Based on staff and resident interviews for one (1) of three (3) residents, it was determined that facility staff failed to notify the physician timely when the sacral wound deteriorated and additionally, the progression of an excoriated peri area. Resident #1 The findings include: Resident # 1 was admitted on (MONTH) 4, (YEAR). He/she was transferred to the hospital on (MONTH) 9, (YEAR) through (MONTH) 5, (YEAR) for rapid heart rate and difficulty breathing. Resident #1 was hospitalized on (MONTH) 25, (YEAR) for heavy amount of purulent drainage with odor from the sacroguteal wound and did not return to the facility. …
F580 citations in District of Columbia
Notifying of changes · Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
District of Columbia cites F580 more often than its own record predicts
1.08 times the share F580 takes of citations nationally.
Of every deficiency written in District of Columbia in 2025, this is the portion that was F580.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What District of Columbia surveyors wrote
F580 findings written in District of Columbia, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on record review and staff interviews, for one (1) of 1 sampled residents who had an outside speech-language pathologist consultation, the facility failed to have documented evidence that they discussed with the resident's physician: (1) they were not able to schedule a Modified Barium Swallow Study (diagnostic test) in 8 weeks, as recommended by outside speech therapist on 03/06/25 and approved the facility's nurse practitioner on 03/07/25; and (2) the resident not provided swallowing exercises, chin tucks, and effort swallow techniques as recommended by an outside speech-language pathologist on 03/06/25 and approved the facility's nurse practitioner on 03/07/25. …
The short window
Recent years
| Year | Share of District of Columbia citations | vs expected |
|---|---|---|
| 2023 | 1.36% | 0.95× |
| 2024 | 1.53% | 1.01× |
| 2025 | 1.60% | 1.08× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else District of Columbia surveyors cite →
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