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
Facility staff failed to accurately code a resident’s Quarterly MDS for a sacral deep tissue injury (DTI). Nursing notes and wound assessments documented that an open area on the sacrum was first observed after admission, later assessed as a full-thickness pressure ulcer with maroon discoloration and identified as an in-house–acquired DTI. Despite this, the MDS was completed indicating one unstageable pressure injury present on admission rather than facility acquired, and the MDS coordinator later acknowledged that the sacral wound had been miscoded.
A diabetic resident with intact cognition and multiple comorbidities was admitted with orders and care plan interventions requiring daily foot inspections, referral to podiatry or a foot care nurse, and nail care. Over several weeks, repeated skin and wound notes recommended routine in‑house podiatry evaluation for thickened nails, and a podiatrist was present in the facility on multiple occasions, yet the resident was never seen by podiatry. Weekly nurse skin assessments documented no skin impairment and continued the plan of care without addressing the toenails. On observation, the surveyor, CNA, LPN, DON, and unit manager all noted overgrown, thickened, yellow toenails on both feet, with several nails curved and digging into the skin, and staff confirmed the resident had not received podiatry services, while the administrator cited pending Medicaid coverage despite acknowledging the facility could have covered the cost.
Facility staff failed to follow a resident’s documented shellfish allergy and nutritional care plan when a shrimp entrée from the posted dinner menu was plated and delivered despite clear allergy notation and an allergy indicator on the meal ticket. A pantry worker reported relying mainly on diet texture information and cited difficulty seeing allergy information on a new ticket format, while a CNA acknowledged not following her usual practice of verifying the meal against the ticket before the family member took the tray. The resident’s family identified the shrimp on the plate, prompting the tray’s return, and the complainant later reported that the replacement items offered were limited to sandwiches, chips, small pieces of chicken, and cold spinach, which they considered nutritionally inadequate, leading them to obtain another meal for the resident.
A resident with multiple medical conditions and a documented shellfish allergy was not provided a nourishing, palatable, well-balanced meal at a safe and appetizing temperature when the scheduled dinner entrée contained shrimp. Instead, the resident was first offered a peanut butter and jelly sandwich, a ham sandwich, and potato chips, followed by three small pieces of chicken in a plastic container and later a container of cold spinach. The resident’s care plan called for honoring food preferences and providing a prescribed diet while noting the shellfish allergy, and the facility had an always-available menu intended to provide made-to-order alternatives served on plates, but the Dietary Director acknowledged that the alternative food provided was cold and not served as intended.
A resident with severe cognitive impairment and multiple diagnoses was found with a right hip fracture of unknown origin. Staff became aware of the injury and ordered an X-ray, which confirmed the fracture, and the resident was transferred to the hospital. However, the required report to the State Agency was not submitted within 24 hours, as acknowledged by the DON, resulting in a deficiency.
A physician did not sign and date a progress note at the time of a psychiatric consultation for a resident with multiple diagnoses, including depression and anxiety. The note was signed 52 days after the visit, despite documentation of the visit and new medication orders in the medical record. The physician acknowledged the delay during a staff interview.
Surveyors identified widespread housekeeping deficiencies, including dust buildup, dirty and sticky floors, soiled toilets, stained privacy curtains, dirty trash cans, and a strong urine odor in several areas. These issues were acknowledged by facility staff and affected multiple resident rooms and common areas.
Staff did not maintain an effective pest control program, as flies were observed in three resident rooms. In one case, a soiled trash can with a dark substance attracted flies, while in another, flies were found near human waste under a portable toilet. Additional flies were seen on a privacy curtain and pillow in a third room. These deficiencies were confirmed by staff interviews and direct observation.
Facility staff did not post the most recent survey results in an accessible location and failed to provide survey reports from the past three years, including certification surveys and complaint investigations, upon request. When a resident's representative asked for the latest survey results, only an outdated report was provided, and staff were unable to promptly locate the required documentation.
A resident with complex medical needs, including chronic respiratory failure and mobility limitations, was discharged without proper coordination of home care and oxygen therapy services. The social worker did not document arrangements for post-discharge care or confirm acceptance by a home care agency, and family members reported that promised services were not provided, leading to the resident using outdated equipment and experiencing falls at home.
