LISNER LOUISE DICKSON HURTHOME
Non profit - Corporation
60 Beds
Independent
Data: November 2025
Trust Grade
85/100
#4 of 17 in DC
Last Inspection: April 2023
Over 2 years since last inspection. Current conditions may differ from available data.
Overview
The Lisner Louise Dickson Hurt Home has a Trust Grade of B+, which means it is recommended and above average compared to other facilities. It ranks #4 out of 17 in Washington, D.C., placing it in the top half of local nursing homes. The facility is improving, with issues decreasing from 9 in 2023 to just 2 in 2025. Staffing is a strong point, with a 5 out of 5-star rating and only an 18% turnover rate, significantly lower than the 34% state average, indicating stable and experienced staff. However, there are some concerns, including a failure to timely report a resident-to-resident abuse allegation and unsanitary food storage practices, though there have been no fines or critical issues reported. Overall, while there are strengths in staffing and quality ratings, families should be aware of the recent compliance issues.
- Trust Score
- B+
- In District of Columbia
- #4/17
- Safety Record
- Low Risk
- Inspections
- Getting Better
- Staff Stability ✓ Good
- 18% annual turnover. Excellent stability, 30 points below District of Columbia's 48% average. Staff who stay learn residents' needs.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most District of Columbia facilities.
- Skilled Nurses ✓ Good
- Each resident gets 68 minutes of Registered Nurse (RN) attention daily — more than 97% of District of Columbia nursing homes. RNs are the most trained staff who catch health problems before they become serious.
- Violations ⚠ Watch
- 23 deficiencies on record. Higher than average. Multiple issues found across inspections.
85/100
Top 23%
No red flags
9 → 2 violations
★★★★★
5.0
Overall Rating
★★★★★
5.0
Staff Levels
★★★★★
5.0
Care Quality
★★★★★
5.0
Inspection Score
↔
Stable
2023: 9 issues
2025: 2 issues
The Good
-
5-Star Staffing Rating · Excellent nurse staffing levels
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Low Staff Turnover (18%) · Staff stability means consistent care
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover is low (18%)
30 points below District of Columbia average of 48%
Facility shows strength in staffing levels, quality measures, staff retention, fire safety.
The Bad
No Significant Concerns Identified
This facility shows no red flags. Among District of Columbia's 100 nursing homes, only 1% achieve this.
The Ugly 23 deficiencies on record
Jun 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interviews for one (1) of 26 sampled residents, the facility staff failed to show documented e...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interviews for one (1) of 26 sampled residents, the facility staff failed to show documented evidence that an allegation of resident-to-resident sexual abuse was reported to the state agency in the required time frame of 24 hours as evidenced by an allegation of possible sexual abuse first documented in Resident #27's medical record on 04/22/24 but not reported to the state agency until 04/24/24. Resident #27.
The findings included:
A review of the facility's policy titled Policy and Procedures for Abuse Prevention Program with an effective date of June 2023 documented the following: Sexual abuse-this refers to non-consensual sexual contact of any type with a resident. It includes but is not limited to sexual harassment, sexual coercion, inappropriate touching or sexual assault. Should an incident investigation lead to suspicion or allegation of resident abuse, the administrator, or his/her designee, will appoint an individual to investigate the incident.
Resident #27 was admitted to the facility on [DATE] with multiple diagnoses that included the following: Unspecified Dementia Severe with Anxiety, Unspecified Glaucoma, Repeated Falls, and Unsteadiness on Feet.
A review of the medical record revealed the following:
A nurse's general note dated 04/22/24 at 1:44 PM documented Resident continues to be confused with no evidence of pain or discomfort.
A psychosocial progress note dated 04/22/24 at 3:06 PM documented in part, This SW (social worker) received report that the resident was observed hugging/kissing and being touched over her clothing by a male resident in the hallway outside her room around 10AM the prior day. It is unclear who initiated contact but resident was not upset by the physical touch. Residents separated by staff. This resident observed at the time/today for changes to behavior. None noted. Contact appeared reciprocal despite resident cognitive status. Guardian contacted. She stated that if the resident was not upset by the incident she has no immediate concerns but she wishes that they be kept separate in the future. She does not feel this is a case of sexual abuse even though the resident is severely demented.
A review of the facility's investigative documents into this incident showed that there were 54 statements from the facility staff that dated the incident as occurring on 04/21/24. One (1) statement not of the 54 was blank except for a signature on the line marked for supervisor and one (1) form not of the 54 had a check mark no to the question Did you witness this incident? The facility's investigation also contained 2 intakes that were submitted to the State Agency.
A review of a Facility Reported Incident (FRI) that was submitted to the State Agency on 04/24/24 documented the following: Staff observed this resident (Resident #27) and a male resident in the hallway. Residents were embracing. Male resident noted to kiss resident and touch resident's breasts. Resident is alert but not oriented. Resident was not tearful, did not become upset, did not push male resident away. Resident unable to give consent for physical contact due to severe dementia. Male resident (84) is alert and oriented x (times) 2-3 (to place and time) Residents separated. Male resident educated not to have physical contact with resident. Male resident denied additional occurrences. Male resident agreed to no future physical contact. Guardian of this female resident informed and did not wish to pursue this as abuse. Staff interviewed. No evidence of past occurrences noted other than what was observed. Residents have not had any physical contact for past several days. Investigation conducted and remains active at this time.
It is noted that there is no documented evidence that the facility submitted the allegation of sexual abuse to the State Agency in the required 24-hour timeframe.
During a face-to-face interview conducted on 06/20/25 at approximately 2:00 PM, Employee #2 (Director of Nursing) stated that the facility determined that this was not sexual abuse and acknowledged the findings.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
Based on observations and interview, during a tour of the kitchen on June 16, 2025, at approximately 10:45 AM, facility staff failed to store and distribute food under sanitary conditions.
The finding...
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Based on observations and interview, during a tour of the kitchen on June 16, 2025, at approximately 10:45 AM, facility staff failed to store and distribute food under sanitary conditions.
The findings include:
1. One (1) of one (1) thirty-two-ounce container of Liquid Whole Eggs with Citric Acid
stored in the walk-in refrigerator had a use-by date of April 24, 2025.
