Deanwood Rehab: Care Quality Deficiencies - DC
The discrepancy involved Resident #1, who was admitted with major depressive disorder, adjustment disorder, unspecified dementia and metabolic encephalopathy. A cognitive assessment scored the resident at 02 on the Brief Interview for Mental Status, indicating severely impaired cognitive function, with a mood severity score of 10 showing moderate depression.
On August 14, a physician ordered Trazodone HCl oral tablet 50 mg, one tablet by mouth at bedtime for depression. The resident's medication administration record showed staff initialed check marks indicating they gave the full 50-milligram dose on August 14, 15, 16, 17 and 18.
But when inspectors examined the medication cart on August 19 at 10:25 AM, they found a blister packet labeled for Resident #1 containing "Trazadone 50 MG tab[let]. Give 0.5 tablet by mouth at bedtime for Depression." The tablets were white and in half-tablet form, each containing 25 milligrams.
The facility's own medication policy from January 2025 requires staff to check the label to verify "the right medication, right dose, right time and right method." It states medications must be administered in accordance with prescriber's orders.
Employee #2, the Assistant Director of Nursing, acknowledged the findings during an interview on August 19. When asked how staff were ensuring the resident received the prescribed 50-milligram dose when only 25-milligram tablets were available, the administrator said, "A prudent nurse would know to give two of the half tablets to equal the 50 MG, but I don't have a way of knowing if that is what was being done."
The documentation error persisted for five straight days without detection. Federal inspectors classified the violation as having minimal harm or potential for actual harm, affecting few residents.
Trazodone is commonly prescribed for depression in elderly patients, particularly those in nursing homes. The medication requires precise dosing, especially for residents with cognitive impairment who cannot advocate for themselves or report side effects.
The case highlights a fundamental breakdown in medication management systems. Staff either administered the wrong dose to a vulnerable resident with severe cognitive impairment, or they falsified records by documenting medications they never gave.
For a resident already struggling with major depression and dementia, medication errors can have serious consequences. Underdosing antidepressants may leave depression untreated, while overdosing can cause dangerous side effects including confusion, falls and cardiac problems.
The nursing administrator's response suggested systemic problems beyond this single case. Her acknowledgment that she had "no way of knowing" whether staff were properly calculating doses indicates inadequate oversight of medication administration for residents who cannot monitor their own care.
Federal regulations require nursing homes to maintain accurate medical records and safeguard resident-identifiable information. The Deanwood case demonstrates how documentation failures can mask potential medication errors, leaving vulnerable residents at risk.
The inspection occurred following a complaint, suggesting someone noticed problems serious enough to alert federal authorities. The facility's medication errors affected a resident with multiple psychiatric conditions who scored among the lowest possible ratings for cognitive function.
Resident #1 remains dependent on staff accuracy for proper medication management. The five-day documentation discrepancy raises questions about how many other medication errors may have gone undetected at the facility.
The case underscores the critical importance of accurate record-keeping in nursing homes, where residents with severe cognitive impairment cannot verify whether they received prescribed medications or advocate for proper care.
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 discrepancy involved Resident #1, who was admitted with major depressive disorder, adjustment disorder, unspecified dementia and metabolic encephalopathy.
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.