Inaccurate MDS Coding of Facility-Acquired Sacral DTI
Penalty
Summary
Facility staff failed to ensure an accurate assessment for one resident by incorrectly coding a facility-acquired pressure injury on the Quarterly MDS. The resident was admitted with multiple diagnoses including Type 2 diabetes mellitus, Alzheimer's disease, dementia, muscle weakness, and major depressive disorder. On 10/29/25, nursing staff identified an open area on the resident's sacrum during routine ADL/incontinent care, and the NP, wound team, and dietitian were notified. On 10/30/25, a comprehensive skin and wound assessment documented a sacral pressure ulcer/injury with full-thickness tissue loss and a central area of marooning, and the wound team determined it would be followed as a deep tissue injury (DTI). On 11/11/25, a wound/pressure ulcer note documented a sacral DTI pressure ulcer/injury that was specifically identified as in-house acquired. Despite this documentation, the Quarterly MDS assessment coded the resident as having one unstageable pressure injury that was present upon admission, rather than facility acquired. During an interview, the MDS coordinator reviewed the MDS, acknowledged the discrepancy, and stated that the sacral wound had been miscoded as present on admission instead of correctly coded as not present on admission.
Failure to Obtain Podiatry Care and Provide Foot Care for Diabetic Resident
Penalty
Summary
Facility staff failed to provide necessary podiatry consultation, treatment, and foot care for a diabetic resident over a three‑month period following admission. The resident was admitted with Type 2 Diabetes Mellitus, hyperlipidemia, cerebral infarction, and schizophrenia, and had physician orders for PRN podiatry consults as well as weekly skin assessments and heel offloading. Multiple skin and wound notes dated over several weeks (10/14, 10/21, 10/28, 11/07, and 11/14) repeatedly documented recommendations for routine in‑house podiatry evaluation for nail trimming and management of thickened nails. The resident’s care plan directed staff to inspect feet daily, refer to podiatry or a foot care nurse for monitoring and nail cutting, and to check nail length and trim and clean nails on bath days and as necessary. Despite these orders and care plan interventions, the resident was not seen by a podiatrist during the three months since admission, even though a podiatrist was documented as being in the facility on multiple occasions. Quarterly MDS data showed the resident had intact cognition and required supervision or touching assistance for bathing, lower body dressing, and footwear, indicating dependence on staff for foot care. Weekly skin assessments by licensed nurses in late December and early January documented no skin impairment and continuation of the plan of care, without addressing the ongoing need for podiatry services or the condition of the resident’s toenails. On observation, the surveyor noted that the resident’s toenails on both feet were overgrown, thickened, yellow, and in several toes curved downward and digging into the skin on the bottoms of the feet. The assigned CNA and LPN confirmed these findings when called to the room, and the LPN stated she had noticed that the toenails were long and that the resident needed to see podiatry. The DON and unit manager also observed the condition of the resident’s feet and confirmed that the resident had not been seen by a podiatrist since admission, although he was on the list to be seen. The administrator later stated that the resident’s Medicaid application was pending and that he did not yet have insurance coverage for podiatry, but acknowledged that exceptions could be made and the facility could cover the cost, which had not occurred during the three‑month period in question.
