Deanwood Rehab: Medical Records Violations - DC
Resident #1, admitted to Deanwood Rehabilitation and Wellness Center with major depressive disorder and severely impaired cognitive function, was prescribed Trazodone 50 milligrams at bedtime. The physician's order from August 14 was clear: give one 50mg tablet by mouth nightly for depression.
Staff initialed the medication administration record each night from August 14 through August 18, documenting they had given the resident exactly what the doctor ordered — Trazodone 50mg, one tablet.
But when inspectors checked the medication cart on August 19, they found something different. The blister packet labeled with the resident's name contained only 25mg tablets — half the prescribed strength. The label on the packet even specified the reduced dose: "Give 0.5 tablet by mouth at bedtime."
The white tablets in the cart were visibly cut in half.
For five consecutive nights, nursing staff had signed off on giving the patient a 50mg dose when only 25mg tablets were available. Either the resident received half the prescribed medication, or staff gave two half-tablets but falsely documented it as a single full-strength dose.
Employee #2, the assistant director of nursing, acknowledged the discrepancy when confronted by inspectors. Asked how the facility ensured the resident actually received the correct 50mg dose when only 25mg tablets were stocked, she offered no reassurance.
"A prudent nurse would know to give two of the half tablets to equal the 50mg," she said. "But I don't have a way of knowing if that is what was being done."
The medication error involved a patient particularly vulnerable to dosing mistakes. The resident's mental status assessment showed a score of 2 out of 15, indicating severely impaired cognitive function. They also scored 10 on a mood severity scale, reflecting moderate depression — the very condition the Trazodone was meant to treat.
Facility policy requires staff to verify the right medication, right dose, right time and right method before administration. The policy states medications must be given in accordance with prescriber's orders.
The documentation violations occurred during the resident's first week at the facility. Their admission assessment had already flagged them as receiving antidepressant medications, making accurate dosing critical for continuity of care.
Trazodone is commonly prescribed for depression and sleep disorders in elderly patients. Underdosing can leave depression untreated, while inconsistent dosing can cause withdrawal symptoms or reduced effectiveness.
The assistant nursing director's admission that she had "no way of knowing" whether staff were following proper procedures raises questions about medication oversight at the facility. Her comment suggested that even if nurses were giving the correct dose by using two half-tablets, the documentation practice violated federal requirements for accurate record-keeping.
The inspection found that staff either systematically underdosed a cognitively impaired patient with severe depression, or they gave the right amount while falsifying federal medication records. Both scenarios represent serious lapses in resident care and regulatory compliance.
The facility's own policy emphasized checking labels to verify correct dosing, but supervisory staff acknowledged they couldn't confirm whether nurses were actually following these protocols.
The resident remains at Deanwood with multiple complex medical conditions including unspecified dementia and metabolic encephalopathy, conditions that make accurate medication administration essential for their wellbeing and recovery.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Deanwood Rehabilitation and Wellness Center from 2025-08-20 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
DEANWOOD REHABILITATION AND WELLNESS CENTER in WASHINGTON, DC was cited for violations during a health inspection on August 20, 2025.
The physician's order from August 14 was clear: give one 50mg tablet by mouth nightly for depression.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.