2. Three (3) of three (3) one and-one-half size pans, and four (4) of four (4) one-quarter
size pans were stacked wet, on a shelf, ready for use.
These findings were acknowledged by Employee #11 during a face-to-face interview on June 18, 2025, at approximately 10:00 AM.
Apr 2023
9 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, for one (1) of 29 sampled residents, facility staff failed to implement its policies...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, for one (1) of 29 sampled residents, facility staff failed to implement its policies and procedures for investigating an allegation of abuse. Resident #41.
The findings included:
Review of the facility policy titled [Facility Name] Abuse Investigation Protocol, not dated, documented, .The individual conducting the investigation will, as a minimum . Conduct all interviews in the presence of a witness; Make every effort to interview staff members giving direct care to the resident for two days prior to the incident . Interview any staff members or others who may have knowledge of the incident . The following guidelines will be used when conducting interviews .Witness reports will be reduced to writing. Witnesses will be required to sign and date such reports .
Resident #41 was admitted to the facility on [DATE] with diagnoses that included: Vascular Dementia, with Anxiety, Chronic Pain and Muscle Weakness.
A Quarterly Minimum Data Set (MDS) dated [DATE] showed facility staff coded: a Brief Interview for Mental Status (BIMS) Summary Score of 04, indicating severe cognitive impairment; no indicators of psychosis or behavior issues; required extensive assistance with one-person physical assist for bed mobility, transfers, dressing, toilet use and personal hygiene.
Resident #41's medical record revealed the following information:
03/21/22 at 2:47 PM [Psychosocial Note Late Entry] Care conference held on 3/17/2022 for quarterly review. Resident participated in assessment but did not wish to attend meeting. RP (representative) .notified of meeting but declined to attend. Care plan reviewed. Resident scored 4/15 on BIMS assessment. [Resident] was able to repeat 2/3 test words, could not recall test words with cueing, and was able to accurately state the month, but not day of the week or year. Resident is generally oriented to self, others, and place, although [resident] shows deficits in short-term memory as evidenced by repeating conversations and difficulty accurately recalling events .
03/23/22 at 4:42 AM [Nurses General Note] Resident continue c/o (complain of) throat discomfort. Throat culture collected, awaiting technician to pick it up. Resident remain afebrile. No coughing .Lung sounds clear on auscultation.
03/25/22 at 8:40 AM [Psychosocial Note] On 3/22/22, at Resident Council, resident reported concerns to include [resident] is treated roughly by staff and had a sore throat that was not addressed by staff. Staff investigated reports and RP . notified about concerns. Resident interviewed. Unable to give details of staff treatment such as which staff, which day or which shift the treatment occurred on .Staff interviewed. No unusual incidents observed. Staff to monitor resident for additional reports. Investigation closed at this time.
A Facility Reported Incident (FRI), DC00010646, received by the State Agency on 03/28/22 documented, On 3/22/22, at Resident Council, resident reported concerns to include [resident] treated roughly by staff and had a sore throat that was not addressed by staff. Staff investigated reports. Resident interviewed. Unable to give details of staff treatment such as which staff, which day or which shift the treatment occurred .
Review of the facility's investigation documents provided to this surveyor on 04/06/23 showed a typed document dated March 22, 2022 that documented, Investigation of Claims of Rough Handling- Resident Council. DN (Director of Nursing) interviewed [Resident #41] following resident council . DN verbally interviewed the following staff who are usual caregivers. [Names of four (4) staff members]. No unusual incidents observed .There is no evidence of abuse. Investigation concluded.
The 4 employee names who the Director of Nursing (DON) documented she verbally interviewed were cross-referenced to the facility's assignment sheets for dates 03/20/22 and 03/21/22 (the two days prior to the incident/allegation being reported) and it should be noted that two (2) of those employees did not provide direct care to Resident #41 in that time frame. The assignment sheets also revealed that there were six (6) employees who did provide direct care to Resident #41 during that time frame (03/20/22 to 03/22/22) for which there was no documented evidence of an interview or that they provided a signed and dated witness report/statement regarding Resident #41's allegation of being roughly handled.
The evidence showed that the facility staff who conducted the investigation of Resident #41's allegation of abuse failed to follow the facility's policies and procedures as evidenced by failing to:
1. Provide documented evidence that the interviews (Resident #41 and the 4 staff members) were conducted in the presence of a witness;
2. Make every effort to interview all staff members giving direct care to the resident for two days prior to the incident being reported;
3. Obtain signed and dated written witness reports/statements from the employees.
During a face-to-face interview conducted on 04/12/23 at 12:39 PM, Employee #2 (Director of Nursing), who conducted the investigation of this allegation of abuse stated, I interviewed [Resident #41]. [Resident #41] had a lot of paranoia and documented memory problems. When asked why none of the staff members interviewed provided a signed and dated written report/statement, Employee #2 stated, There weren't any witnesses; (Resident #41) couldn't tell us who did it or when. I just interviewed the regular staff who took care of [resident]. Employee #2 was then asked if any these interviews (resident and staff) were conducted in the presence of a witness, to which [Resident #41] stated, No. When asked why all the staff who cared for Resident #41 in the two days prior to the allegation being reported were not interviewed or provided a written report/statement, Employee #2 stated, [Resident #41] was not able to tell me when this occurred. That would've meant having to interview and get statements from almost all the staff. We didn't have time for that.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, for one (1) of 29 sampled residents, facility staff failed to have documented eviden...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, for one (1) of 29 sampled residents, facility staff failed to have documented evidence that an allegation of abuse was thoroughly investigated. Resident #41.
The findings included:
Review of the facility policy titled [Facility Name] Abuse Investigation Protocol, not dated, documented, .The individual conducting the investigation will, as a minimum . Conduct all interviews in the presence of a witness; Make every effort to interview staff members giving direct care to the resident for two days prior to the incident . Interview any staff members or others who may have knowledge of the incident . The following guidelines will be used when conducting interviews .Witness reports will be reduced to writing. Witnesses will be required to sign and date such reports .
Resident #41 was admitted to the facility on [DATE] with diagnoses that included: Vascular Dementia, with Anxiety, Chronic Pain and Muscle Weakness.
