District of Columbia ›Washington

Capitol City Rehab and Healthcare Center

2425 25th Street SE, Washington, DC 20020 · The District County · 360 certified beds · avg 289 residents/day · certified since Jun 22, 1989

Abuse citation flag (CMS)

Part of chain: PRESTIGE HEALTHCARE ADMINISTRATIVE SERVICES (15 facilities, chain avg rating 3.2★)

The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.

1/5
Health inspection rating (on-site)
13
Serious findings on record
$384,200
Fines, last 3 years
4.59
Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5

⚠ The most recent standard health inspection was more than 2 years ago — conditions may have changed.

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

Most serious findings (actual harm or immediate jeopardy)

▲ Immediate jeopardy, one-off · Jun 20, 2024 · F-0600 · triggered by a complaint

The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.

Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.

Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.

Corrected: Aug 15, 2024 (Deficient, Provider has date of correction)

▲ Immediate jeopardy, one-off · May 6, 2024 · F-0689 · triggered by a complaint

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.

Corrected: Jul 25, 2024 (Deficient, Provider has date of correction)

▲ Immediate jeopardy, one-off · Aug 25, 2023 · F-0610 · triggered by a complaint

The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do.

Why it matters: When allegations aren't investigated, harm to residents can continue unchecked.

Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.

Corrected: Dec 12, 2023 (Deficient, Provider has date of correction)

▲ Immediate jeopardy, one-off · Aug 25, 2023 · F-0745 · triggered by a complaint

The facility did not provide the social services residents need — such as counseling, help with adjustment, or connecting to outside resources — to achieve the best possible quality of life.

Why it matters: Without social services support, residents can struggle emotionally and miss out on help they're entitled to.

Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.

Corrected: Dec 12, 2023 (Deficient, Provider has date of correction)

▲ Immediate jeopardy, repeated · Mar 10, 2023 · F-0760

The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.

Why it matters: A serious medication error can cause real harm, hospitalization, or worse.

Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.

Corrected: Jul 6, 2023 (Deficient, Provider has date of correction)

▲ Immediate jeopardy, repeated · Mar 10, 2023 · F-0761

The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.

Why it matters: Unlocked or mislabeled medications can be taken by the wrong person or given in error, with serious consequences.

Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.

Corrected: Jul 6, 2023 (Deficient, Provider has date of correction)

▲ Immediate jeopardy, one-off · Mar 10, 2023 · F-0624

The facility did not properly prepare residents for a safe transfer or discharge. Before a resident leaves, the facility must get them ready and make sure the move is safe and orderly.

Why it matters: An unprepared discharge can send a resident somewhere unsafe or without the care arrangements they need.

Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.

Corrected: Jun 9, 2023 (Deficient, Provider has date of correction)

▲ Immediate jeopardy, one-off · Mar 10, 2023 · F-0803

The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician.

Why it matters: When menus aren't planned and followed properly, residents may not get the nutrition their health depends on.

Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.

Corrected: Jun 9, 2023 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Feb 13, 2026 · F-0689 · triggered by a complaint

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Apr 15, 2026 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Aug 25, 2023 · F-0760 · triggered by a complaint

The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.

Why it matters: A serious medication error can cause real harm, hospitalization, or worse.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Oct 10, 2023 (Deficient, Provider has date of correction)

All citations in the current public record (163)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

