Capitol City Rehab: Care Quality Deficiencies - DC
The resident's granddaughter had been complaining to nurses that her grandmother "did not seem like herself" and "appeared pale and almost unresponsive." Her pressure wound had become infected.
Staff only called an ambulance after the granddaughter alerted them around 4:15 PM on September 3 that she was having trouble waking the resident up.
Employee #5, the assigned licensed practical nurse, told inspectors she coordinated the resident's transfer to the emergency room. She said the granddaughter was in the room when she arrived, and the resident "seemed off" and appeared disoriented.
"When she asked the resident what her name was? She was saying something that was not her name," the nurse told inspectors during an October 20 telephone interview.
The nurse confirmed she received the transfer order at approximately 1:58 PM on September 3. But she could not explain why she didn't coordinate the resident's ambulance transport until 4:57 PM.
That's nearly three hours after the doctor ordered the emergency transfer.
Employee #6, the nurse practitioner who issued the transfer order, described the sequence of events to inspectors. On the evening of September 2, between 4 PM and 5 PM, a nurse called her about the resident.
"I believe I saw her at the bedside; her vital signs were fine. A family member was at the bedside, [I] ordered some stat labs," the nurse practitioner said.
The next day, September 3, staff called again in the afternoon "around 1 to 2-ish" saying the resident had altered mental status.
"So I ordered for the resident to be sent out," the nurse practitioner told inspectors.
The resident's condition had deteriorated enough that family members noticed she was unresponsive and had to alert staff. The granddaughter described her grandmother as appearing "pale and almost unresponsive" with an infected pressure wound.
Despite the nurse practitioner's clear order to transfer the resident for emergency care, the assigned nurse delayed calling for ambulance transport for hours.
The three-hour gap between receiving the transfer order and actually coordinating emergency transport meant the resident remained at the facility while her condition warranted hospital-level care.
Federal inspectors interviewed the facility's administrator and director of nursing on October 20. Both acknowledged the findings during the face-to-face meeting.
The inspection classified the violation as causing minimal harm or potential for actual harm, affecting few residents. But the case illustrates how delays in emergency response can occur even when medical providers issue clear orders for immediate transfer.
The resident's family had been raising concerns about her condition and appearance before the emergency transfer became necessary. Their vigilance ultimately prompted staff action when they alerted nurses that the resident was difficult to wake up.
The nurse practitioner had ordered stat labs the evening before, suggesting medical staff were already monitoring the resident's declining condition. When her mental status deteriorated further the next day, the order for emergency transfer was immediate.
But the gap between medical decision-making and nursing execution left the resident waiting hours for the ambulance that should have arrived shortly after 2 PM.
The administrator and director of nursing's acknowledgment of the findings suggests facility leadership recognized the breakdown in emergency response protocols that left a deteriorating resident waiting for care she needed immediately.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Capitol City Rehab and Healthcare Center from 2025-11-13 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
CAPITOL CITY REHAB AND HEALTHCARE CENTER in WASHINGTON, DC was cited for violations during a health inspection on November 13, 2025.
Staff only called an ambulance after the granddaughter alerted them around 4:15 PM on September 3 that she was having trouble waking the resident up.
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.