Review of Resident #41's medical record revealed:
A Quarterly Minimum Data Set (MDS) dated [DATE] showed facility staff coded: a Brief Interview for Mental Status (BIMS) Summary Score of 04, indicating severe cognitive impairment; no indicators of psychosis or behavior issues; required extensive assistance with one person physical assist for bed mobility, transfers, dressing, toilet use and personal hygiene.
03/21/22 at 2:47 PM [Psychosocial Note Late Entry] Care conference held on 3/17/2022 for quarterly review. Resident participated in assessment but did not wish to attend meeting. RP (representative) .notified of meeting but declined to attend. Care plan reviewed. Resident scored 4/15 on BIMS assessment. [Resident] was able to repeat 2/3 test words, could not recall test words with cueing, and was able to accurately state the month, but not day of the week or year. Resident is generally oriented to self, others, and place, although she shows deficits in short-term memory as evidenced by repeating conversations and difficulty accurately recalling events .
03/23/22 at 4:42 AM [Nurses General Note] Resident continue c/o (complain of) throat discomfort. Throat culture collected, awaiting technician to pick it up. Resident remain afebrile. No coughing .Lung sounds clear on auscultation.
03/25/22 at 8:40 AM [Psychosocial Note] On 3/22/22, at Resident Council, resident reported concerns to include [resident] is treated roughly by staff and had a sore throat that was not addressed by staff. Staff investigated reports and RP . notified about concerns. Resident interviewed. Unable to give details of staff treatment such as which staff, which day or which shift the treatment occurred on .Staff interviewed. No unusual incidents observed. Staff to monitor resident for additional reports. Investigation closed at this time.
A Facility Reported Incident (FRI), DC00010646, received by the State Agency on 03/28/22 documented, On 3/22/22, at Resident Council, resident reported concerns to include [resident] is treated roughly by staff and had a sore throat that was not addressed by staff. Staff investigated reports. Resident interviewed. Unable to give details of staff treatment such as which staff, which day or which shift the treatment occurred .
Review of the facility's investigation documents provided to this surveyor on 04/06/23 showed a typed document dated March 22, 2022 that documented, Investigation of Claims of Rough Handling- Resident Council. DN (Director of Nursing) interviewed [Resident #41] following resident council . DN verbally interviewed the following staff who are usual caregivers. [Names of four (4) staff members]. No unusual incidents observed .There is no evidence of abuse. Investigation concluded.
The 4 employee names who the DN documented she verbally interviewed were cross-referenced to the facility's assignment sheets for dates 03/20/22 and 03/21/22 (the two days prior to the incident/allegation being reported) and it should be noted that two (2) of those employees did not provide direct care to Resident #41 in that time frame. The assignment sheets also revealed that there were six (6) employees who did provide direct care to Resident #41 during that time frame (03/20/22 to 03/22/22) for which there was no documented evidence of an interview or that they provided a signed and dated witness report/statement regarding Resident #41's allegation of being roughly handled.
The evidence showed that the facility staff who conducted the investigation of Resident #41's allegation of abuse failed have documented evidence that an allegation of abuse was thoroughly investigated by failing to:
1. Make every effort to interview all staff members giving direct care to the resident for two days prior to the incident being reported;
2. Obtain signed and dated written witness reports/statements.
During a face-to-face interview conducted on 04/12/23 at 12:39 PM, Employee #2 (Director of Nursing), who conducted the investigation of this allegation of abuse stated, I interviewed her [Resident #41]. Had a lot of paranoia and documented memory problems. When asked why none of the staff members interviewed provided a signed and dated written report/statement, Employee #2 stated, There weren't any witnesses; (Resident #41) couldn't tell us who did it or when. I just interviewed the regular staff who took care of [resident] . Employee #2 was then asked if any these interviews (resident and staff) were conducted in the presence of a witness, to which she stated, No. When asked why all the staff who cared for Resident #41 in the two days prior to the allegation being reported were not interviewed or provided a written report/statement, Employee #2 stated, [Resident #41] was not able to tell me when this occurred. That would've meant having to interview and get statements from almost all the staff. We didn't have time for that.
Cross Reference: 22B DCMR sec. 3232.2
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, record review and staff interview, for one (1) of 29 sampled residents, facility staff failed to accurate...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, record review and staff interview, for one (1) of 29 sampled residents, facility staff failed to accurately code one resident's dental status in the Significant Change Minimum Data Set (MDS). Resident #21.
The findings included:
Resident #21 was admitted to the facility on [DATE] with diagnoses that included: Mixed Hyperlipidemia, Vesicointestinal Fistula, and Long Term use of Anticoagulants.
Review of Resident #21's medical record revealed:
12/31/22 at 11:33 [Nutrition Assessment] .Oral/Dental Condition: Dentures- full upper; Dentures- full lower.
A Significant Change MDS dated [DATE] showed facility staff coded: a Brief Interview for Mental Status (BIMS) Summary Score of 11, indicating moderate impaired cognition. Section L0200 (Dental), directed check all that apply, which included, No natural teeth or tooth fragments (edentulous). The MDS showed facility staff documented an X at the line None of the above were present.
During a face-to-face interview conducted on 04/05/23 at 2:59 PM, Resident #21 was noted to have no upper or lower teeth. Resident #21 stated, I wear dentures. The resident's assigned Certified Nurse Aide (CNA) showed the surveyor a small, white container that contained a set of full upper and lower dentures.
During a face-to-face interview conducted on 04/12/23 at 9:55 AM, Employee #6 (MDS Coordinator) reviewed the MDS and stated, You are correct. I was on vacation and someone else did this MDS.
Cross Reference: 22B DCMR sec. 3231.12
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interviews, for one (1) of 29 sampled residents, the facility staff failed to update a residen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interviews, for one (1) of 29 sampled residents, the facility staff failed to update a resident's care plan to include goals and approaches to address one resident's Sacral pressure ulcer. Residents' #50.
Findings included:
Resident #50 was admitted to the facility on [DATE] with diagnoses that included: Hypertension, Hyperlipidemia, Osteoarthritis, Chronic Obstructive Pulmonary Disease, Anemia, Hypertensive Heart Disease, and Major Depressive Disease.
