Citations in District Of Columbia
Comprehensive analysis of citations, statistics, 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
Two residents experienced head injuries due to inadequate accident prevention measures and supervision. One resident with mobility limitations and confusion was readmitted and left unattended in a bed that staff knew was stuck in a high position; the bed was not lowered or otherwise made safe before the resident attempted to get to a chair and fell, sustaining a forehead injury. Another resident with muscle weakness, hemiparesis, and moderate cognitive impairment, who required two‑person assist for showers, was turned toward a wall and grab bar in a small shower room; with staff hands slippery from soap, the resident struck his head on the wall/grab bar, causing forehead swelling. The CNA involved acknowledged the room was too small for two staff and did not initially report the fall to the nurse.
Surveyors found that survey results were not readily accessible to residents and families. A binder labeled “Survey Results” was stored behind the receptionist’s desk in the lobby, rather than in a public area. The receptionist reported that this binder is always kept behind the desk and is only given to individuals if they specifically request to view it, meaning survey results could not be examined without asking staff.
Staff did not develop or implement a comprehensive, person-centered care plan to address a resident’s documented egg allergy and preference for double portions at meals. The resident, who had multiple medical conditions including DM and ESRD and was cognitively intact, had a therapeutic diet order and clearly documented allergies and double-portion instructions on meal tickets. Despite this, the care plan did not include the egg allergy or double-portion preference, and the resident reported repeatedly receiving eggs and not receiving double portions, supported by photos of meal tickets and trays. The DON stated that care plans are implemented by clinical staff based on identified focus areas, and an RN unit manager confirmed that food allergies and preferences should be included in the comprehensive care plan.
Surveyors found that the facility failed to keep care plans current for two residents. One resident with multiple chronic conditions and documented ophthalmology visits, including recommended follow-up, did not have these visits or recommendations reflected in the care plan or progress notes. Another cognitively impaired, functionally dependent resident experienced an unwitnessed fall in her room, was found on the floor with a right elbow skin tear and later diagnosed with right femoral neck and ulnar fractures requiring surgery, yet the care plan was not updated to document the fall event itself, despite existing plans for the skin tear and femur fracture.
A dependent resident with severe cognitive impairment, hemiplegia, and bowel and bladder incontinence did not have any documented ADL care, including toileting, incontinence care, personal hygiene, mobility assistance, turning and repositioning, and hydration, during a night shift. The care plan required checks every two hours, toileting assistance, and pericare after each incontinent episode. CNA task records for that shift were blank for multiple required tasks, and there was no record of care refusal. Staff interviews revealed that the unit was short staffed, that CNAs are responsible for documenting care in the kiosk, and that the nursing supervisor oversees ensuring tasks are completed in the EMR, but no documentation existed to show the required care was provided.
Staff failed to follow physician orders for two residents, resulting in missed fall precautions and improper wound care. One resident with a history of falls and multiple medical conditions had physician orders and a care plan requiring floor mats on both sides of the bed and the bed in the lowest position when in bed, yet an observation found the resident in bed without floor mats, and staff were unaware or unsure of the floor mat requirement. Another resident with severe cognitive impairment and documented Stage 4 and unstageable pressure ulcers had specific wound care orders for the right heel and sacrogluteal areas, including cleansing with wound cleanser and applying zinc oxide to the periwound, but an LPN used normal saline instead of wound cleanser and did not apply zinc oxide to the sacrogluteal periwound, despite the DON confirming that wound cleanser was available and zinc oxide should have been used as ordered.
Facility staff did not ensure a resident received vision care in accordance with professional standards when they failed to arrange and document a recommended annual follow-up with an ophthalmologist. The resident, who had multiple medical conditions including presbyopia and dry eye syndrome, had an ophthalmology report directing a one-year follow-up, but records showed no evidence that this visit occurred and that the resident had not seen an ophthalmologist for several years. During the survey, the resident expressed a desire to see an ophthalmologist, and the DON was informed that the ordered follow-up had been missed.
