Sibley Mem Hosp Renaissance
5255 Loughboro Road NW, Washington, DC 20016 · Non profit - Other · 45 certified beds · (202) 537-4000 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- a high payroll-based staffing rating (5/5)
- lower-than-typical staff turnover (26% vs 45% nationally) — better care continuity
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has a citation for mishandling residents’ money or property (F0565)
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (34) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $8,827 in federal fines (most recent 2024-02-06)
- its last standard health inspection was over 3 years ago — the star rating may not reflect current conditions
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 4 to 5 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Short-stay residents who newly got an antipsychotic medication | 1.3% | 0.8% | 1.4% | typical |
| Short-stay residents given the seasonal flu vaccine | 100.0% | 73.2% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 21.2% | 18.5% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 10.2% | 8.6% | 12.0% | better |
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
71.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 335 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 14.2% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 204 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 2.90 therapist hours per resident per day in 2026Q1 — more than 100% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 12% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 71.3%CMS range 65.8–76.9 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.8%CMS range 7.4–13.3 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 14.2% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 10.8% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 18.6% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 91.6% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 88.1% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.8% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.8% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 5.1%CMS range 3.1–7.8 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.84 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 45 beds and averages 30.6 residents a day — about 68% occupied, or roughly 14 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 6.48 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 4.41 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.07 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 5.69 hrs/resident/day on weekends vs 6.80 on weekdays — 16% thinner on weekends. RN hours go from 4.73 to 3.61 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 26% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
This trend is not current. The most recent of these two inspections was over 3 years ago; the arrow describes what inspectors found then, not what the home is like now.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
34 citations, most serious first. The 12 most serious are shown; the remaining 22 are one tap away and print in full.
- Immediate jeopardy · J2024-02-06 · tag F0740 — failed to provide behavioral / mental-health care — isolatedEnsure each resident must receive and the facility must provide necessary behavioral health care and services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, for one (1) of five (5) sampled residents, facility staff failed to provide the necessary social and health care services to attain, maintain, or support the behavioral health (emotional and mental well-being) needs of Resident #1. Due to these failures, an Immediate Jeopardy (IJ-J) was identified on February 5, 2024 at 12:07 PM. During this survey, Immediate Jeopardy was identified at 42 CFR §483.40, Behavioral Health (F740), on February 5, 2024 at 12:07 PM. The facility's Administrator submitted a corrective action plan to the Survey Team that was accepted on February 5, 2024 at 7:52 PM. The Survey Team verified implementation of the corrective plan while onsite and the Immediate Jeopardy was lifted on February 6, 2024 at 2:15 PM. After removal of the immediacy, the deficient practice remained at a potential for harm at the scope and severity level of G. The findings included: Resident #1 was admitted to the facility on [DATE] to room [ROOM NUMBER] with multiple…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2021-04-23 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and resident and staff interview, facility staff failed to ensure that Resident #20, who was admitted to the facility with a bruise to the left heel received necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent a deep tissue injury from developing for approximately 14 days, for one (1) of 17 sampled residents. The findings included . Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon, or purple discoloration - Intact or non-intact skin with localized area or persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister. Pain and temperature changes often preceded skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-08-14 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident #123 Abuse 08/13/24 09:20 AM #123 [NAME] DOB [DATE] DOA [DATE] Discharge [DATE] DX: - Rupture of Quadriplegic tendon - Lumbar Dengerative Disc Disease - Status Fall F610 The facility failed to ensure an alleged perpetrator did not have access to a resident who made an allegation of rough handling. Additionally, the facility failed to conduct a through investigation. As evidence by not having documented evidence of interview with the companion who was in the room on the night if the alleged incident of rough handling. OBSERVATION Unable to conduct observations, resident was discharged on [DATE] RECORD REVIEW MDS ADD Info see hard copy Care Plan- see hard copy 04/27/24 and 04/28/24 flow sheeted did not document any concerns or complaints from the resident. 