A review of the medical record revealed the following:
A review of care plans showed a focus area, [Resident Name] has potential for impairment to skin integrity related to frail/fragile skin, memory impairment, impaired mobility, use of hypertensive medications, initiated on 2/23/2023.
The admission Minimum Data Set (MDS) dated [DATE] showed in Section C (Cognitive Patterns), a Brief Interview for Mental Status (BIMS) summary score of 15, indicating an intact cognitive response.
Under Section G (Functional Status) - Bed Mobility and Personal Hygiene the resident was coded as requiring extensive assistance with one person's physical assistance from facility staff.
In Section M (Skin Condition), M0210 indicated Does this resident have one or more unhealed pressure ulcers/injuries, the facility staff coded, yes. M0300 indicated, Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar coded as 1. The number of these unstageable pressure ulcers that were present upon admission/entry or reentry coded as 1.
2/22/2023 18:15 [6:15 PM] Medication Reconciliation Note: Resident admitted to this nursing facility this afternoon. Reviewed discharged orders with MD. New orders received . Use Dakin's solution to clean coccyx wound daily and PRN
2/22/2023 20:45 [8:45 PM] (Physician's Order) Dakin's (1/4 strength) external solution (sodium hypochlorite) Apply to coccyx topically as needed for dressing soiling /lifting. After cleansing with ¼ strength Dakin's solution follow with gauze and cover with foam dressing.
4/5/2023 10:55 Skin/wound notes . [AGE] year-old A [patient] pt seen at bedside earlier today. sacral pressure injury . The sacrum is an unstageable pressure injury that is covered with 40% thin slough and 60% pale granulation around the wound edges. It is surrounded with intact tissue with scant s/s drainage continue the current treatment.
4/10/2023 16:31 Nurses Skilled Notes: . Wound still present and with scant slough in bed, no mal odor to the wound while observing for infection . wound care done and no bleeding observed .
There was no documented evidence that facility staff updated Resident #50's care plan to reflect the open area found on 2/22/2023.
During a face-to-face interview conducted on 4/12/2023, at approximately 9:00 AM with Employee #3 (ADON/Educator), she acknowledged the finding.
Cross Refrence: 22B DCMR sec.3210.4
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and staff interviews, for two (2) of 29 sampled residents, facility staff failed to accoun...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and staff interviews, for two (2) of 29 sampled residents, facility staff failed to account for the dispensing of a controlled medications. Residents' #6 and #23.
The findings included:
1. Facility staff failed to account for the dispensing of Resident #6's ordered Tramadol (narcotic pain reliever).
Resident #6 was admitted to the facility on [DATE] with diagnoses that included: Polyosteoarthritis, Idiopathic Peripheral Autonomic Neuropathy and Dementia.
Review of Resident #6's medical record revealed:
A physician's order dated 08/25/22 that directed, Tramadol HCl (hydrochloride) Tablet 50 MG Give 0.5 tablet by mouth everyday shift for pain control .
During a narcotic count conducted on 04/06/23 at 10:16 AM of the Team A medication cart with Employee #7 (Licensed Practical Nurse), it was noted that Resident #6's inventory sheet for Tramadol (narcotic pain reliever) 50 mg (milligrams) ½ (half) tablets documented 21 remaining, however, the blister packet was observed to have 20 half tablets remaining.
Review of the Medication Administration Record (MAR) for April 2023 showed that Employee #7 initialed to indicate that Resident #6 was administered Tramadol 25 MG on 04/06/23 for day shift.
During a face-to-face interview conducted at the time of the observation, Employee #7 acknowledged the findings and stated, I gave it to [resident] this morning and forgot to sign it out.
2. Facility staff failed to account for the dispensing of Resident #23's ordered Lorazepam (anti-anxiety medication).
Resident #23 was admitted to the facility on [DATE] with multiple diagnoses that included: Dementia with Anxiety, Hallucinations and Hypertensive Heart Disease.
A physician's order dated 07/20/21 that directed, Ativan tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth every 6 hours for anxiety.
Review of the Medication Administration Record (MAR) for April 2023 showed that Employee #8 initialed to indicate that Resident #23 was administered Lorazepam 0.5 mg tablet at 1:00 PM.
During a narcotic count on 04/11/23 at 1:08 PM of the Team A medication cart with Employee #8 (Licensed Practical Nurse), it was noted that Resident #23's inventory sheet for Lorazepam 0.5 mg tablets documented 6 remaining, however, the blister packet was observed with 5 tablets remaining.
During a face-to-face interview conducted at the time of the observation, Employee #8 acknowledged the findings and stated, I know to sign out the narcotic medications when I give it. I don't know what happened.
Cross Reference: 22B DCMR sec 3224.3
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
Based on observations and staff interview, facility staff failed to distribute and serve foods under sanitary conditions as evidenced by final rinse temperatures from one (1) of two (2) dishwashers th...
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Based on observations and staff interview, facility staff failed to distribute and serve foods under sanitary conditions as evidenced by final rinse temperatures from one (1) of two (2) dishwashers that were consistently below 180 degrees Fahrenheit (F) in high heat disinfect mode.
The findings included:
During observations in dietary services on April 5, 2023, at approximately 12: 45 PM, one (1) of one (1) dishwasher in the main kitchen failed to reach a minimum of 180 degrees Fahrenheit on numerous consecutive occasions.
Two (2) of two (2) trays of dishes and utensils that had been washed were rewashed in the chemical disinfect dishwasher located in the resident's small kitchen, on the Long-Term Care unit.
When tested, the chemical disinfect solution from that dish machine was at 200 PPM.
Employee #10 confirmed the findings on April 10, 2023, at approximately 11:00 AM.
Cross Refrence: 22 DCMR sec.3219.1
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for one (1) of 29 sampled residents, facility staff failed to maintain medical record...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for one (1) of 29 sampled residents, facility staff failed to maintain medical records on each resident that were complete. Residents' #105.
The findings included:
Resident #105 was admitted to the facility on [DATE], with diagnoses that included Peripheral vascular Disease, Gastroesophageal Reflux Disease, Chronic Kidney Disease, and Major Depression.