Staff failed to protect a resident’s right to privacy in receiving mail when two personal Amazon packages were opened by staff before being given to the resident. The cognitively intact resident, with a history of obesity, type 2 DM, and CHF, reported that staff said they opened the packages because they thought they belonged to the facility. A recreation aide who delivers mail also described a separate incident in which a resident’s package was already open and she refused to deliver it, indicating that opened resident packages had occurred previously, although she could not recall which staff or resident were involved.
Surveyors identified widespread environmental and sanitation deficiencies affecting multiple resident rooms and kitchen areas, including soiled furniture surfaces, missing or damaged baseboards and ceiling tiles, loose or broken toilet handrails, clogged or broken hand-washing sinks, missing or broken soap dispensers, absence of hand soap and trash cans in some restrooms, and stained bedding and bedrails. In shared restroom and tub areas, a broken hot water faucet valve and slow sink drainage were noted. In the kitchen, damaged drywall, dust accumulation above clean utensil racks, an unclean backsplash at the three-compartment sink, significant grease buildup on cooking equipment, and a missing ceiling tile above the dishwashing area were observed and acknowledged by facility leadership.
Surveyors found that staff did not provide required written discharge notices, including bed-hold policy details and notifications to the Ombudsman and State Agency, for two residents who were transferred to the hospital. One resident with severe cognitive impairment and multiple medical conditions was sent to the ER after a fall with a head injury, and another cognitively intact resident with stroke, HTN, DM, and DVT was transferred to a hospital at the request of the resident and family. In both cases, record review showed no documentation of the mandated written discharge/transfer notice, and the Director of Social Work acknowledged that the standard discharge/transfer form was not present in the records.
Failure to Maintain Safe Bed Positioning and Shower Supervision Resulting in Resident Head Injuries
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision to prevent accidents for two residents, resulting in falls with head injuries. For the first resident, who had difficulty walking, muscle weakness, severe anemia, and fibromyalgia, the facility’s own Fall Prevention Program policy required that beds be locked and lowered so that the resident’s feet could be flat on the floor when sitting on the edge of the bed, and that high‑risk residents receive additional interventions such as a low bed. On the evening of readmission, nursing documentation shows the resident was received in bed, alert and verbally responsive. Shortly thereafter, staff were called to the room and found the resident on the floor between two beds, with the resident stating she had jumped out of bed trying to get to her chair. Assessment documented swelling and a superficial open area on the right forehead, and the resident was noted to be alert and oriented to 2–3, with confusion also documented on a fall risk evaluation. Nursing notes further documented that the assigned nurse, upon receiving the resident around 11:03 p.m., checked the resident and noted that the bed was in a high position. The nurse attempted to lower the bed but was unable to do so and went to inform the supervisor about fixing the bed. Around 11:15 p.m., before the issue was resolved, the resident fell from the bed and was found lying on her face, bleeding, with swelling on the right forehead. Staff interviews corroborated that the bed was elevated and not in the lowest position, with the nurse supervisor stating that when she entered the room the bed was at maximum elevation and would not go down. The supervisor also stated that on readmission the nurse should complete a head‑to‑toe assessment and fall assessment and that the bed should be low with items in close proximity for safety, noting that the bed was elevated and things were out of place when she arrived. For the second resident, who had muscle weakness, lack of coordination, left‑side hemiparesis, moderate cognitive impairment, and was dependent on staff for showers, the facility had identified the resident as a moderate fall risk. A nursing note documented that during shower time, the assigned CNA reported that while she and another staff member were assisting the resident by trying to turn him to the side, the resident sustained a fall in the shower room and was later noted with swelling on the right forehead. Subsequent documentation and interviews clarified that two CNAs were assisting the resident in the shower when the incident occurred. One CNA stated that the other CNA turned the resident toward him, but his hands were slippery with soap and he could not stop the resident from hitting his head on the wall, resulting in forehead swelling. The assisting CNA reported that he was on the side of the shower bed near the wall. In a separate interview, the assigned CNA stated that she turned the resident toward the wall where she was standing in the shower room, and that the resident hit his head on the grab bar on the wall when he was trying to pull himself over. When asked why the resident was so close to the wall that he could hit his head, she stated that the resident required two‑person assistance for showers and that the room was too small for two people. She also stated that she did not tell the nurse that the resident fell. The unit manager later stated that both the nurse and the resident told her that he fell in the shower room while staff were giving him a shower, and she could not explain how the resident sustained a hematoma to the head while two staff members were assisting. These events demonstrate that the resident was positioned close enough to the wall and grab bar during assisted showering that he was able to strike his head, and that the assigned CNA did not initially report the fall to the nurse.
