Deanwood Rehabilitation And Wellness Center
Inspection Findings
F-Tag F0684
F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
25 MG tablets. Employee #2 stated, 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 evidence showed that facility staff failed to ensure that Resident #1 had the correct dose of Trazadone 50 MG available for administration and failed to ensure that the resident had received the correct dose 08/14/25, 08/15/25, 08/16/25, 08/17/25 and 08/18/25 (five days).It should be noted that Resident #1 did not suffer any negative outcomes from this deficient practice.Cross reference 22B DCMR Sec. 3211.1(a)
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
08/20/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Deanwood Rehabilitation and Wellness Center
5000 Nannie Helen Burroughs Ave. NE Washington, DC 20019
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0726
F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
order medication order on the blister packet label, Employee #2 stated, Trazadone is not a narcotic, so the nurses are allowed to use their own judgement and make adjustments in order for the resident to receive
the correct dose. When asked if that is within the scope and practice of a licensed registered nurse to make medication prescription order adjustments, Employee #2 stated, That's what a prudent nurse would do.The evidence showed that a licensed nurse, who did not have prescribing authority, made medication prescription order changes to Resident #1's Trazadone medication order label with no evidence that the resident's physician was made aware. Cross reference 22B DCMR Sec. 3227.11
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
08/20/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Deanwood Rehabilitation and Wellness Center
5000 Nannie Helen Burroughs Ave. NE Washington, DC 20019
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0842
F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review and staff interview, for one (1) of six sampled residents, facility staff inaccurately documented that they administered Trazadone (antidepressant medication) 50 MG (milligrams), one tablet to Resident #1.The findings included: A facility policy titled Administering Medications dated 01/2025 documented:- Medications are administered in accordance with prescriber's orders.- The individual administering the medication checks the label to verify the right medication, right dose, right time and right method (route).Resident #1 was admitted to the facility on [DATE REDACTED] with multiple diagnoses that included: Major Depressive Disorder, Adjustment Disorder, Unspecified Dementia, and Metabolic Encephalopathy.Review of the resident's medical record showed the following: An admission Minimum Date Set (MDS) assessment dated [DATE REDACTED] showed that facility staff coded: a Brief Interview for Mental Status (BIMS) summary score of 02 indicating severely impaired cognitive function; total mood severity score of 10, indicating moderate depression; and received antidepressant medications.A physician's order dated 08/14/25 directed, Trazodone HCl oral tablet 50 MG, give 1 tablet by mouth at bedtime for Depression.Review of the Resident #1's Medication Administration Record (MAR) for August 2025 showed that facility staff documented a check mark and their initials to indicate that the resident received Trazodone HCl oral tablet 50 MG, 1 tablet by mouth at bedtime for Depression on 08/14/25, 08/15/25, 08/16/25, 08/17/25 and 08/18/25.During an observation of the 2 south medication cart 2 on 08/19/25 at 10:25 AM, it showed a blister packet with Resident #1's name labeled, Trazadone 50 MG tab[let]. Give 0.5 tablet by mouth at bedtime for Depression. The tablets were noted to be white and were in half tablet form (25 MG).
The evidence showed that Resident #1 only had Trazadone 25 MG (50 MG half tablets) available for administration however, facility staff documented that they administered Trazodone 50 MG, 1 tablet by mouth at bedtime on 08/14/25, 08/15/25, 08/16/25, 08/17/25 and 08/18/25.During a face-to-face interview
on 08/19/25 at approximately 3:00 PM Employee #2 (Assistant Director of Nursing/ADON), acknowledged
the findings and was asked how they were ensuring that Resident #1 was receiving Trazadone 50 MG, 1 tablet when the resident only had available 25 MG tablets. Employee #2 stated, 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.Cross reference 22B DCMR Sec. 3231.10
Event ID:
Facility ID:
If continuation sheet
DEANWOOD REHABILITATION AND WELLNESS CENTER in WASHINGTON, DC inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in WASHINGTON, DC, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from DEANWOOD REHABILITATION AND WELLNESS CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.