The facility submitted a facility reported incident (FRI) on 2/1/2023 to the State Agency, that documented, Resident reported to Guardian during routine monthly visit that he had been slapped by a staff member at 3 AM [morning] on the day of the visit. Guardian reported to social worker staff. Investigation initiated. Resident interviewed by [registered nurse] RN on day of report. Resident interviewed by Dir of SW [Director of Social Work] on day after report and two days after report. Resident did not repeat report in theses interviews. No bruising, or abraisions noted. Alert and oriented to person only, Hx of Vascular dementia, with paranoid ideation. Hx of recent GDR [gradual drug reduction] of antipsychotic and tx [treatment]of UTI [urinary tract infection]. Staff interviewed by DN [director of nursing] with written statement taken. No unusual incident reported, Investigation concluded as not substantiated for abuse. Resident to be tx [treated] by behavioral health and followed by SW services for possible f/u report.
Review of the medical record showed progress notes dated 1/27- 2/2023 documentation was not complete as there was no mention in the progress note of resident #105's reported allegation of abuse information .
The evidence showed that facility staff failed to maintain resident #105's medical records which were not complete with the resident's allegation of abuse information in the progress note when it was reported on 1/28/2023.
During a face-to-face interview conducted on 4/11/2023 at 11:00 AM, Employee #4 (Director of Social Service) acknowledged the findings and stated, I made a mistake of not documenting it in the resident record.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, record review, and staff interviews, facility staff failed to maintain infection prevention and control practices during a wound care dressing change observation for one resident...
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Based on observation, record review, and staff interviews, facility staff failed to maintain infection prevention and control practices during a wound care dressing change observation for one resident. Resident #50.
The findings included:
According to the National Library of Medicine, when performing wound care, staff should, Wash your hands Clean the trolley using soap and water, or disinfectant, and a cloth. Start at the top of the trolley and work down to the bottom legs of the trolley using single strokes with your damp cloth. Place the sterile dressing/procedure pack on the top of the trolley. Open the sterile dressing pack on top of the trolley. Open the sterile field using the corners of the paper. Open any other sterile items needed onto the sterile field without touching them. Wash your hands and put on non-sterile gloves (to protect yourself) before removing an old dressing. Dispose of this dressing in a separate dirty clinical waste bag. Fold up the dressing/procedure pack and place all contaminated material in a bag designated for clinical waste, making sure all sharps are removed and disposed of in a sharp's container.Remove gloves and place them in a waste bag. Wash your hands. (www.ncbi.nlm.nih.gov/pmc/articles/PMC4579997/)
During wound care observation for Resident #50's pressure ulcer on 04/06/23 at 11:27 AM Employee #7 was observed cleaning the sacral wound with gauze covered with Dakin solution. He then placed the used unclean gauze on the bedside table with the clean gauze and foam dressing he needed to complete the dressing change.
Physician orders dated 02/22/23 at 8:45 PM showed, Dakin's (1/4 strength) external solution (sodium hypochlorite) Apply to coccyx topically as needed for dressing soiling /lifting. After cleansing with ¼ strength Dakin's solution follows with gauze and cover with foam dressing.
During wound care observation on resident #50 4/6/2023 at 11:27 AM Employee #7 was observed cleaning the sacral wound with gauze covered with Dakin solution. He then placed the used unclean gauze on the bedside table with the clean gauze and foam dressing he needed to complete the dressing change.
In a face-to-face interview conducted on 4/6/2023 at approximately 11:28 AM, Employee #7 stated, I did not have a red bag to put it (used soiled gauzed) in. He was able to verbalize the procedure for completing the dressing change.
A face-to-face interview was conducted on 4/12/2023, at approximately 9:00 AM with Employee #5 (Infection Control), she acknowledged the finding and stated, Staff will be trained.
Cross Reference: 22B DCMR sec 3217.6
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected 1 resident
Based on observations and staff interview, facility staff failed to maintain essential equipment in safe condition as evidenced by final rinse temperatures that were below 180 degrees Fahrenheit (F) o...
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Based on observations and staff interview, facility staff failed to maintain essential equipment in safe condition as evidenced by final rinse temperatures that were below 180 degrees Fahrenheit (F) on April 4, 2023, at approximately 12:45 PM.
The findings include:
During observation in dietary services on April 5, 2023, at approximately 12:45 PM, final rinse temperatures from one (1) of one (1) dishwasher in the main kitchen did not reach a minimum of 180 degrees Fahrenheit as required.
Facility staff attempted to use the dishwasher in chemical disinfect mode. However, when tested, the chlorine disinfect solution failed to reach the minimum requirement of 50 Parts per Million (PPM).
Employee #10 confirmed the findings on April 10, 2023, at approximately 11:00 AM
Cross Refrence: 22B DCMR sec. 3258.13
Mar 2021
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interview, for one (1) of 16 sampled residents, facility staff failed to implement the interve...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interview, for one (1) of 16 sampled residents, facility staff failed to implement the interventions specified in the care plan for monitoring a resident on antidepressant and antipsychotic medications. Resident #5.
Findings included .
Resident #5 was admitted to the facility on [DATE], with diagnoses that included Anxiety Disorder, Coronary Artery Disease, Hypertension, and Hyperlipidemia.
Review of the medical record showed the following physician's orders:
8/24/2020 at 17:00 (5:00 PM) Seroquel Tablet 25 MG (milligrams) . Give 0.5 tablet by mouth in the evening for Delusions 0.5tab (tablet) 12.5mg
8/25/2020 at 09:00 (AM) Seroquel Tablet 25 MG . Give 1 tablet by mouth one time a day for Delusions
8/25/2020 at 09:00 (AM) Zoloft Tablet 25 MG . Give 1 tablet by mouth one time a day for Anxiety
Review of the care plans dated 02/22/2021, showed the following focus area: [Resident #5] is at risk for adverse reaction related to . use of antidepressant medication, use of antipsychotic medication with the following interventions:
Administer medications per orders. Monitor/document for effectiveness and any side effects.
Administer Psychotropic medications as ordered by physician. Monitor for side effects and effectiveness Q (every)-shift.
A review of the nursing progress notes, behavior tab, treatment administration record, and the paper chart dated from 08/24/2020, to 03/10/2021, showed that there was no documented evidence that the facility staff monitored Resident # 5 for effectiveness or side effects of the antidepressant and antipsychotic medication as outlined in the care plan.