Survey Results Not Readily Accessible to Residents and Families
Penalty
Summary
The facility failed to ensure that survey results were placed in a readily accessible area where individuals wishing to examine the results did not have to ask to see them, affecting 65 of 65 sampled residents and/or their families. During an observation of the lobby, the survey results were found stored in a binder labeled “Survey Results” located behind the receptionist’s desk rather than in a publicly accessible location. In a face-to-face interview, the receptionist stated that the survey results binder is always kept behind the desk and is only provided to individuals upon request, confirming that survey results were not freely available for viewing without asking staff.
Failure to Care Plan and Honor Resident’s Egg Allergy and Double-Portion Preference
Penalty
Summary
Facility staff failed to develop and implement a comprehensive, person-centered care plan with measurable objectives and individualized interventions to address a resident’s documented egg allergy and preference for double portions at each meal. The resident was admitted with multiple diagnoses including spinal stenosis, type 2 diabetes with hyperglycemia, discitis, end stage renal disease, and weakness. The medical record included a physician’s order for an LCS/NAS diet with regular texture and thin liquids, and a history and physical that listed allergies to aspirin, codeine, and eggs. A comprehensive MDS showed the resident had intact cognition (BIMS score of 14) and was on a therapeutic diet. However, the comprehensive care plan revised on 01/13/26 did not include the resident’s egg allergy or preference for double portions. During an interview, the cognitively intact resident reported repeated problems with meals over the past weekend, stating that staff kept sending eggs despite the egg allergy and were not providing the requested double portions. The resident stated they had taken photos as evidence and had called the kitchen and spoken with the Director of Kitchen Services several times. The resident’s meal tickets, as shown in photos dated 02/07/26, clearly listed the diet order, egg allergy, dislike of eggs, and a note for double portions/2x meat or protein, along with specific standing orders for breakfast items. Despite this, a photographed breakfast tray showed only a single slice of toast (cut in half) and one slice of breakfast ham, and a photographed lunch tray showed a chef’s salad containing chopped boiled egg. In interviews, the DON explained that care plans are implemented by various clinical staff based on identified focus areas, and a unit manager RN acknowledged that food allergies and preferences should be included in the comprehensive care plan.
Failure to Update Care Plans After Specialist Visits and Unwitnessed Fall
Penalty
Summary
The deficiency involves the facility’s failure to update and revise comprehensive care plans based on residents’ changing needs and clinical events. For one resident with anemia, polyneuropathy, atherosclerotic heart disease, peripheral vascular disease, HIV, presbyopia, and dry eye syndrome, the care plan did not reflect ophthalmology follow-up visits or recommendations. The resident reported wanting to see an ophthalmologist, and record review showed the resident had been seen by an ophthalmologist multiple times since admission, including a visit with a recommendation for a one-year follow-up. However, the care plan contained no updated documentation that these follow-up visits occurred, and progress notes lacked evidence that the recommended ophthalmology follow-up was completed. For another resident with leukemia, dementia, asthma, and respiratory failure, who required substantial to maximal assistance for mobility and used a wheelchair, the facility did not update the care plan after an unwitnessed fall with injury. Nursing documentation described the resident being found on the floor in her room with a right elbow skin tear and complaints of right-sided pain, followed by orders for an X-ray and transfer to the ER. Hospital records documented a right femoral neck fracture and right ulnar fracture, with subsequent surgical procedures. Although a care plan was initiated for the right elbow skin tear and later for the right femur fracture with surgical site and staples, the care plan was not updated to include that the resident had an unwitnessed fall in her room. The facility’s own documentation policy requires complete, accurate, and timely documentation of residents’ experiences, but the care plan did not reflect this fall event.