DateSeverityWhat the facility was cited for
Feb 13, 2026▲ G · Actual harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Feb 13, 2026F · Potential for harm, facility-wideThe facility did not make its inspection results easy for residents to see, or made it hard for residents to contact advocacy agencies like the ombudsman. · from a complaint
Feb 13, 2026E · Potential for harm, repeatedThe facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint
Feb 13, 2026D · Potential for harm, one-offThe facility did not give residents reasonable access to and privacy in using ways to communicate, such as phones, mail, and email. Residents have the right to stay in touch with the outside world privately. · from a complaint
Feb 13, 2026D · Potential for harm, one-offThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint
Feb 13, 2026D · Potential for harm, one-offThe facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay). · from a complaint
Feb 13, 2026D · Potential for harm, one-offThe facility did not reassess a resident after a significant change in their condition, such as a sudden decline in health. A full new assessment is required when a resident's condition changes in a major way. · from a complaint
Feb 13, 2026D · Potential for harm, one-offThe facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · from a complaint
Feb 13, 2026D · Potential for harm, one-offThe facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint
Feb 13, 2026D · Potential for harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Feb 13, 2026D · Potential for harm, one-offThe facility did not help a resident get vision and hearing services — such as eye exams, glasses, hearing tests, or hearing aids. · from a complaint
Feb 13, 2026D · Potential for harm, one-offThe facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. · from a complaint
Feb 13, 2026D · Potential for harm, one-offThe facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. · from a complaint
Feb 13, 2026D · Potential for harm, one-offThe facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. · from a complaint
Feb 13, 2026D · Potential for harm, one-offThe facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives. · from a complaint
Feb 13, 2026D · Potential for harm, one-offThe facility did not serve meals and snacks at times that fit residents' needs, preferences, and requests, or did not offer nourishing alternatives for residents who want to eat outside scheduled meal times. · from a complaint
Feb 13, 2026D · Potential for harm, one-offThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · from a complaint
Feb 13, 2026D · Potential for harm, one-offThe facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint
Feb 13, 2026D · Potential for harm, one-offThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint
Feb 13, 2026D · Potential for harm, one-offThe facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices. · from a complaint
Feb 13, 2026D · Potential for harm, one-offThe facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area. · from a complaint
Feb 13, 2026D · Potential for harm, one-offThe facility did not have firmly secured handrails on both sides of its hallways. · from a complaint
Feb 13, 2026D · Potential for harm, one-offThe facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests. · from a complaint
Nov 13, 2025D · Potential for harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Nov 13, 2025D · Potential for harm, one-offThe facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint
Aug 26, 2025D · Potential for harm, one-offThe facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · from a complaint
Aug 26, 2025D · Potential for harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Aug 26, 2025D · Potential for harm, one-offThe facility did not safely and appropriately administer IV fluids (fluids given through a vein) for residents who needed them. · from a complaint
Aug 26, 2025D · Potential for harm, one-offThe facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. · from a complaint
Aug 26, 2025D · Potential for harm, one-offThe facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. · from a complaint
Aug 26, 2025D · Potential for harm, one-offThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint
Aug 26, 2025D · Potential for harm, one-offThe facility did not educate residents and staff about COVID-19 vaccination, offer the vaccine to those eligible after that education, or properly document everyone's vaccination status. · from a complaint
Apr 17, 2025D · Potential for harm, one-offThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
Apr 17, 2025D · Potential for harm, one-offThe facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint
Jun 20, 2024▲ J · Immediate jeopardy, one-offThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Jun 20, 2024D · Potential for harm, one-offThe facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. · from a complaint
Jun 20, 2024D · Potential for harm, one-offThe facility did not honor residents' right to share a room with their spouse or a roommate of their choosing, or moved residents to a different room without written notice beforehand. · from a complaint
Jun 20, 2024D · Potential for harm, one-offThe facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. · from a complaint
Jun 20, 2024D · Potential for harm, one-offThe facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. · from a complaint
May 6, 2024▲ J · Immediate jeopardy, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
May 6, 2024E · Potential for harm, repeatedThe facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · from a complaint
May 6, 2024D · Potential for harm, one-offThe facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint
May 6, 2024D · Potential for harm, one-offThe facility did not keep residents' personal and medical information private and confidential. · from a complaint
May 6, 2024D · Potential for harm, one-offThe facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. · from a complaint
May 6, 2024D · Potential for harm, one-offThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
May 6, 2024D · Potential for harm, one-offThe facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint
May 6, 2024D · Potential for harm, one-offThe facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint
May 6, 2024D · Potential for harm, one-offThe facility was not managed in a way that uses its money, staff, and resources effectively and efficiently to care for residents. · from a complaint
May 6, 2024D · Potential for harm, one-offThe facility did not have a proper governing body legally responsible for its policies and operations, or that body failed to appoint a properly licensed administrator to manage the facility. · from a complaint
May 6, 2024D · Potential for harm, one-offThe facility did not conduct and document a facility-wide assessment of what staff, supplies, and resources it needs to care for its residents properly — during everyday operations, nights, weekends, and emergencies. · from a complaint
