Based on observations, record reviews and staff interviews for six (6) residents and one (1) of three (3) of the six (6) residents with an active diagnosis of Dysphagia, it was determined that the facility's staff failed to ensure that Resident #1 was provided with adequate monitoring during meals, had a physician order to provide close supervision while eating, ensured speech documentation contained accurate information related to diet and liquid consistency, completed speech recommendations following a Modified Barium Swallow Study that showed laryngeal aspiration and failed to implement special dietary instructions for the resident whose diagnoses include oropharyngeal dysphagia. …
F684 citations in District of Columbia
Quality of care · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
District of Columbia cites F684 less often than its own record predicts
0.93 times the national share — cited less often here than elsewhere.
Of every deficiency written in District of Columbia in 2025, this is the portion that was F684.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What District of Columbia surveyors wrote
F684 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 ten (10) sampled residents, facility staff failed to administer 10 doses of Resident #71's ordered anticonvulsant medication from 06/06/25 through 06/12/25. Due to these failures, Resident #71 suffered harm as evidenced by having three (3) seizures during that time frame and required hospitalization. The findings included: Review of the facility policy titled, Medication and Treatment Orders dated 12/09/25 documented in part:Drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than three (3) days prior to the last dosage being administered to ensure that refills are readily available. …
Based on record reviews and staff interviews, for one (1) of five (5) sampled residents, facility staff failed to ensure that they followed Resident #1's physician's order to not be assigned a male Certified Nursing Assistant/CNA.The findings included: Resident #1 was admitted to the facility on [DATE] with multiple diagnoses that included Dementia, Congestive Heart Failure, Hypertension and Age Related Macular Degeneration. Review of the resident's medical record revealed the following: A physician's order dated 07/28/24 that directed, Per resident request - every shift, no male CNA. …
The short window
Recent years
| Year | Share of District of Columbia citations | vs expected |
|---|---|---|
| 2023 | 3.64% | 1.00× |
| 2024 | 3.06% | 0.77× |
| 2025 | 4.00% | 0.93× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else District of Columbia surveyors cite →
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction