable because it was hot in her room; her room temperature was measured at 88.2 degrees Fahrenheit. A third resident with chronic respiratory failure with hypoxia, obstructive sleep apnea, asthma, paraplegia, and morbid obesity was observed sweating and stated that it was very hot in the room and that she could not sleep the night before; her room temperature was measured at 88.2 degrees Fahrenheit. A fourth resident with COPD, chronic respiratory failure with hypoxia, and oxygen therapy was observed in bed and stated, "I'm hot." Her room temperature was measured at 85 degrees Fahrenheit. During interviews, maintenance staff stated that contractors were on-site working on the HVAC system and that the system had been turned off that morning to repair a leaking pipe. The administrator stated she was not aware the HVAC system had been turned off or that resident rooms had excessive temperatures.
Failure to Prevent and Properly Manage Pressure Ulcers
Penalty
Summary
Facility staff failed to provide necessary treatment and services to prevent the development and progression of pressure ulcers for two residents who developed wounds that were first identified at advanced stages. One resident was admitted with multiple diagnoses including fracture of the first lumbar vertebra, gait and mobility abnormalities, generalized muscle weakness, severe protein-calorie malnutrition, and need for assistance with personal care. On admission, nursing documentation described redness and dryness in the perineal, right groin, and sacral areas, and the resident had a Braden score of 14, indicating moderate risk for pressure ulcer development. The record also included conflicting skin documentation, with one admission skin evaluation noting a sacral ulcer with redness/moisture-associated skin damage and stage 2 pressure injury, while later staff interviews stated the resident had no open areas and that the stage 2 entry was documented in error. The resident’s record later showed a history and physical documenting a stage 1 pressure ulcer in the sacral region with an offloading protocol, barrier cream, wound consult, and repositioning every 2 hours. However, the medical record lacked documented evidence of the resident’s left buttock wound before a skin evaluation on 04/23/26 that identified a left buttock deep tissue injury that was unstageable, measuring 8.0 cm by 2.0 cm, with slough and dermis tissue. A wound care physician later stated that 04/23/26 was the first time he assessed the resident’s wounds and that staff told him the resident had been admitted with three wounds, including an unstageable sacral pressure ulcer and a left buttock pressure ulcer. The DON stated staff did not make her aware of the left buttock unstageable wound. A second resident was admitted from home with dementia, diabetes mellitus type 2, and hypertension. Admission documentation stated the skin was intact and no pressure injuries were noted, although the resident had pink scar tissue on the coccyx and right lateral ankle and was at risk due to unsteady gait, incontinence, and limited mobility. On 04/28/26, nursing documented a sacral opening measuring 0.2 cm by 0.3 cm, and the wound was later evaluated as a stage 3 pressure wound of the sacrum. The resident’s care plan was updated to reflect the open sacral area related to limited mobility and incontinence, and wound treatment orders were entered after the opening was identified.
Controlled Medication Reconciliation Not Followed
Penalty
Summary
Facility staff failed to ensure the accurate reconciliation of controlled medications for a resident admitted with metabolic encephalopathy, muscle weakness, and chronic kidney disease. The resident had physician orders for oxycodone 5 mg every 4 hours as needed for moderate to severe pain, acetaminophen 650 mg every 4 hours as needed for pain, and gabapentin 200 mg daily for pain. The resident’s MDS showed a BIMS score of 10, indicating moderately impaired cognitive status, and documented occasional pain rated 6 out of 10 with an opioid medication ordered. During review of a facility-reported incident, staff found that an oxycodone blister pack had been tampered with and taped closed, and the oxycodone tablets had been replaced with loratadine tablets of similar appearance. Five tablets were missing in total. Interviews showed that the nurses who completed the narcotic count did not inspect the medication card or blister pack for tampering when they signed off that the count was correct, and one nurse stated that turning the package over to inspect it was not typically done. In a separate observation, an LPN on another unit had not signed the narcotic logbook at the start of the shift with the outgoing nurse, despite the facility’s controlled substances policy requiring the oncoming and offgoing nurses to count controlled medications together and document discrepancies.
LPN Returned After Narcotics Incident Without Required Education
Penalty
Summary
Facility staff failed to implement an effective training program for existing staff when Employee #6, an LPN involved in a reported incident of missing narcotics, returned to work after suspension without documented education on drug diversion and narcotics reconciliation. A Facility Reported Incident documented a possible narcotics variance, and the follow-up report stated that Employee #6 found an Oxycodone IR 5 mg tablet difficult to remove from the pack, discovered the back of the pack had been tampered with and taped closed with clear tape, and found the Oxycodone tablet had been replaced with Loratadine tablets of similar color, size, and shape. The report also stated that five tablets were missing in total. Review of the employee’s timecard showed she worked the night shift after suspension, and review of education records showed no documented evidence that she had completed or received the required drug diversion/narcotics reconciliation education before returning to work. The DON and Staff Development/Educator acknowledged that the employee should have received the education prior to restarting work after suspension.
Failure to Provide Required Discharge Notification
Penalty
Summary
The facility failed to notify Resident #195 and the resident representative in writing, and in a manner they understood, at least 30 days before discharge. Resident #195 was admitted with diagnoses including arthritis, osteoporosis, deep vein thrombosis, urinary tract infection, and a history of falls. A complaint intake received by the State Agency alleged that the facility was performing an unsafe discharge and that a discharge meeting was never held. During interviews, the Assistant Director of Nursing stated that staff did not know about the discharge until the afternoon of the discharge day, when the resident's son said he needed a wheelchair to take his mother home and reported that she had already been discharged. She stated the social worker did not follow the usual discharge process, including listing residents to be discharged and obtaining discharge orders in advance, and noted there was no documented physician discharge order in the resident's record. The Social Services Manager stated she did the discharge planning meeting with the resident, the son, and physical therapy on the day of discharge, but was unsure what information had been communicated earlier about the discharge plan or barriers to discharge, and acknowledged that the discharge planning meeting was not complete if other departments were unavailable.
Incomplete PASARR Screening and Delayed PASARR II Referral
Penalty
Summary
The facility failed to ensure that a resident's PASARR II referral was completed within 30 days of admission for Resident #150, who was admitted with diagnoses including Unspecified Psychosis, Anxiety Disorder, and Major Depressive Disorder. The resident's PASARR I form dated 04/09/26 did not capture a history of serious mental illness, was incomplete, and did not document whether a PASARR II referral was needed. A care plan dated 04/09/26 stated that Level II PASARR was not needed. During interview on 06/01/26, the Director of Social Work stated that the PASARR I form had been completed incorrectly and that she would complete another PASARR I and submit a PASARR II referral because of the resident's mental health diagnoses.
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Compliance trends in District Of Columbia
Data through May 2026Comparisons below measure the most recent period Jun 2025 – May 2026 against the prior period Jun 2024 – May 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.
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 Jun 2025 – May 2026 vs the prior period Jun 2024 – May 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. Jun 2025 – May 2026 vs the prior period Jun 2024 – May 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).
No tags meet the emerging criteria for this period — nothing rare is spiking right now.
Trusted data from CMS and state health departments
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