Based on review of a facility reported incident, medical records, facility documentation, and interviews with family members and staff, for four (4) of 101 sampled residents, the facility's staff failed to 1. safely administer medications in accordance with Standard of Practice or Manufactures Specifications as evidenced by (1) Employee #22 (Agency Registered Nurse; RN) administered one unit of Novolog R insulin to Resident #313 without a physician's order on [DATE], (2) Employee # 25 (Agency RN) signed that he administered medication to Resident #494 who had no medication in the facility, (3) Employee #11 (RN) administered Resident #5 a deceased resident's (Resident #488) medication (Gabapentin), and (4) storing and administering expired Humalog (Lispro) insulin medication to Resident #… …
F760 citations in District of Columbia
Significant medication errors · Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
District of Columbia cites F760 more often than its own record predicts
1.23 times the share F760 takes of citations nationally.
Of every deficiency written in District of Columbia in 2025, this is the portion that was F760.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What District of Columbia surveyors wrote
F760 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 interview, for one (1) of 12 sampled residents, facility staff failed to ensure that Resident #8 was free of a significant medication error. This failure resulted in actual harm to Resident #8 on July 19, 2023. The findings included: Review of the facility policy Medication Administration last revised on 05/10/23 documented, .Medications are administered by licenses nurses . as ordered by the physician and in accordance with the professional standards of practice, in a manner to prevent contamination or infection . obtain and record vital signs, when applicable or per physician orders. When applicable hold medication for those vital sounds outside the physician prescribed parameters . …
Based on record review and staff interviews for one (1) of 12 sampled residents, facility staff failed to ensure that one resident was free of a significant medication error as evidenced by ordering. transcribing and dispensing a medication that included an incorrect route for the Resident's medication. Resident #4 The findings included: Resident # 4 was admitted to the facility on [DATE] with diagnoses that included: Seizure Disorder, Adrenal Insufficiency, resolved COVID-19, Bowel dysfunction, Diabetes Mellitus DM, Intellectual Delay, Ogilvie syndrome, Gastrostomy Status, Dependence on Supplemental Oxygen, Aspiration Pneumonia. …
The short window
Recent years
| Year | Share of District of Columbia citations | vs expected |
|---|---|---|
| 2023 | 1.82% | 1.64× |
| 2024 | 0.51% | 0.44× |
| 2025 | 1.60% | 1.23× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else District of Columbia surveyors cite →
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