Based on record review and staff interviews, for two (2) of 12 sampled residents, facility staff failed to implement corrective actions to prevent further potential abuse or mistreatment of Resident #12 while the investigation is in progress and failed to conduct a thorough investigation of Resident #2's allegation of employee abuse. Residents' #12 and #2. The findings included: Review of the facility policy Abuse, Neglect and Exploitation last reviewed on 05/19/23 documented, .Investigations of alleged abuse .include . identifying and interviewing all involved persons, including . …
F610 citations in District of Columbia
Investigating alleged violations · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
District of Columbia cites F610 more often than its own record predicts
1.58 times the share F610 takes of citations nationally.
Of every deficiency written in District of Columbia in 2025, this is the portion that was F610.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What District of Columbia surveyors wrote
F610 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 53 sampled residents, facility staff failed to complete a thorough investigation for a facility-reported incident (FRI) that alleged a facility staff removed a 10-tablet blister pack of Resident #38's narcotic pain medication.The findings included:Resident #38 was admitted to the facility on [DATE] with diagnoses that included: Pressure Ulcer of Sacral Region Stage 4, Anoxic Brain Damage; Epilepsy; and Muscle Weakness.Review of the resident's medical record revealed the following:A physician's order dated 08/21/25 that directed: Tramadol (narcotic pain reliever) HCl oral tablet 50 mg (milligram), give 50 mg via PEG-Tube (Percutaneous Endoscopic Gastrostomy tube) every 8 hours for moderate to severe pain.The Medication… …
The short window
Recent years
| Year | Share of District of Columbia citations | vs expected |
|---|---|---|
| 2023 | 5.45% | 4.26× |
| 2024 | 3.06% | 2.14× |
| 2025 | 2.40% | 1.58× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else District of Columbia surveyors cite →
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