04/28/24 at 8:37 AM [[NAME]'s (alleged perpetrator) Nursing Note] Pt. slept well .companion with patient from mid-night resident remains stable with no new complaints/concerns. 05/08/24 Facility Investigation- included statements from all staff who…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-08-14 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident #17 Unnecessary Meds, Psychotropic Meds, and Med Regimen Review 08/12/24 09:58 AM #17 [NAME] DOB - [DATE] DOA - [DATE] DX: - Gram positive Bacteria -Anemia -Endocarditis -DVT -Thrombophilia -Insomnia [DATE] admission MDS C-11 I - Insomnia 483.45 Pharmacy (F756) - The physician failed to documented response to pharmacist recommendations. 08/12/24 10:01 AM OBSERVATION During an observation on 08/08/24 at 11:00 AM, the resident was observed lying in bed. A, OX 3, no bruising noted. RECORD REVIEW 07/16/23 - MMR Please monitor patient for additive CNS depressant effect and QTC prolongation due to DDI between Quetiapane and Mirtazine. The physcian failed to documented hi response. [DATE]- admission MDS C-11 I - Insomnia N- antipsychotics, anticoags. o 07/29/24 - Eliquis (anticoagulant) 5mg po BID for VTE Tx. no monthly labs need for this mediation o 07/29/24 -Trazadone (psychotropic) 25mg (1/2 tab) prn nightly X1 for sleep. It should be noted the resident has not received this medication since start date.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-08-14 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Facility staff failed to ensure that their infection control policies were reviewed annually. During a review of the facility's infection control policies on 08/09/24 revealed a policy titled Mandatory COVID-19 Vaccination Policy - Policy Number ADMIN033 that documented Effective Date 11/10/2022 and Supersedes Date 09/23/2022. A face-to-face interview conducted on 08/09/24 at 12:50 PM, Employee #2 (Director of Nursing/DON) acknowledged the findings and stated, We adopt our policies from the hospital. We need to show that the policies are being reviewed annually and the review date should be reflected on the policy. Cross Reference: 22B DCMR Sec. 3206.3 Based on observation, record review and staff interview, for one (1) of 18 sampled residents, facility staff failed to follow the facility's policy of acceptable Infection Control Standards and Practices while changing a Peripherally Inserted Central Catheter (PICC) line dressing; and failed to ensure that their infection control policies were reviewed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-06 · tag F0745 — failed to provide medically-related social services — isolatedProvide medically-related social services to help each resident achieve the highest possible quality of life.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews, for one (1) of five (5) sampled residents, the facility's staff (Employee #5) failed to provide appropriate medically-related social services to meet Resident #1's needs, as evidenced by the employee's failure to conduct a follow-up assessment on 01/29/24 after the resident expressed that he wanted to die. The findings included: A review of Employee #5's job description signed on 05/11/22, revealed the following Job title Social Worker II (Department Case Coordination) .Provides expeditious patient assessments and collaborates with medical providers in determining the appropriate disposition and treatment for behavioral health patients and other vulnerable patient populations .Conducts behavioral health assessments using standardized assessment and screening tools in conjunction with the department of psychiatry policies and procedures. Communicates psychiatric crisis intake assessments and clinical information to psychiatric medical provider and develops disposition…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-06 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews for one (1) of five (5) sampled residents, the facility staff failed to maintain a complete medical record for Resident #1. The findings included: A review of the facility's policy titled Records and Record Keeping with an effective date 03/24/23, documented .Staff are responsible for maintaining current and accurate documentation of interventions on behalf of the patient utilizing the charting system adopted by (Facility Name) . Entries on the patients electronic medical record should be responsive to physician direction and facilitate communication among all staff members involved in the patient's care . Resident #1 was admitted to the facility on [DATE] to room [ROOM NUMBER] with multiple diagnoses that included: Orthostatic Hypotension, Rapid Eye Movement (REM) Sleep Disorder, Diabetes Mellitus, Parkinson's Disease, and Coronary Artery Disease. A review of the medical record revealed the following: An admission Minimum Data Set (MDS) assessment dated [DATE] showed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-01-09 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation of nine (9) nasal cannulas (delivers oxygen via the nose), facility staff failed to maintain respiratory/oxygen care equipment in accordance with the professional standards of practice. The findings included: During an observation of the Respiratory Equipment Cart on [DATE] at 12:14 PM, nine (9) of nine (9) Vyaire (manufacturer) nasal cannula tubing with expiration dates of 2022-10-08 ([DATE]) were stored for resident use, approximately three (3) months after the expiration date. During a face-to-face interview conducted on [DATE] at 12:59 PM, Employee #12 (Respiratory Therapy Manager) stated, There's no daily or weekly inventory check of the respiratory equipment cart. If supplies are needed, they [the nurses] call us and we bring the supplies. The employee was shown the expired nasal cannula tubing's and stated, Oh wow! I will get rid of these and get new ones. Employee #12 further stated that the nasal cannulas come from central supply. During a face-to-face interview on [DATE] at 2:13…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-01-09 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, for one (1) of 16 sampled residents, facility staff failed to offer a resident or their representative the right to formulate or refuse an Advanced Directive (AD). Resident #79. The findings included: Resident #79 was admitted to the facility on [DATE] with diagnoses that included Osteoarthritis, Osteoporosis, Chronic Pain Syndrome, Right Hip Pain, and Obesity. Review of Resident #79's medical record revealed the following: Review of the Resident's Face Sheet revealed that the resident had a legal guardian. An admission Minimum Data Set (MDS), dated [DATE], showed facility staff coded the resident as having a Brief Interview for Mental Status score of 15, indicating intact cognition. Resident #79's electronic medical record documented, Advance Directives - Living Will - Patient has [an] advance directive. Copy in [physical] Chart. Review of Resident #79's physical chart showed that there were no documents filed under the Advance Directive tab. During a face-to-face…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-01-09 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — the official record, unedited, may be distressing
Based on observations and interview, facility staff failed to provide housekeeping services necessary to maintain a safe, clean, comfortable environment as evidenced by soiled bathroom vents in four (4) of eight (8) resident's rooms, and walls marred with peeling paint in three (3) of eight (8) resident's rooms. The findings include: During an environmental walkthrough of the facility on January 4, 2023, at approximately 3:15 PM, the following were observed: 1. Bathroom vents were soiled on the inside and outside in four (4) of eight (8) resident's rooms including rooms #322, #327, #328, and #330. 2. Paint was peeling from the walls in three (3) of eight (8) resident's rooms (#322, #327, #330). These findings were acknowledged by Employee #8 on January 4, 2023, at approximately 4:00 PM.
- Potential for harm · D2023-01-09 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, for three (3) of 16 sampled residents, facility staff failed to implement its policies and procedures for reporting and investigating incidents involving abuse, neglect, and injuries of unknown origin. Residents' #81, #80 and #85. The findings included: Review of the Abuse and Neglect Policy with an effective date of 12/23/21, documented, .The Director of Nursing (DON) shall be notified in order to assist in appropriately implementing the notification requirements . incidents of abuse .shall be reported to the DC (District of Columbia) Metropolitan Police, the Long-Term Care Ombudsman, and Adult Protective Services: within 2 hours after the allegation has been made if the event(s) that caused the allegation involve(s) abuse .Investigation . All reports of alleged abuse, misappropriation of property, and injuries of unknown origin are investigated promptly in a systematic and thorough manner . The facility shall report the results of all investigations to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-01-09 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility records, reported incidents, policies, and staff interview for four (4) of 16 sampled residents, facility staff failed to report the following incidents to the state agency in the required timeframes for one (1) resident who had a witnessed fall with staff that resulted in injury, one (1) residents with injuries of unknown origin, and one (1) resident with an allegation of abuse. (Residents' #81, #80, and #85) The findings included: A facility policy titled Abuse and Neglect Policy (Formerly 01-28-01), effective 12/23/2021, documented: .Procedure .E. The Director of Nursing shall be notified to assist in appropriately implementing the notification requirements . incidents of abuse .shall be reported to the DC Metropolitan Police, the Long-Term Care Ombudsman, and Adult Protective Services: within 2 hours after the allegation has been made if the event(s) that caused the allegation involve abuse .Investigation: a. All reports of alleged abuse, misappropriation of property, and injuries…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 22 citations
- Potential for harm · Dcited before2023-01-09 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility records, reported incidents, policies, and staff interviews for two (2) of 16 sampled residents, the facility's staff failed to show evidence of conducting thorough investigations for one (1) resident that had a fall with injury and one (1) resident with an injury of unknown origin. Residents' #81 and #80. The findings included: Review of the facility's policy titled Abuse and Neglect Policy with an effective date of 12/23/21 instructs .The Director of Nursing, and or Administrator or designee of the [Facility Name], will investigate all allegations as soon as they have knowledge of the event .The facility shall report the results of all investigations to the administrator or his/her designated representative and to other officials in accordance with DC law, including the State Survey Agency, within five (5) working days of the incident and if the alleged violation is verified, appropriate corrective action must be taken . 