Failure to Follow Allergy-Specific Diet Order and Provide Adequate Meal Replacement
Penalty
Summary
Facility staff failed to ensure that a resident’s menu and meal service met her nutritional needs and documented food allergy, resulting in a shellfish-containing entrée being served to a resident with a known shellfish allergy. The resident was admitted with multiple diagnoses including status post reverse arthroplasty of the left shoulder, asthma, hypertension, and gastroesophageal reflux disease, and had a clearly documented shellfish allergy in the Physician’s Order Reconciliation and History and Physical. An admission MDS showed the resident was cognitively intact, and the care plan identified risk for altered nutritional status with interventions to provide the prescribed diet, note the shellfish allergy, provide ordered nourishment/supplements, and honor food preferences. On the date of the incident, the facility’s dinner menu included penne pasta with spinach and shrimp. The resident’s meal ticket, as later observed by the surveyor, listed multiple shellfish-related allergies and had a red circular sticker indicating an allergy. Despite this, the pantry worker plated the shrimp entrée for the resident. The pantry worker reported that she based plating on the diet type listed on the ticket (e.g., regular or mechanical) and stated that on the new ticket format the allergy information was printed much smaller, and that she had not received sufficient training, which she believed contributed to her error. The Chef Manager stated that pantry workers are supposed to read the ticket and only plate food specific to the resident, and that nurses are supposed to read the ticket and ensure the food is correct before giving it to the resident. A CNA delivered the tray containing shrimp to the resident’s room. The CNA stated that her usual practice is to place the tray on the table and then remove the dome cover to check the meal against the ticket, but on this occasion she did not do so because the resident’s daughter assisted and immediately took the tray. The daughter opened the cover, saw the shrimp, and stated that the resident was allergic, at which point the CNA apologized and returned the tray to the kitchen. The complaint submitted to the State Agency reported that the replacement food initially offered consisted of a peanut butter and jelly sandwich, a ham sandwich, and two bags of potato chips, which was described as not nutritionally appropriate for an elderly patient, and that subsequent attempts to remedy the situation included three small pieces of chicken in a plastic container and later a container of cold spinach, leading the complainant to reorder a meal on the resident’s behalf.
Failure to Provide Palatable, Nutritious, and Proper-Temperature Meal to Resident With Shellfish Allergy
Penalty
Summary
Facility staff failed to provide a cognitively intact resident with a nourishing, palatable, well-balanced, attractive meal at a safe and appetizing temperature, as required by facility policy. The resident had multiple diagnoses including status post reverse arthroplasty of the left shoulder, asthma, hypertension, and gastroesophageal reflux disease, and a documented shellfish allergy. The resident’s care plan identified risk for altered nutritional status and directed staff to provide the prescribed diet, note the shellfish allergy, provide ordered nourishment/supplements, and honor food preferences. On a dinner menu that included penne with spinach and shrimp, the resident, who could not receive shellfish, required an alternative meal. According to the complaint intake, the replacement food offered for dinner consisted of a peanut butter and jelly sandwich, a ham sandwich, and two bags of potato chips, which was described as not nutritionally appropriate for an elderly patient. Subsequent attempts to remedy the situation included three small pieces of chicken served in a plastic container, followed later by a container of cold spinach at approximately 7:03 PM. The Dietary Director acknowledged that an “Always Available Menu” existed with hot and cold items that could be ordered without a cut-off time and that such items should be served on a plate and logged as a special request. The Dietary Director also acknowledged awareness that the alternative food item served to the resident was cold, but was not aware of how the resident would have received it in a to-go container.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
Facility staff failed to report an incident of injury of unknown origin to the State Agency within the required 24-hour timeframe for one resident. The resident, who had a history of repeated falls, difficulty walking, and seizures, was found to have severe cognitive impairment and required substantial assistance with activities of daily living. On the morning of the incident, the resident complained of right hip pain and was unable to get out of bed. Assessment revealed swelling and warmth in the right hip, and pain medication was administered without relief. An X-ray was ordered, which later confirmed an acute comminuted displaced intertrochanteric fracture of the right femur with associated soft tissue swelling. The resident was subsequently transferred to the hospital for further evaluation and admission. Despite being aware of the injury on the day it was discovered, facility staff did not submit the required Facility Reported Incident (FRI) to the State Agency until three days later. The Director of Nursing acknowledged the delay, attributing it to IT issues that prevented timely submission of the report. The failure to report the injury of unknown origin within 24 hours constituted a deficiency as identified by the surveyors.