May 6, 2024D · Potential for harm, one-offThe facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint
May 6, 2024D · Potential for harm, one-offThe facility did not have a written plan describing how it runs its quality improvement program — the ongoing process of finding problems in care and fixing them. · from a complaint
May 6, 2024D · Potential for harm, one-offThe facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices. · from a complaint
Aug 25, 2023▲ J · Immediate jeopardy, one-offThe facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint
Aug 25, 2023▲ J · Immediate jeopardy, one-offThe facility did not provide the social services residents need — such as counseling, help with adjustment, or connecting to outside resources — to achieve the best possible quality of life. · from a complaint
Aug 25, 2023▲ G · Actual harm, one-offThe facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint
Aug 25, 2023F · Potential for harm, facility-wideThe facility was not managed in a way that uses its money, staff, and resources effectively and efficiently to care for residents. · from a complaint
Aug 25, 2023F · Potential for harm, facility-wideThe facility did not have a proper governing body legally responsible for its policies and operations, or that body failed to appoint a properly licensed administrator to manage the facility. · from a complaint
Aug 25, 2023F · Potential for harm, facility-wideThe facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. · from a complaint
Aug 25, 2023E · Potential for harm, repeatedThe facility was not properly licensed, or did not operate in compliance with federal, state, and local laws, regulations, and accepted professional standards. · from a complaint
Aug 25, 2023D · Potential for harm, one-offThe facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave. · from a complaint
Aug 25, 2023D · Potential for harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Mar 10, 2023▲ K · Immediate jeopardy, repeatedThe facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
Mar 10, 2023▲ K · Immediate jeopardy, repeatedThe facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Mar 10, 2023▲ J · Immediate jeopardy, one-offThe facility did not properly prepare residents for a safe transfer or discharge. Before a resident leaves, the facility must get them ready and make sure the move is safe and orderly.
Mar 10, 2023▲ J · Immediate jeopardy, one-offThe facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician.
Mar 10, 2023▲ G · Actual harm, one-offThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Mar 10, 2023F · Potential for harm, facility-wideThe facility did not have a written plan describing how it runs its quality improvement program — the ongoing process of finding problems in care and fixing them.
Mar 10, 2023E · Potential for harm, repeatedThe facility did not properly hold, secure, and manage residents' personal money that was deposited with it for safekeeping. Facilities holding residents' funds must keep careful, honest accounts.
Mar 10, 2023E · Potential for harm, repeatedThe facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care.
Mar 10, 2023E · Potential for harm, repeatedThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs.
Mar 10, 2023E · Potential for harm, repeatedThe facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly.
Mar 10, 2023E · Potential for harm, repeatedThe facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required.
Mar 10, 2023E · Potential for harm, repeatedThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Mar 10, 2023E · Potential for harm, repeatedThe facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature.
Mar 10, 2023E · Potential for harm, repeatedThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Mar 10, 2023E · Potential for harm, repeatedThe facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards.
Mar 10, 2023E · Potential for harm, repeatedThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Mar 10, 2023E · Potential for harm, repeatedThe facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations.
Mar 10, 2023E · Potential for harm, repeatedThe facility did not educate residents and staff about COVID-19 vaccination, offer the vaccine to those eligible after that education, or properly document everyone's vaccination status.
Mar 10, 2023D · Potential for harm, one-offThe facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand.
Mar 10, 2023D · Potential for harm, one-offThe facility did not inform residents of their visitation rights or did not treat all visitors equally. Residents have the right to receive the visitors they choose.
Mar 10, 2023D · Potential for harm, one-offThe facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away.
Mar 10, 2023D · Potential for harm, one-offThe facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection.
Mar 10, 2023D · Potential for harm, one-offThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation.
Mar 10, 2023D · Potential for harm, one-offThe facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable.
Mar 10, 2023D · Potential for harm, one-offThe facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Mar 10, 2023D · Potential for harm, one-offThe facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Mar 10, 2023D · Potential for harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Mar 10, 2023D · Potential for harm, one-offThe facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Mar 10, 2023D · Potential for harm, one-offThe facility did not make sure residents actually saw their doctor face-to-face at all required visits. Doctors must examine nursing home residents in person on a regular schedule.
Mar 10, 2023D · Potential for harm, one-offThe facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems.
Mar 10, 2023D · Potential for harm, one-offThe facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area.
Dec 23, 2021F · Potential for harm, facility-wideThe facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems.
Dec 23, 2021F · Potential for harm, facility-wideThe facility did not conduct and document a facility-wide assessment of what staff, supplies, and resources it needs to care for its residents properly — during everyday operations, nights, weekends, and emergencies.
Dec 23, 2021F · Potential for harm, facility-wideThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Dec 23, 2021E · Potential for harm, repeatedThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs.
Dec 23, 2021E · Potential for harm, repeatedThe facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Dec 23, 2021E · Potential for harm, repeatedThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Dec 23, 2021E · Potential for harm, repeatedThe facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Dec 23, 2021E · Potential for harm, repeatedThe facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline.
Dec 23, 2021E · Potential for harm, repeatedThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Dec 23, 2021E · Potential for harm, repeatedThe facility did not provide safe and appropriate pain management for a resident who needed it.