1. Facility staff failed to thoroughly investigate Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-01-09 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, for two (2) of 16 sampled residents, facility staff failed to develop and implement comprehensive person-centered care plans with goals and approaches to address one (1) resident who is prescribed nine (9) prescribed medications; and one (1) resident who contracted COVID-19. Residents' #128 and #3. The findings included: 1. Facility staff failed to develop a comprehensive-person-centered care plan with goals and approaches to address Resident #128 being on nine (9) prescribed medications. Resident #128 was admitted to the facility on [DATE] with multiple diagnoses that included: Hypertension, Hyperlipidemia, Benign Prostatic Hyperplasia (BPH), and Hypothyroidism. Review of resident #128's medical record revealed the following physician's orders: 12/21/22 Benzonatate (cough suppressants) . capsule 100mg (Milligram) . 12/21/22 Enoxaparin (anticoagulant) . syringe 40 mg Subcutaneous, every evening 12/21/22 Simvastatin (cholesterol lowering medication) tablet 5 mg oral…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-01-09 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, for two (2) of 16 sampled residents, facility staff failed to revise/update the comprehensive care plan with new goals and approaches that addressed: one (1) resident's family bringing in foods from outside the facility; and one (1) resident's fall. Residents' #277 and #278. The findings included: 1. Facility staff failed to revise/update Resident #277's nutritional care plan to include foods brought in from outside the facility. Policy NUSE-GEN061 dated 11/04/20 documented, .Food and Nutrition Services will not serve food prepared outside the food and nutrition services .The department of Food and Nutrition Services does not accept responsibility for patient illness resulting from foods provided by a family member or outside sources . Resident #277 was admitted to the facility on [DATE], with multiple diagnoses that included Asthma, Congestive Heart Failure, Chronic Lymphocytic Leukemia, Hypertension, and Hyponatremia. During an interview on 01/04/23 at 11:00 AM,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-01-09 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and staff interview, facility staff failed to distribute and serve foods under sanitary conditions as evidenced by: foods such as grilled chicken and beans that tested below 135 degrees Fahrenheit (F); inconsistent dish machine final rinse temperatures that were below 180 degrees Fahrenheit (F); and a crawling pest that was observed on the kitchen floor. The findings included: 1. Lunch food temperatures were inadequate and failed to test above 135 degrees Fahrenheit (F) or more during a food tray test on January 4, 2023, at approximately 1:00 PM, on two (2) of three (3) observations. Grilled chicken breast tested at 126 degrees Fahrenheit, and black beans tested at 127 degrees Fahrenheit. 2. Final rinse dish machine temperatures failed to reach 180 degrees Fahrenheit during observations on January 4, 2023. Dishes and utensils were disinfected with the disinfectant solution from the 3-compartment sink. Final rinse temperatures were normal on January 5, 2023, at approximately 2:30 PM 3. A crawling insect was observed on the kitchen floor near the grill during…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-01-09 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interview, for one (1) of 16 sampled residents, the facility's staff failed to maintain infection control policies and procedures as evidenced by: inappropriately transporting soiled linen; staff not performing hand hygiene and wearing a facemask inappropriately during meal tray distribution. Resident #1. The findings included: Review of the facility's policy titled Wound Care Policy with an effective date of 06/23/20 instructed staff to .maintain standard precautions and isolation precautions as indicated. After completion of the procedure, clean, store and/ or dispose of equipment and supplies in the appropriate manner as identified per facility infection control policy . Review of the policy titled Hand Hygiene Policy with an effective date of 06/15/20 instructs staff to do the following .Hand hygiene with either alcohol-based hand sanitizer and or soap and water is required .Before handling food .when carrying supplies, dietary trays or transporting a patient…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-01-09 · tag F0908 — failed to keep essential equipment working — isolatedKeep all essential equipment working safely.
What the surveyor found here — the official record, unedited, may be distressing
Based on observations and staff interview, facility staff failed to maintain essential equipment in safe condition as evidenced by dish machine final rinse temperatures that were below 180 degress Fahrenheit on January 4, 2023, at approximately 2:30 PM. The findings included: During observation in dietary services on January 4, 2023, at approximately 2:30 PM, final rinse temperatures from the dish machine were about 154 degress Fahrenheit and did not reach a minimum of 180 degress Fahrenheit (F) as required. Dishes and utensils were disinfected from the three-compartment sink disinfectant solution. Final rinse temperatures were at or above 180°F on January 5, 2023, at approximately 2:30 PM Employee #4 acknowledged the findings on January 4, 2023, at approximately 3:00 PM.