Physician Failed to Timely Sign and Date Progress Note
Penalty
Summary
A deficiency was identified when a physician failed to sign and date a resident's progress note at the time of the visit. The resident, who had multiple diagnoses including depression, anxiety disorder, sepsis, hyperlipidemia, and intrahepatic bile duct carcinoma, was admitted to the facility and underwent an initial psychiatric consultation. The consultation note included clinical observations and recommendations, such as continuing and potentially adjusting antidepressant medication. However, the physician did not sign and date the progress note until 52 days after the visit. This lapse was discovered through a review of the resident's medical record and confirmed during a staff interview. The nurse's note documented that the resident was seen by the behavioral MD and that a new medication order was entered, but the corresponding physician's note was not signed and dated contemporaneously. The physician acknowledged the delay, attributing it to a habit of reviewing notes later and sometimes forgetting to sign them.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
Facility staff failed to provide adequate housekeeping services necessary to maintain a safe, clean, and comfortable environment for residents. During an environmental walkthrough, surveyors observed dust buildup under handwashing sinks, under beds, in wall corners, and around furniture in all resident rooms on two floors. Additional findings included soiled window tracks and frames with cobwebs in a dayroom, dirty and sticky floors in multiple resident rooms and common areas, and a strong urine odor in one resident care unit and a resident room. Toilets in two resident rooms were found soiled with dark stains, and trash cans in three rooms were dirty, with one having a broken step pedal. Further observations revealed stained privacy curtains in three resident rooms and dusty window blinds in five rooms. These environmental deficiencies were acknowledged by a facility employee during a face-to-face interview. The report does not mention any specific medical history or conditions of the residents affected, nor does it detail any immediate harm, but it documents the failure to maintain a clean and homelike environment as required.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
Facility staff failed to maintain an effective pest control program, as evidenced by the presence of flies in three out of thirteen resident rooms on the third floor. In one room, numerous flies were observed, and further investigation revealed a trash can with a dark substance at the bottom that appeared to attract the flies. In another room, flies were found, and a dark, lumpy substance identified as human waste was discovered on the floor under a portable toilet near the foot of a bed. In a third room, flies were seen on the privacy curtain and on a pillow on one of the beds. These findings were confirmed through direct observation and staff interviews.
Failure to Make Survey Results and Reports Readily Accessible
Penalty
Summary
Facility staff failed to post the results of its most recent survey in a location that was readily accessible to residents, family members, and resident representatives. Observations revealed that only a sign indicating the survey book was available upon request was posted at the front security desk, rather than the actual survey results. When a resident's representative requested the most recent survey results, she was provided with an outdated report from 2022. Additionally, during a surveyor's visit, the front desk staff were unable to immediately locate the survey book and had to refer the surveyor to the Administrator. The Administrator confirmed that only the 2024 survey report was available at the front desk at that time. Further investigation showed that the facility did not have reports from the three preceding years, including certification surveys, complaint investigations, and any plan of correction in effect, available upon request for review by any individual. The Administrator acknowledged the absence of these reports during the surveyor's inquiry. The deficiency was identified through direct observation, staff interviews, and review of the available documentation, which confirmed that the facility did not meet the requirements for making survey results and related reports accessible to residents and the public.
Failure to Ensure Safe Discharge Planning and Coordination of Post-Discharge Services
Penalty
Summary
The facility failed to implement its discharge planning process to ensure a safe discharge for a resident with multiple complex medical needs, including chronic respiratory failure, morbid obesity, and sleep apnea. The resident required substantial to total assistance with mobility and activities of daily living, was incontinent, and was receiving physical therapy, occupational therapy, and oxygen therapy. Documentation indicated that the resident was to continue receiving therapy and home health services, as well as oxygen therapy, after discharge. However, the discharge was not properly coordinated, as the social worker did not have documented evidence of arranging home care services or confirming acceptance by a home care agency. Additionally, the social worker did not coordinate ongoing oxygen therapy services, stating she was unaware of the resident's need for oxygen, despite documentation to the contrary. Family members reported that they were unable to reach the social worker after discharge and that promised wrap-around services were not provided. They also stated that they had to use an old oxygen concentrator from two years prior, and that the resident experienced falls at home post-discharge. The home care agency representative confirmed that services were verbally denied to the social worker, but there was no documentation of this communication. The lack of documented coordination and follow-through resulted in the resident being discharged without the necessary support and services to ensure a safe transition home.
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