During a face-to-face interview conducted with Employee #5 on 03/10/2021, at approximately 2:20 PM, she stated, I have not been documenting any behavior assessments on Resident #5. Employee #5 then proceeded to show the surveyor the blank Behavior section in the electronic health record.
Continued interview revealed that the facility also uses a paper copy of the checklist for monitoring behaviors and side effects however, Employee #5 stated, Resident #5 has not had one.
During a face-to-face interview on 03/10/2021, at approximately 2:30 PM with Employee #6 (Unit Manager), acknowledged the finding and stated, I am not sure why she [Resident #5] hasn't been getting monitored but she needs to be and needs a behavior sheet.
Facility staff failed to implement the interventions (monitor/document for effectiveness and any side effects) specified in the care plan for monitoring Resident #5 who receives antidepressant and antipsychotic medications.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for one (1) of 16 sampled residents, facility staff failed to follow the professional...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for one (1) of 16 sampled residents, facility staff failed to follow the professional standards of practice for completing the assessment on Resident #24 prior to leaving the facility for dialysis treatment.
Findings included .
Resident #24 was admitted to the facility on [DATE], with diagnoses that include: End Stage Renal Disease, Diabetes Mellitus 2, Peripheral Vascular Disease, Hypertensive Heart Disease, Anxiety and Major Depressive Disorder.
A review of the physician's order dated 07/16/2020, showed, Appointment: Hemodialysis three times a week .every day shift every Tue [Tuesday], Thu [Thursday] and Sat [Saturday].
A review of Resident #24's Dialysis Communication Record [A form used to facilitate communication between the nursing facility and the dialysis center] showed the following:
On 01/30/2021, facility staff failed to complete the resident assessment (resident status, intake by mouth, graft site function, vital signs, mobility, and dialysis transportation) on the form prior to the resident leaving the facility for dialysis treatment.
On 02/27/2021, facility staff failed to record the vital signs obtained from the resident on the dialysis communication form prior to leaving the facility for dialysis treatment.
During a face-to-face interview on 03/11/2021, at 12:30 PM with Employee # 9, she stated, The information from the facility to the dialysis center is from the Resident's morning assessment that includes resident status, intake by mouth, graft site function, vital signs, mobility and dialysis transportation to dialysis. At the time of the interview, Employee #9 acknowledged the findings.
Facility staff failed to follow the professional standards of practice for completing the assessment on a resident going out for dialysis treatment.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interview, for one (1) of 16 sampled residents, facility staff failed to adequate monitoring a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interview, for one (1) of 16 sampled residents, facility staff failed to adequate monitoring a resident who is on antipsychotic medication. Resident #5.
Findings included .
Resident #5 was admitted to the facility on [DATE], with diagnoses that included Anxiety Disorder, Coronary Artery Disease, Hypertension, and Hyperlipidemia.
Review of the medical record showed the following orders:
8/24/2020 17:00 (5:00 PM) Seroquel Tablet 25 MG (milligrams) . Give 0.5 tablet by mouth in the evening for Delusions 0.5tab (tablet) 12.5mg
8/25/2020 09:00 (AM) Seroquel Tablet 25 MG . Give 1 tablet by mouth one time a day for delusions
Review of the care plan dated 02/22/2021, showed the following focus area: [Resident #5] is at risk for adverse reaction related to . use of antipsychotic medication with the following interventions:
Administer medications per orders. Monitor/document for effectiveness and any side effects.
Administer psychotropic medications as ordered by physician. Monitor for side effects and effectiveness Q (every)-shift.
A review of the nursing progress notes, behavior tab, treatment administration record, and the paper chart dated 08/24/2020 to 03/10/2021, showed that there was no documented evidence that the facility staff monitored Resident #5 for effectiveness or side effects of the antidepressant and antipsychotic medication as outlined in the care plan.
During a face-to-face interview conducted with Employee #5 on 03/10/2021, at approximately 2:20 PM, she stated, I have not been documenting any behavior assessments on Resident #5. Employee #5 then proceeded to show the surveyor the blank Behavior section in the electronic health record.
Continued interview revealed that the facility also uses a paper copy of the checklist for monitoring behaviors and side effects however, Employee #5 stated, Resident #5 has not had one.
During a face-to-face interview on 03/10/2021, at approximately 2:30 PM with Employee #6 (Unit Manager), acknowledged the finding.
Facility staff failed to adequately monitor a resident who is on antipsychotic medication.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, facility staff failed to store biologicals in safe condition as evidenced by nine (9) ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, facility staff failed to store biologicals in safe condition as evidenced by nine (9) of 54 containers of sterile water, that were stored past their expiration date of November 2019, in the oxygen storage room located on the [NAME] Drive unit.
Findings included .
During a walkthrough of the facility on March 11, 2021, at approximately 1:10 PM, nine (9) of 54, 3.4 ounces containers of sterile water were stored past their expiration date of November 2019, in the oxygen room located on the [NAME] Drive unit.
Employee #3 acknowledged the findings during a face-to-face interview on March 11, 2021, at approximately 1:15 PM.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
Based on observations made on March 8, 2021, at approximately 12:30 PM, it was determined that dietary staff failed to store and prepare food in accordance with professional standards for food service...
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Based on observations made on March 8, 2021, at approximately 12:30 PM, it was determined that dietary staff failed to store and prepare food in accordance with professional standards for food service safety, as evidenced by one (1) of one (1) open pack of parmesan cheese and one (1) of one (1) open container of mustard that were stored beyond their use-by-date of March 4, 2021, one (1) of one (1) grease fryer that was soiled with cooked food residue, and four (4) of seven (7) sheet pans that were dented throughout.
Findings included .
1. One (1) of one (1) open pack of parmesan cheese and one (1) of one (1) container of mustard were stored in one (1) of one (1) walk-in refrigerator beyond their use-by-date of March 4, 2021.
2. One (1) of one (1) grease fryer was soiled with leftover fried food residue.
3. Four (4) of seven (7) sheet pans, stored in the ready-for-use area, were dented throughout.
These observations were acknowledged by Employee #7 during a face-to-face interview on March 12, 2021, at approximately 11:00 AM.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, facility staff failed to maintain building equipment in good working condition as evidenced ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, facility staff failed to maintain building equipment in good working condition as evidenced by one (1) of one (1) hopper that did not function as intended.