- Potential for harm · D2023-01-09 · tag F0925 — failed to control pests — isolatedMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and staff interview, facility staff failed to maintain an effective pest control program as evidenced by a crawling pest observed on the floor, around the flat grill, in dietary services. The findings included: A crawling pest was seen on the kitchen floor, by the flat grill, on January 5, 2023, at approximately 2:30 PM. The vermin was removed and discarded by staff. Employee #4 (Director of Nutrition Food) acknowledged the findings on January 6, 2023, at approximately 10:00
- Potential for harm · Ecited before2021-04-23 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — the official record, unedited, may be distressing
Based on observations and staff interview, facility staff failed to prepare and distribute foods under sanitary conditions as evidenced by one (1) of two (2) soiled convection oven in the bake shop area, two (2) of two (2) soiled convection ovens in the patient hotline area, and 32 of 33 food service trays that were cracked at both handles. The findings included . During a walkthrough of dietary services on 04/19/2021, at approximately 11:15 AM, the following were observed: 1. One (1) of two (2) convection ovens in the bake shop area was soiled with burnt food residue. 2. Two (2) of two (2) convection ovens in the patient hotline area were soiled with burnt food residue. 3. 32 of 33 food service trays stored for use in the dishwashing machine area were cracked at both handles. Employee #4 acknowledged the findings during the walkthrough on 04/19/2021, at approximately 2:00 PM.
- Potential for harm · Ecited before2021-04-23 · tag F0908 — failed to keep essential equipment working — patternKeep all essential equipment working safely.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and staff interview, facility staff failed to maintain essential equipment in good working condition as evidenced by two (2) of six (6) convection ovens with a loose door handle, and one (1) of two (2) steam kettles that intermittently blew out steam from its connection valve in the patient hotline area. The findings included . During a walkthrough of dietary services on 04/19/2021, at approximately 11:15 AM, essential pieces of equipment were not functioning as intended: 1. One (1) of two (2) convection ovens in the bake shop area had a loose door handle. 2. One (1) of four (4) convection ovens at station #6 had a loose door handle. 3. The connection valve located at the bottom of one (1) of two (2) steam kettles kept releasing occasional bursts of steam in the patient hotline area. Employee #4 acknowledged the findings during the walkthrough on 04/21/2021, at approximately 2:00 PM.
- Potential for harm · D2021-04-23 · tag F0557 — isolatedHonor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview, for one (1) of 17 sampled residents, facility staff failed to treat a resident with an indwelling catheter with respect and dignity as evidenced by his urinary collection bag being exposed while walking in the hallway. Resident #284. The findings included . Resident #284 was admitted to the facility on [DATE], with diagnoses that included: Left hip postop wound infection, Deep Vein Thrombosis (DVT), Post-Operative Pain, Difficulty Urinating due to Benign Prostatic Hypertension and Insomnia. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed in Section H (Bowel and Bladder) 16 Fr [French] Catheter Balloon size 10mL (milliliters) Placement 4/8/2021 by urology. Review of the care plan dated 04/14/2021, revealed for the problem, Indwelling Catheter Maintenance, intervention #12, Nursing staff will ensure resident's Foley bag is covered when out of resident's room to ensure resident dignity During a tour of unit 3 south on 04/20/2021, at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-04-23 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, for one (1) of 17 sampled residents, facility staff failed to update the resident's code status and failed to address the resident's option to formulate an Advanced Directive. Resident #3. The findings included . Resident #3 was admitted to facility on [DATE], with diagnoses that included: Constipation, Diabetic Ulcer of Left Foot and Type 2 Diabetes Mellitus (DM). Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #3 had a Brief Interview for Mental Status Score (BIMS) of 15 indicating intact cognition. Review of the Code Status History revealed an order which directed, Code status CPR (cardiopulmonary resuscitation)- Full . with an active date of [DATE] at 1704 (5:04 PM). According to the physician's order, Resident #3's code status became inactive on [DATE] at 0720 (7:20 AM) . Review of the electronic health record (EHR) on [DATE], at 11:31 AM in the section labeled Code Status revealed the entry, update needed. Review of the paper chart…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-04-23 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, for one (1) of 17 sampled residents, the facility's staff failed to update/revise the compromised skin integrity care plan to address a resident's impaired skin integrity. Resident #20. The findings included . Resident #20 was admitted to the facility on [DATE], with multiple diagnoses, including Fracture of the Tibial Plateau, Status Post Open Reduction and Internal Fixation, Deep Vein Thrombosis, Rheumatoid Arthritis, and Osteoporosis. Review of the Care Plan (Compromised Skin Integrity) with a start date of 03/18/2021, revealed the following Interventions: .2. Observe and relieve pressure to boney prominences. 3. Avoid sheering. 4. Keep skin clean and dry .6. Apply or encourage use of lotion/moisturizer on intact skin as indicated .8. Consult with wound, ostomy and/or continence nurse as needed. Review of the admission Minimum Data Set (Assessment Reference Date of 03/24/21), docuemnted the following: in Section C0500 (Brief Interview for Mental Status), the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-04-23 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — the official record, unedited, may be distressing