Dec 23, 2021E · Potential for harm, repeatedThe facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason.
Dec 23, 2021E · Potential for harm, repeatedThe facility did not provide routine dental care and 24-hour emergency dental care for residents.
Dec 23, 2021E · Potential for harm, repeatedThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Dec 23, 2021E · Potential for harm, repeatedThe facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards.
Dec 23, 2021E · Potential for harm, repeatedThe facility did not educate residents and staff about COVID-19 vaccination, offer the vaccine to those eligible after that education, or properly document everyone's vaccination status.
Dec 23, 2021D · Potential for harm, one-offThe facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
Dec 23, 2021D · Potential for harm, one-offThe facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups.
Dec 23, 2021D · Potential for harm, one-offThe facility did not give residents reasonable access to and privacy in using ways to communicate, such as phones, mail, and email. Residents have the right to stay in touch with the outside world privately.
Dec 23, 2021D · Potential for harm, one-offThe facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care.
Dec 23, 2021D · Potential for harm, one-offThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Dec 23, 2021D · Potential for harm, one-offThe facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection.
Dec 23, 2021D · Potential for harm, one-offThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation.
Dec 23, 2021D · Potential for harm, one-offThe facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do.
Dec 23, 2021D · Potential for harm, one-offThe facility transferred or discharged a resident without a valid reason, or failed to provide the required documentation and information when moving a resident out.
Dec 23, 2021D · Potential for harm, one-offThe facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal.
Dec 23, 2021D · Potential for harm, one-offThe facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave.
Dec 23, 2021D · Potential for harm, one-offThe facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Dec 23, 2021D · Potential for harm, one-offThe facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services.
Dec 23, 2021D · Potential for harm, one-offThe facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required.
Dec 23, 2021D · Potential for harm, one-offThe facility did not properly plan a resident's discharge to meet the resident's goals and needs after leaving.
Dec 23, 2021D · Potential for harm, one-offThe facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own.
Dec 23, 2021D · Potential for harm, one-offThe facility did not help a resident get vision and hearing services — such as eye exams, glasses, hearing tests, or hearing aids.
Dec 23, 2021D · Potential for harm, one-offThe facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections.
Dec 23, 2021D · Potential for harm, one-offThe facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Dec 23, 2021D · Potential for harm, one-offThe facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.
Dec 23, 2021D · Potential for harm, one-offThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
Dec 23, 2021D · Potential for harm, one-offThe facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Dec 23, 2021D · Potential for harm, one-offThe facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature.
Dec 23, 2021D · Potential for harm, one-offThe facility did not provide or arrange specialized rehabilitation services — such as physical, occupational, or speech therapy — for residents who needed them.
Dec 23, 2021D · Potential for harm, one-offThe facility did not perform required COVID-19 testing on residents and staff.
Dec 23, 2021D · Potential for harm, one-offThe facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices.
Dec 23, 2021D · Potential for harm, one-offThe facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area.
Feb 20, 2020▲ G · Actual harm, one-offThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Feb 20, 2020▲ G · Actual harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Feb 20, 2020F · Potential for harm, facility-wideThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Feb 20, 2020E · Potential for harm, repeatedThe facility did not properly hold, secure, and manage residents' personal money that was deposited with it for safekeeping. Facilities holding residents' funds must keep careful, honest accounts.
Feb 20, 2020E · Potential for harm, repeatedThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs.
Feb 20, 2020E · Potential for harm, repeatedThe facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required.
Feb 20, 2020E · Potential for harm, repeatedThe facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
Feb 20, 2020E · Potential for harm, repeatedThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Feb 20, 2020E · Potential for harm, repeatedThe facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices.
Feb 20, 2020E · Potential for harm, repeatedThe facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area.
Feb 20, 2020D · Potential for harm, one-offThe facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
Feb 20, 2020D · Potential for harm, one-offThe facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups.
Feb 20, 2020D · Potential for harm, one-offThe facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care.
Feb 20, 2020D · Potential for harm, one-offThe facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection.
Feb 20, 2020D · Potential for harm, one-offThe facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do.
Feb 20, 2020D · Potential for harm, one-offThe facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Feb 20, 2020D · Potential for harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Feb 20, 2020D · Potential for harm, one-offThe facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections.
Feb 20, 2020D · Potential for harm, one-offThe facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Feb 20, 2020D · Potential for harm, one-offThe facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes.
Feb 20, 2020D · Potential for harm, one-offThe facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.
Feb 20, 2020D · Potential for harm, one-offThe facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail.
Feb 20, 2020D · Potential for harm, one-offThe facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident.
Feb 20, 2020D · Potential for harm, one-offThe facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day.
Feb 20, 2020D · Potential for harm, one-offThe facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems.
Feb 20, 2020D · Potential for harm, one-offThe facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits.
Feb 20, 2020D · Potential for harm, one-offThe facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature.
Feb 20, 2020D · Potential for harm, one-offThe facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them.