Failure to Provide and Document Required ADL Care for a Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide and document necessary activities of daily living (ADL) care, including toileting, incontinence care, personal hygiene, mobility assistance, turning and repositioning, and hydration, for one dependent resident during a night shift. The resident had multiple significant diagnoses, including Type 2 Diabetes Mellitus, diffuse traumatic brain injury, chronic idiopathic constipation, schizoaffective disorder (depressive type), need for assistance with personal care, flaccid hemiplegia of the left dominant side, contractures, and aphasia. An admission MDS documented severe cognitive impairment with a BIMS score of 07 and coded the resident as dependent on staff for toileting, personal hygiene, bed mobility, and as frequently incontinent of bowel and bladder. The resident’s care plan required staff to check the resident every two hours, assist with toileting as needed, observe incontinence patterns, initiate a toileting schedule if indicated, provide bedpan/bedside commode, ensure loose-fitting clothing, and provide pericare after each incontinent episode. Record review of CNA task documentation for the specified night shift showed no entries indicating that the resident received required ADL care, with multiple tasks left blank, including additional fluids, bed mobility, bowel incontinence, bowel movements, new skin observation, personal hygiene, toileting hygiene, and turning and repositioning. The assignment sheet showed one nursing supervisor, two charge nurses, and five CNAs assigned to the unit that night. A charge nurse stated the resident was total care and dependent on staff for bowel care and that CNAs are responsible for documenting care. One CNA reported the unit was short staffed with only three CNAs on the floor, stated the resident was already soaked at the beginning of the shift, and described changing the bed, providing care, and addressing a later bowel movement, but admitted she did not document the care provided. The RN supervisor stated she oversees CNA documentation and that CNAs often do not complete documentation due to short staffing, but could not recall specific events from that night. There was no documentation in the medical record that the resident refused care, and no documentation to show the resident received toileting assistance, incontinence care, turning and repositioning, or personal hygiene during that night shift as required by the care plan.
Failure to Follow Physician Orders for Fall Precautions and Wound Care
Penalty
Summary
Facility staff failed to follow physician orders and the care plan for a resident with a history of falls and multiple medical conditions, including difficulty walking, muscle weakness, severe anemia, and fibromyalgia. The resident’s care plan, dated 02/04/25, identified a fall with a resulting open area on the right forehead and required floor mats on both sides of the bed when the resident was in bed to minimize fall-related injuries. Physician orders dated 02/07/25 and 02/09/25 further specified fall precautions every shift, including keeping the bed in the lowest position and placing floor mats on both sides of the bed every shift. Despite these orders and documentation that floor mats were in place on 02/09/25, an observation on 01/29/26 at 10:15 AM found the resident in bed with no floor mats on either side. During subsequent interviews, the CNA, RN, and Unit Manager each indicated they were unaware of or unsure about the floor mat requirement, and the DON later confirmed that the orders and care plan required floor mats on both sides of the bed. Facility staff also failed to follow physician orders for wound care for another resident with a history of pressure ulcers and dysphagia, who was severely cognitively impaired, dependent for ADLs, and had one Stage 4 pressure ulcer and one unstageable pressure ulcer. Physician orders directed that the right heel wound be cleansed with wound cleanser, patted dry, treated with betadine, and left open to air twice daily, and that the sacrogluteal wound be cleansed with wound cleanser, patted dry, and treated with collagen, calcium alginate, and zinc oxide paste to the periwound, then covered with a silicone-bordered superabsorbent dressing. A wound assessment documented an unstageable right heel pressure ulcer with 100% eschar and a Stage 4 sacrogluteal pressure ulcer. However, during an observation of wound care, the LPN/Wound Nurse used normal saline instead of wound cleanser on both the right heel and sacrogluteal wounds and did not apply zinc oxide to the periwound of the sacrogluteal wound, although zinc oxide was applied to the buttocks. The LPN/Wound Nurse stated wound cleanser was not available, while the DON later stated that wound cleanser was available and that zinc oxide should have been applied to the sacrogluteal periwound as ordered.
