Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Unique Rehabilitation And Health Center Llc during CMS and state inspections, most recent first.
Facility staff did not develop care plans to address two residents' specific needs: one resident's ongoing refusal to allow staff to clean his room or change his linens, and another resident's requirement for a mechanical lift and two-person assistance for transfers due to total dependence and a stage 3 pressure ulcer. Staff interviews and care plan reviews confirmed that these issues were not addressed in the residents' care plans.
Staff failed to ensure a clean and comfortable environment for multiple residents, resulting in dirty floors, foul odors, clutter, flies, and missing bed linens. Some residents reported not receiving clean linens or assistance with cleaning, while staff cited linen shortages and uncertainty about when rooms could be cleaned.
A resident with multiple medical conditions reported being handled roughly by an aide during ADL care, which occurred while a respiratory therapist was present. Facility staff did not attempt to identify or interview the aide or the respiratory therapist involved, and did not conduct a thorough investigation as required by policy, instead providing only general reassurances and staff education.
Facility staff did not provide adequate supervision or timely intervention to prevent an aggressive resident, who had not received his prescribed PRN anxiety medication for several days, from striking another resident in the courtyard with a piece of plastic smoke equipment. This altercation resulted in the second resident sustaining a fractured left forearm. The staff member supervising the area was unable to intervene in time, and the aggressive resident's escalating behaviors had been previously documented.
Facility staff did not follow required timeframes for reporting incidents involving two residents in a physical altercation resulting in injury and another resident found unresponsive and treated with Naloxone for suspected overdose. In each case, notifications to the State Agency were delayed beyond policy requirements, and staff interviews confirmed the facility's reporting procedures were not followed.
Facility staff failed to timely report multiple incidents to the State Agency, including a resident-to-resident altercation with injuries, an unresponsive resident who was administered Naloxone, and a resident's allegation of being handled roughly by a CNA. In each case, required notifications and investigations were not completed within mandated timeframes, and staff did not always recognize or act on allegations as reportable abuse or neglect.
Staff did not consistently implement a care plan intervention to keep a resident's bed in the lowest position, despite the resident's high risk for falls and history of serious injuries. The bed was observed elevated, and the resident experienced multiple falls resulting in significant injuries.
A resident with a history of pain and cancer was prescribed Hydromorphone 2 mg, one tablet every four hours as needed. An LPN administered two tablets at once, contrary to the physician's order, and could not explain the deviation. The resident did not experience any harm from the incident.
A resident with dementia, aphasia, and seizure disorder alleged abuse by a CNA, leading to the CNA's suspension. Facility policy requires staff involved in abuse investigations to receive education on abuse before returning to work, but there was no documentation or staff recollection of such education being provided before the CNA resumed duties.
Failure to Develop and Implement Comprehensive Care Plans for Resident Needs
Penalty
Summary
Facility staff failed to develop and implement comprehensive care plans for two residents with specific needs. One resident, admitted with diagnoses including major depression, substance abuse, and muscle weakness, consistently refused to allow nursing staff to clean his room, nightstand, or closet, and would not permit staff to make his bed or change his linen. Despite these ongoing refusals, there was no documented care plan outlining how staff should address or manage the resident's refusals regarding room cleanliness and personal space. Staff interviews confirmed that the resident's preferences were not addressed in the care plan, and the facility's protocol for daily cleaning was not followed for this resident due to his refusals. Another resident, admitted with a history of falls, muscle weakness, obesity, and a stage 3 sacral pressure ulcer, was totally dependent on staff for activities of daily living and mobility. This resident required the use of a mechanical lift and assistance from at least two staff members for transfers out of bed. However, a review of the care plan revealed that it did not address the use of a mechanical lift for transfers. Staff interviews confirmed that the mechanical lift was used for this resident, but this intervention was not documented in the care plan.