Findings included .
One (1) of one (1) hopper, located in the soiled utility room on the [NAME] Drive unit failed to flush when tested.
During a face-to-face interview on March 11, 2021, at approximately 1:45 PM, Employee #8 acknowledged that the hopper was no longer functioning and needed to be removed from the soiled utility room.
May 2019
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interview, facility staff failed to provide necessary housekeeping services in resident areas as...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interview, facility staff failed to provide necessary housekeeping services in resident areas as evidenced by exhaust fans that were inoperative in eight (8) of 15 resident rooms, one (1) of one (1) hopper that was out of order on the [NAME] Drive unit ,10 of 10 sixteen-ounce bottles of alcohol that were expired as of February 2018, and one (1) of one (1) thirty fluid ounce unopened container of Prosource protein drink with an expiration date of [DATE].
Findings included .
During a walk-through of the facility on [DATE], between 9:48 AM and 11:00 AM the following was observed:
1. Exhaust fans located in the resident bathrooms did not provide any suction in eight (8) of 15 resident rooms
including rooms #102, 104, 105, 109, 114, 116, 120 and #122.
2. One (1) of one (1) hopper located in the Soiled Utility room on the [NAME] Drive unit was broken.
3. Ten (10) of ten (10) sixteen-ounce bottles of alcohol stored in the storage room on the [NAME] Drive unit
were expired as of February 2018.
4. One (1) of one (1) thirty fluid ounce unopened container of Prosource protein drink stored in the storage room
on the [NAME] Drive unit had an expiration date of [DATE].
During a face-to-face interview on [DATE], at approximately 11:00 AM, Employee #10 and /or Employee #11 acknowledged the findings.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility's staff failed to ensure that Resident #49 was referred to the District...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility's staff failed to ensure that Resident #49 was referred to the District of Columbia Department of Behavioral Health to have a Level II Evaluation conducted for one (1) of 26 sampled residents.
Findings included .
Resident #49 was re-admitted to the facility on [DATE], with diagnoses that included Schizophrenia, Depression, Hypertension and Anemia.
A review of a document entitled, Level I Pre-admission Screening/Resident Review for Serious Mental Illness, Intellectual Disabilities, or Related Conditions, showed the form. was signed as completed by the facility's staff on January 24, 2019. Further review of the form, revealed under Section B: Evaluation Criteria for Serious Mental Illness, that Resident #49 was not coded as having a known diagnosis of a major mental disorder. However, according to the Significant Change Minimum Data Set form completed January 24, 2019, under Section I - Active Diagnoses, Resident #49 was coded as having a diagnosis of Schizophrenia.
Continued review of the Level I Pre-admission Screening/Resident Review for Serious Mental Illness, Intellectual Disabilities, or Related Conditions, dated January 24, 2019, lacked documented evidence the facility's staff identified Resident #49 as having a positive screen for serious mental illness.
Subsequently, the Resident #49, who had a diagnosis of Schizophrenia was not referred to the District of Columbia Department of Behavioral Health for a Level II evaluation as stipulated by the form. Which indicates if The beneficiary is considered to have a positive serious mental illness (SMI) if (1) questions 1 or 2 in section B are answered Yes. With a positive screen for SMI the beneficiary must be referred to the District of Columbia Behavioral Health for a Level II Evaluation.
During a face-to-face interview with Employee #6 on May 16, 2019 at 2:00 PM, after a review of the findings, she acknowledged that the Level II evaluation screening was not conducted.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interviews, for one (1) of 26 sampled records facility staff failed to u...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interviews, for one (1) of 26 sampled records facility staff failed to update/revise the care plan to include resident-centered goals and approaches for a resident with Dysphagia. Resident #34.
Findings included .
Resident #34 was admitted to the facility on [DATE], with diagnoses, which included Ventral Hernia without Obstruction or Gangrene, Dysphagia, Oral Phase, Essential (Primary) Hypertension, Unspecified Dementia without Behavioral Disturbance, and Major Depressive Disorder.
On 5/13/19, at approximately 10:00 AM the resident was observed in her room eating breakfast. At this time, no staff were present in the resident's room.
During a resident interview on 5/13/19, at 11:00 AM, Resident states, I don't eat in the dining room with the other residents because I don't want to choke I have to concentrate on my chewing and the noise from the resident's may cause me not to concentrate. Resident further states, They don't supervise me when I eat, they just bring in the tray and I eat my food.
Review of a physician's order dated 04/04/19 showed the resident was ordered a Physical, Occupational and Speech Therapy Screen.
Review of the Minimum Data Set completed on 04/08/19 showed under Section B [Hearing, Speech and Vision], Resident #34 was coded as 0, which indicated the resident's speech pattern is clear, able to make self-understood and has clear comprehension and able to understand others. Section G [Functional Status] showed the resident is coded as independent in eating (no help or staff oversight at anytime).
Review of the Speech Therapy Progress & Discharge Summary note dated 5/8/19 showed goal met on 5/8/19, the patient demonstrates ability to utilize compensatory strategies to increase safe oral intake with mild impairment (25-50% impairment; risk of aspiration on liquids mild oral residue and may need meats ground or chopped; cueing and intermittent supervision for carry-over).
During a face-to-face interview with the Speech Therapist on 5/16/19, at approximately 12:30 PM, she stated, The staff were trained on swallowing techniques, I know the staff are busy on the floor but that they need to intermittently supervise the resident when eating to be sure the resident changes from solid to liquid to be sure there is no residual food to cause choking, the staff all know to do this.
During an interview on 5/16/19 at approximately 2:00 PM, Employee #13, (Certified Nurse Aide) states I have worked with her a lot, she is not a feeder I don't supervise her or sit in the room with her I just bring in her tray and she can feed herself.
Facility staff failed to update/revise the resident's care plan to include the following speech therapist recommendations: 25-50% impairment risk of aspiration on liquids; mild oral residue and may need meats ground or chopped cueing and intermittent superivsion for carry-over.