Based on one (1) of one (1) medication storage observation, facility staff failed to ensure that a syringe containing Neurontin (an anti-epileptic drug) was not stored for use beyond the expiration date. The findings included . During an observation of the 3 south medication refrigerator on 04/20/2021, at approximately 10:45 AM, it was observed that one (1) of one (1) syringe labeled, Neurontin 250 mg (milligrams)/5 ml (milliliters) solution 300 mg dose = 8 ml expiration date 4/18/21 was stored for use. Employee #9 acknowledged the finding at the time of the observation and stated that the resident had been discharged and that the medication should have been removed from the unit by the pharmacy technician during their rounds.
- Potential for harm · Dcited before2021-04-23 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on two (2) of two (2) observations, record review and staff interview, facility staff failed to maintain infection control prevention practices in accordance with standards of practice to minimize the potential spread of infections. The findings included . 1. Facility staff failed to don required personal proctective equipment while in a resident care area. During a tour of unit 3 south on 04/19/2021, at approximately 11:00 AM, it was noted that there was a sign on all the resident's doors that revealed, Please wear the following when entering in resident's room: Gown, gloves, surgical mask, face shield . During an observation on 04/19/2021, at 1:18 PM, Employee #10 was observed inside resident room [ROOM NUMBER], not wearing a gown while setting up the resident's meal tray. It should be noted that the employee was wearing a mask, face shield and gloves. During a face-to face interview conducted at the time of the observation, Employee #10 acknowledged the finding and stated, I just came back from lunch…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2019-09-13 · tag F0565 — failed to support the resident council — patternHonor the resident's right to organize and participate in resident/family groups in the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and staff interviews, facility staff failed to act promptly upon the May and July 2019, grievances of the Resident Council concerning issues related to resident care and life in the facility. The resident census was 27 on the first day of the survey. Findings included . The Facility's Grievance Policy last revised 08/12/2019 Stipulated: .2)A grievance and/or complaint may be submitted orally or in writing by the resident or the person filing the grievance and/or complaint to the appropriate area of responsibility .6) the resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems. Such report will be made orally by the Administrator or his or her designee within five (5) working days of the filing of the written report of the findings. A written summary of the report will also be provided to the resident. A review of the May 10, 2019 Resident Council meeting minutes showed residents had concerns which included…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2019-09-13 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interview, it was determined that facility staff failed to store, prepare and distribute foods under sanitary conditions as evidenced by expired food items: 11 of 11 forty-six fluid ounce containers of cranberry juice cocktail and one (1) of three (3) plastic containers of ready-for-use vegetable broth, soiled equipment - four (4) of six (6) convection ovens and oven racks, one (1) of one (1) [NAME] Shaam brand food warmer, one (1) of one (1) Trauslen brand food warmer with shelves, 24 of 24 plastic containers of various sizes, and 40 of 80 food trays stored in the dishwashing area that were cracked at the handles. Findings included . The following observations were made during a walkthrough of dietary services on September 9, 2019, at approximately 10:05 AM: 1. 11 of 11 forty-six fluid ounce containers of cranberry juice cocktail located in the dry storage room were labeled with a 'best before' date of January 22, 2019. 2. One (1) of three (3) plastic container of ready-for-use…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2019-09-13 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and staff interview the facility staff failed to develop a system of surveillance to identify infections or communicable diseases; and failed to store drinkware under sanitary conditions as evidenced by 55 of 55 clean drinking cups were stacked wet in the dishwashing room. The census on the first day of survey was 27. Findings included . 