Inspection trend by year

Citations from standard inspections decreased between the last two inspection cycles (42 → 31).

YearCitationsSerious (G–L)Worst severity that year
2020282G ▲
2021420F
2023408K ▲
2024192J ▲
2025110D
2026231G ▲

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

4 fines totaling $384,200, plus 2 Medicare payment denial periods.

DateTypeAmount / length
Feb 13, 2026Fine$199,800
May 6, 2024Fine$121,632
May 6, 2024Payment Denial21 days from Jul 25, 2024
Aug 25, 2023Fine$14,908
Aug 25, 2023Fine$47,860
Aug 25, 2023Payment Denial17 days from Nov 25, 2023

Nurse staffing (from payroll records, adjusted for how much care residents need)

MeasureThis facilityDistrict of Columbia avgU.S. avgWhere it stands
Total nurse staffing (hours per resident per day)4.594.763.95top 47% in District of Columbia; top 21% in the U.S.
Registered Nurse hours1.081.480.69bottom 20% in District of Columbia; top 13% in the U.S.
Weekend total nurse staffing4.264.353.50bottom 47% in District of Columbia; top 16% in the U.S.
Weekend RN hours (not acuity-adjusted)0.851.280.48bottom 27% in District of Columbia; top 10% in the U.S.
Total nursing staff turnover (%)46.234.045.8bottom 27% in District of Columbia; bottom 47% in the U.S.
RN turnover (%)41.832.542.9bottom 20% in District of Columbia; bottom 49% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.20, RN 0.99, weekend 3.90. Staffing rating: 4/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 4/5 · long-stay residents: 5/5 · short-stay residents: 3/5

Who owns this facility

For profit - Limited Liability company

Owner / managerTypeRoleStakeSince
Karmel, JacobIndividual5% or Greater Direct Ownership Interest90%09/01/2020
Stern, MosheIndividual5% or Greater Direct Ownership Interest10%09/01/2020
Brice, JohnIndividualW-2 Managing EmployeeNOT APPLICABLE09/01/2020

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

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Facility data as of CMS processing date 2026-08-01. CCN 095022.