Failure to Ensure Timely Ophthalmology Follow-Up for Vision Care
Penalty
Summary
Facility staff failed to ensure a resident received treatment and care in accordance with professional standards of practice for vision services by not completing a recommended ophthalmology follow-up visit. The resident, admitted on 08/25/2017 with diagnoses including anemia, polyneuropathy, atherosclerotic heart disease, peripheral vascular disease, HIV, presbyopia, and dry eye syndrome of the bilateral lacrimal glands, had an ophthalmologist report dated 12/31/2021 that directed a follow-up visit in one year. Record review of nursing progress notes and ophthalmology consult notes showed no documentation that this one-year follow-up visit occurred, and the resident had not been seen by an ophthalmologist in four years. During the survey, the resident told the surveyor, "I want to see the Ophthalmologist," and the DON was made aware that the resident had missed the one-year follow-up and had not seen the ophthalmologist for four years. The evidence in the record, including the last ophthalmologist visit dated 12/31/2021 and the absence of subsequent documentation, demonstrated that the facility did not arrange or document the required annual ophthalmology follow-up for this resident’s vision care.
Failure to Protect Resident Privacy of Mail and Packages
Penalty
Summary
Facility staff failed to ensure a resident’s mail and packages were kept private and unopened prior to delivery. A cognitively intact resident with obesity, type 2 diabetes, and congestive heart failure reported during a Resident Council meeting that staff had opened two Amazon packages that had been delivered for him. The resident stated staff told him they opened the packages because they believed the packages belonged to the facility, although he could not recall which employee was involved or the dates of delivery. Review of the resident’s rights documented that the resident has the right to have privacy in getting mail. In a subsequent face-to-face interview, a recreation aide reported that she delivers mail to residents and recalled a prior incident in which a resident’s package was already opened when it came to her for delivery. She stated she refused to deliver that opened package and told the person who had it that they needed to deliver it to the resident because it was open, but she could not remember which employee or which resident were involved. These interviews and record reviews showed that at least one resident’s packages were opened by staff before being provided to the resident, contrary to the resident’s right to privacy in receiving mail.
Environmental and Sanitation Deficiencies in Resident Rooms and Kitchen Areas
Penalty
Summary
Facility staff failed to maintain a safe, clean, and sanitary environment in multiple resident rooms and kitchen areas. During an environmental walkthrough, surveyors observed soiled nightstand surfaces, missing or detached baseboards, moisture-damaged ceiling tiles, and broken or loose toilet handrails in several rooms. Additional room-related issues included broken or clogged hand-washing sinks, missing or broken hand-washing soap dispensers, absence of hand-washing soap, a missing trash can in a restroom, a sticky restroom floor, a broken wardrobe cabinet door, a wardrobe in poor repair, a missing pillowcase, and stained bedding and bedrails. In a shared restroom, surveyors found a loose toilet handrail, a broken hot water faucet valve at the hand-washing sink, and slow drainage at the hand-washing sink in the tub room. In the kitchen and food service areas, surveyors identified damaged drywall at the delivery receiving area, dust build-up on ceiling tiles and metal grids above the rack for clean utensils, and an unclean stainless steel backsplash wall cover at the three-compartment dish sink area. They also observed significant grease buildup on cooking equipment and a missing ceiling tile above the dishwashing area. These environmental and maintenance deficiencies were directly observed and acknowledged by the Food Service Director, Maintenance Director, and Environmental Services Director during the survey.
Failure to Provide Required Written Discharge and Bed-Hold Notices on Hospital Transfers
Penalty
Summary
Facility staff failed to provide required written notice of discharge, including bed-hold policy and notification to the Long Term Care Ombudsman and State Agency, for two residents who were transferred to the hospital. The first resident was admitted with multiple diagnoses including difficulty walking, muscle weakness, severe anemia, and fibromyalgia, and had a MDS BIMS score indicating severely impaired cognition. A nursing progress note documented that the resident sustained a fall in her room, was found on the floor with swelling and a superficial open area on the right forehead, and was transferred to the emergency room per NP order for further evaluation and treatment. The care plan documented the fall and the intervention to transfer the resident to the ER. Upon record review, there was no documented evidence that written notification of the resident’s discharge, including bed-hold information and required notices, was provided. The second resident was admitted with diagnoses including stroke with left-sided hemiplegia, hypertension, diabetes mellitus, and deep vein thrombosis, and had an admission MDS BIMS score of 15, indicating intact cognition. A social worker progress note documented that the family requested a hospital transfer, was informed there was no medical reason for transfer but that they had the right to proceed, and that the facility completed the transfer with non-emergency transport to the hospital. A physician order documented that the transfer was per the resident’s request. Record review showed no documented evidence that written notification of the discharge, including bed-hold policy and required notifications, was provided. During an interview, the Director of Social Work acknowledged the absence of the required Notice of Discharge, Transfer or Relocation form in the records and could not explain why it was not filed.
Some of the Latest Corrective Actions taken by Facilities in District Of Columbia
- Educated Resident #4 on stair safety, oxygen tank/portable oxygen use, oxygen tubing safety, fall precautions, and leave-of-absence (LOA) precautions to reduce recurrence risk (J - F0689 - DC)
- Implemented staff education on stair safety and resident supervision, including documentation of escort refusal for all staff (with follow-up education for staff not yet trained) (J - F0689 - DC)
- Updated the resident care plan to reflect non-compliance with staff escort while using the stairwell to guide ongoing supervision interventions (J - F0689 - DC)
- Changed the stairwell entry code and educated staff on the new code to control stairwell access (J - F0689 - DC)
Failure to Supervise Resident Using Stairwell with Oxygen
Penalty
Summary
Facility staff failed to ensure adequate supervision and assistance to prevent accidents for Resident #4, who had COPD, chronic respiratory failure with hypoxia, and hypertension, and was receiving 2–3 L/min oxygen via nasal cannula per physician order. The resident’s care plan, revised on 10/29/25, specified that he was to use the stairs when going down and coming back in, with an escort. A Quarterly MDS showed he had intact cognition (BIMS 15), no functional impairment in range of motion, was independent with transfers and walking 150 feet, and used oxygen therapy. On 01/30/26 at 3:47 PM, surveyors observed the resident alone in the 2-north stairwell, going down the stairs, noticeably short of breath, with oxygen at 3 L via nasal cannula, and carrying an E-tank oxygen cylinder in a wheeled caddy. The resident stated he did not like taking elevators and therefore used the stairs, and reported that a staff member had let him down to the stairwell, which required manual entry of a 4-digit code from the units. In a face-to-face interview shortly thereafter, the Administrator acknowledged that the resident used the stairwell due to claustrophobia and stated that he should have someone with him when using the stairs. The evidence showed that serious harm was likely to occur as the resident was short of breath, alone in the stairwell, and carrying an oxygen tank, demonstrating that facility staff did not provide adequate supervision as required under 42 CFR 483.25, F689.
Removal Plan
- Resident #4 was immediately assessed by a licensed nurse, including a head-to-toe assessment and fall risk assessment, with documentation entered in the electronic health record.
- Resident #4 received education by a licensed nurse regarding stair safety, safety with oxygen tank/portable oxygen use, oxygen tubing safety, fall precautions, and leave-of-absence (LOA) precautions.
- The Nurse Educator/designee initiated staff education for all staff on stair safety and resident supervision, including documentation of escort refusal; staff not yet educated will receive education when they come on shift.
- Resident #4's care plan was updated by a licensed nurse to reflect non-compliance with staff escort while using the stairwell.
- The stairwell entry code was changed and education was provided to all staff regarding the new code.
Explore Popular Searches