1. Facility staff failed to develop a system of surveillance to identify infections or communicable diseases that are facility or community acquired. Review of the facility's Infection Control Surveillance logs for May, June and July 2019, list the following information: Medical record number, [resident] name, admit date , culture date, organism, unit/room, comments, opportunities for improvement, unit manager notified . The surveillance logs lacked evidence that the facility staff established a system for surveillance inclusive of the following components: a systematic collection, analysis, interpretation, and dissemination of surveillance data to identify infections acquired within the facility and from the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-09-13 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on an resident interviews during the group meeting, record review and staff interview for four (4) of 26 sampled residents, it was determined that facility staff failed to respond with timeliness to resident call lights when they request assistance. Residents' #1, 5, 29 and T1. Findings include . A review of the May 10, 2019 Resident Council meeting minutes showed residents had concerns which included .would like there to be more consistency with staff here .they need more staff here on the weekend, not enough help to go around for everyone .they need more staff so the wait time is less . The meeting minutes also included the facility's response to the resident's previously identified concerns included, Resident's thoughts, comments and concerns immediately addressed. All patients were provided with Shining Star forms. The July 26, 2019 Resident Council meeting minutes showed residents had the following concerns, which included .There is a lot of confusion about the medicine I am taking and what they are for. Nurse cannot seem to give me a straight answer . Resident's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-09-13 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record reviews, and interviews, the facility's staff failed to ensure that three (3) of 26 sampled residents' Care Plans were patient-centered (Residents' #5, #18, and #90) Findings include . 1. Review of Resident #5 current medical record on 09/13/19 at 11:45 AM showed that the resident was admitted on [DATE] with multiple diagnoses including Chronic Pain. Further review of the record revealed a Care Plan dated 04/18/19 that document Resident #5 used a non-pharmacological cold therapy device for pain management. Observation of the resident's room on 09/11/19 at 10: 15 AM, however, failed to evidence a cold therapy device. During a face-to-face interview on 09/13/19 at 1:00 PM, with the Unit Manager, she stated that the resident never used a cold therapy device, and that type of therapy was a general intervention used for pain management. The Unit Manager also said that she would update and remove the cold therapy device from Resident #5's Care Plan dated 04/13/19. 2. Review of Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-09-13 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility's nursing staff failed to appropriately and accurately assess a significant change of deep tissue wound for one (1) of 26 sampled residents (Resident #18). Findings include . Centers for Medicaid and Medicare Services, State Operation Manual Appendix PP-Guidance to Surveyors for Long Term Care Deep Tissue Pressure Injury .once a deep tissue injury opens to an ulcer, reclassify the ulcer into the appropriate stage . Pressure Ulcer/Injury Characterizes .With each dressing change or at least weekly (and more often when indicated by wound complications or changes in wound characteristics), an evaluation of the PU/PI should be documented. At a minimum, documentation should include the date observed and: - Location and staging; - Size (perpendicular measurements of the greatest extent of length and width of the PU/PI), depth; and the presence, location and extent of any undermining or tunneling/sinus tract; - Exudate, if present: type (such as purulent/serous), color,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-09-13 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, an attending physician failed to document the reason for the continued dose of a medication identified by the pharmacist to increase falls for one (1) of 26 sampled residents (Resident #18). Findings include . Review of Resident # 18's current medical record starting on 09/11/19 at 9:45 AM showed that the resident was admitted on [DATE] with several diagnoses, including Insomnia (unspecified type). Further review of the record revealed that the resident was ordered Temazepam (pharmacologic class: benzodiazepine) 30 mg, orally, nightly as needed for sleep on 07/11/19. Continued review of the record revealed that the facility's pharmacist recommended decreasing the dose of the Temazepam, during three (3) medication regimen reviews, as evidenced below: 07/12/19- Consider reducing the dose of Temazepam to 7.5 - 15 mg (milligrams) if you wish to continue therapy. Patient is at increased risk of falling. 08/09/19- Please consider discontinuing Temazepam 30 mg (milligrams), which…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-09-13 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility's staff failed to: monitor and document Resident #18's response to a PRN (as needed) medication for one (1) of 26 sampled residents. (Resident #18). Findings include . The facility's staff failed to monitor and document Resident #18's response to a PRN medication. Review of Resident #18's current medical record starting on 09/11/19 at 9:45 AM showed that the resident was admitted on [DATE], with several diagnoses, including Insomnia (unspecified type). Further review of the record revealed that the resident was ordered Temazepam (used to treat insomnia) 30 mg, orally, nightly as needed for sleep on 07/11/19. Further review of the record showed the following physician's order, Temazepam 30 mg, orally, nightly as needed for sleep on 07/11/19. Continued review showed the Medication Administration Record dated from 07/11/19 through 09/11/19 which documented the resident received the Temazepam 30 mg, orally every night except on 07/17/19, 07/26/19, and 09/10/19 when…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$8,827 in federal fines across 1 penalty.