During a face-to-face interview on 5/17/19, at 11:00 AM, Employee #2 acknowledged the finding and states the care plan should be resident-centered and specific to that resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
Based on observations and interview, it was determined that facility staff failed to prepare and store foods in sanitary condition as evidenced by soiled equipment such as one (1) of one (1) grease fr...
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Based on observations and interview, it was determined that facility staff failed to prepare and store foods in sanitary condition as evidenced by soiled equipment such as one (1) of one (1) grease fryer, five (5) of five (5) steam table wells in the Nursing Facility kitchen and two (2) of two (2) ovens, and dented utensils such as nine (9) of nine (9) two-inch hotel pans, two (2) of two (2) one-third three-inch pans and four (4) of four (4) one-sixth hotel pans.
Findings included .
The following observations were made during a walkthrough of dietary services on May 13, 2019:
1. Food equipment such as one (1) of one (1) grease fryer, five (5) of five (5) steam table wells in the Nursing Facility
kitchen and two (2) of two (2) ovens were soiled.
2. Nine (9) of nine (9) two-inch hotel pans, two (2) of two (2) one-third three-inch pans and four (4) of four (4)
one-sixth hotel pans were dented throughout.
During a face-to-face interview on May 13, 2019, at approximately 11:00 AM, Employee #9 acknowledged these findings.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review and staff interview for one (1) of 26 sampled records, the facility failed to complete the...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review and staff interview for one (1) of 26 sampled records, the facility failed to complete the personal inventory sheet with the date and signature for Resident # 255.
Findings included .
Record review of facility's policy titled Policy and Procedures for Resident Belongings the facility will encourage each resident or resident representative to complete an initial inventory .list should be completed upon admission and updated periodically .the inventory [sic] will be stored in the medical record.
Resident #255 was admitted to the facility on [DATE] with diagnoses to include Pneumothorax, Unspecified, Emphysema Unspecified, Lobar Pneumonia and Non-ST Elevation Myocardial Infarction. admission Minimum Data Set [MDS] Section C [Cognitive Patterns] showed a Brief Interview for Mental Status score of 15 which indicates cognitively intact.
Review of the medical record on 5/1519 at 12:30 PM showed Resident # 225's Personal Inventory List without a date or signature of the resident. Further review of the form showed a staff signature recorded on the form.
During a face-to-face interview on 5/15/19 at 12:20 PM, Employee #4 stated, I am working on the personal inventory form; the corrected form is in my office. At the time of the medical record review Employee #4 acknowledged the finding.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected 1 resident
Based on observations and staff interview, the facility failed to maintain mechanical and electrical equipment in safe operating condition as evidenced by one (1) of one (1) ice machine in the main ki...
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Based on observations and staff interview, the facility failed to maintain mechanical and electrical equipment in safe operating condition as evidenced by one (1) of one (1) ice machine in the main kitchen that lacked a protective grill cover, one (1) of one (1) Robot Coupe machine with a broken 'OFF' switch and a missing slat from the air curtain in one (1) of one (1) walk-in refrigerator.
Findings included .
During observations in Dietary Services on May 13, 2019, at approximately 9:20 AM:
1. One (1) of one (1) ice machine lacked a cover/grill to prevent access to its internal parts.
2. One (1) of one (1) Robot Coupe machine used to puree foods had a broken 'OFF' switch.
3. The air curtain in the walk-in refrigerator was missing a slat.
During a face-to-face interview on May 13, 2019, at approximately 11:00 AM, Employee #9 acknowledged these findings.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Grade B+ (85/100). Above average facility, better than most options in District of Columbia.
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most District of Columbia facilities.
- • 18% annual turnover. Excellent stability, 30 points below District of Columbia's 48% average. Staff who stay learn residents' needs.
Concerns
- • 23 deficiencies on record. Higher than average. Multiple issues found across inspections.
Bottom line: Generally positive indicators. Standard due diligence and a personal visit recommended.
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About This Facility
What is Lisner Louise Dickson Hurthome's CMS Rating?
CMS assigns LISNER LOUISE DICKSON HURTHOME an overall rating of 5 out of 5 stars, which is considered much above average nationally. Within District of Columbia, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Lisner Louise Dickson Hurthome Staffed?
CMS rates LISNER LOUISE DICKSON HURTHOME's staffing level at 5 out of 5 stars, which is much above average compared to other nursing homes. Staff turnover is 18%, compared to the District of Columbia average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Lisner Louise Dickson Hurthome?
State health inspectors documented 23 deficiencies at LISNER LOUISE DICKSON HURTHOME during 2019 to 2025. These included: 23 with potential for harm.
Who Owns and Operates Lisner Louise Dickson Hurthome?
LISNER LOUISE DICKSON HURTHOME is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility operates independently rather than as part of a larger chain. With 60 certified beds and approximately 58 residents (about 97% occupancy), it is a smaller facility located in WASHINGTON, District of Columbia.
How Does Lisner Louise Dickson Hurthome Compare to Other District of Columbia Nursing Homes?
Compared to the 100 nursing homes in District of Columbia, LISNER LOUISE DICKSON HURTHOME's overall rating (5 stars) is above the state average of 3.3, staff turnover (18%) is significantly lower than the state average of 46%, and health inspection rating (5 stars) is much above the national benchmark.
What Should Families Ask When Visiting Lisner Louise Dickson Hurthome?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Lisner Louise Dickson Hurthome Safe?
Based on CMS inspection data, LISNER LOUISE DICKSON HURTHOME has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 5-star overall rating and ranks #1 of 100 nursing homes in District of Columbia. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Lisner Louise Dickson Hurthome Stick Around?
Staff at LISNER LOUISE DICKSON HURTHOME tend to stick around. With a turnover rate of 18%, the facility is 28 percentage points below the District of Columbia average of 46%. Low turnover is a positive sign. It means caregivers have time to learn each resident's needs, medications, and personal preferences. Consistent staff also notice subtle changes in a resident's condition more quickly. Registered Nurse turnover is also low at 13%, meaning experienced RNs are available to handle complex medical needs.
Was Lisner Louise Dickson Hurthome Ever Fined?
LISNER LOUISE DICKSON HURTHOME has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Lisner Louise Dickson Hurthome on Any Federal Watch List?
LISNER LOUISE DICKSON HURTHOME is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.