- $8,827 — penalty dated 2024-02-06
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| THE JOHNS HOPKINS HEALTH SYSTEM CORPORATION | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 11/01/2010 |
| ABELE, JENNIFER | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 07/01/2020 |
| AMMERMAN, JOSHUA | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 12/09/2013 |
| ARGO, ARCHIE | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 10/22/2004 |
| BARTON, WILLIAM | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 05/23/1997 |
| CARPENTER, CAROLYN | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 08/24/2020 |
| CECIL, GUY | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 07/01/2023 |
| CERNEA, ANDREI | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 02/01/2021 |
| CRYER, DONNA | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 07/01/2019 |
| DURAN, MISHAELA | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 07/01/2024 |
| FARR, MICHAEL | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 01/24/2003 |
| HAJJ, AHMAD | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 07/01/2024 |
| HARRINGTON, JENNY | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 07/01/2023 |
| HERTZ, HARRY | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 07/01/2017 |
| HORTON, KAREN | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 07/01/2022 |
| HUMPHRIES, FRED | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 07/01/2023 |
| LEWIN, CYNTHIA | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 07/01/2023 |
| LEWIS, JOAN | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 07/01/2018 |
| MALLETT, ROBERT | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 07/01/2020 |
| MARSHALL, CAPRICIA | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 07/01/2018 |
| MILLER, EDWARD | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 05/13/1988 |
| MIYAMOTO, SUZANNE | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 07/01/2024 |
| MORRIS, RICHARD | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 05/23/2007 |
| MULLICK, ANU | Individual | CORPORATE DIRECTOR | — | since 05/21/2023 |
| PARKER, CHARLES | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 07/01/2023 |
| PAUL, MARTIN | Individual | CORPORATE DIRECTOR | — | since 07/01/2016 |
| SCHAEFER, THOMAS | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 10/09/1987 |
| SILBERMAN, ROBERT | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 07/01/2016 |
| STRAWBRIDGE, WELSH | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 07/01/2024 |
| WRIGHT, PANDIT | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 07/01/2023 |
| ELYANOW, KIMBERLY | Individual | CORPORATE OFFICER; ADP OF THE SNF | — | since 08/08/2022 |
| HENDRICKS-JACKSON, LAURA | Individual | CORPORATE OFFICER; ADP OF THE SNF | — | since 08/22/2018 |
| MANCINO, PETER | Individual | CORPORATE OFFICER; ADP OF THE SNF | — | since 07/01/2017 |
| OWENS, PAMELA | Individual | CORPORATE OFFICER; ADP OF THE SNF | — | since 07/01/2017 |
| PRATT, TIFFANY | Individual | CORPORATE OFFICER; ADP OF THE SNF | — | since 06/05/2023 |
| REINARD, CHRIS | Individual | CORPORATE OFFICER | — | since 01/01/2025 |
| SHAFA, CAROLINE | Individual | CORPORATE OFFICER | — | since 05/01/2013 |
| SOWERS, KEVIN | Individual | CORPORATE OFFICER | — | since 02/01/2018 |
| ZIA, HASAN | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/01/2019 |
| BARRON, JESSICA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2024 |
| BULEN, JAMES | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2024 |
| CRICKENBERGER, BRIAN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2024 |
CMS files one row per role, so the 79 rows in the source record cover these 42 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
What families pay in DC
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the District of Columbia Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner. The starred figure is the national median (no state figure published).
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 095030. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2023-01-09, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.