Failure to Maintain Clean, Comfortable, and Homelike Resident Environments
Penalty
Summary
Facility staff failed to provide a safe, clean, and homelike environment for four residents, as evidenced by multiple observations of unsanitary and uncomfortable living conditions. In several rooms, floors were found dirty, covered with debris, sticky substances, and wheelchair tire marks. Some rooms had flies present, and there were instances of foul odors, particularly of urine, detectable from the doorway. Additionally, clutter such as boxes, bins, and personal belongings were piled around beds, creating tripping hazards, and some beds were observed without linens. One resident, who was cognitively intact and dependent on staff for most activities of daily living, reported issues with receiving clean linens and assistance with room cleaning. Another resident, with moderate cognitive impairment and significant physical limitations, was found in a room with a strong urine odor, flies, and a sticky, dirty floor. A third resident, also cognitively intact but physically limited, had a bare mattress, cluttered surroundings, and a dirty floor, with staff acknowledging a shortage of linens and uncertainty about when cleaning could occur. A fourth resident's room was observed with a sticky, dirt-stained floor, foul odor, and personal belongings scattered on and around the bed, including trash bags and an empty urinal on the floor. Staff interviews revealed a lack of awareness about the room's condition and indicated that cleaning was dependent on the resident's presence and willingness to allow environmental services staff to enter. These findings demonstrate a pattern of inaction and insufficient attention to maintaining a clean, comfortable, and homelike environment for residents.
Failure to Investigate Resident Grievance of Rough Handling During ADL Care
Penalty
Summary
Facility staff failed to properly investigate a grievance filed by a resident who reported being handled roughly by an aide during activities of daily living (ADL) care. The resident, who had chronic respiratory failure, malignant neoplasm of the lower gum and mouth, and dysphagia, was cognitively intact and able to communicate his concerns. The grievance form documented that the resident felt the aide was in a hurry and that the ADL care was performed simultaneously with trach care by a respiratory therapist, which the resident described as overwhelming. The facility's grievance policy required investigation and resolution of grievances within 72 hours, including steps to investigate, a summary of findings, and any corrective actions. Despite these requirements, there was no evidence that the facility attempted to identify or interview the aide involved or the respiratory therapist who was present during the incident. Staff interviews confirmed that no effort was made to determine which aide was involved or to gather statements from those present. Instead, the response was limited to reassuring the resident and providing general staff education, without a thorough investigation into the specific incident as required by policy.
Failure to Prevent Resident-to-Resident Altercation Resulting in Injury
Penalty
Summary
Facility staff failed to provide adequate supervision and intervention to prevent an altercation between two residents, resulting in one resident sustaining a fractured left forearm. One resident, who had a history of paranoid schizophrenia, severe cognitive impairment, and documented aggressive behaviors, was not administered his prescribed PRN anxiety medication for five days, including the day of the incident. During this period, the resident exhibited escalating physical and verbal aggression, including threats and attempts to harm staff and other residents, as documented in nursing notes. The incident occurred in the facility's courtyard, where the aggressive resident picked up a piece of plastic smoke equipment and struck another resident on the arm. The staff member assigned to supervise the courtyard, a smoking aide, reported that she was unable to reach the residents in time to prevent the altercation. The smoking aide's role was primarily to supervise safe smoking, and she indicated that unit managers or security were called for aggressive behaviors, but this intervention was not timely enough to prevent the incident. The resident who was struck had a medical history including COPD, HIV, chronic hepatitis C, and moderate cognitive impairment. Following the altercation, she reported pain in her left forearm, which was later diagnosed as a fracture of the distal ulna and radius. The incident report and medical records confirm that the injury was a direct result of the altercation, and that the lack of supervision and failure to administer prescribed medication contributed to the escalation of aggressive behavior leading to the injury.
Failure to Timely Report Abuse, Neglect, and Unusual Incidents
Penalty
Summary
Facility staff failed to implement their own written policies and procedures for timely reporting of abuse, neglect, or unusual incidents for three residents. The facility's policy requires immediate reporting of suspected abuse, neglect, exploitation, or misappropriation of resident property to the Administrator and appropriate agencies, with specific timeframes: within 2 hours for incidents involving abuse or serious bodily injury, and within 24 hours for other allegations. However, in three separate cases, staff did not notify the State Agency within the required timeframes. In the first case, two residents were involved in a resident-to-resident altercation. One resident, with a history of chronic heart failure, schizophrenia, dementia, and depression, attacked his roommate with a chair, resulting in the roommate sustaining facial bruises, lacerations, and contusions, and requiring hospital evaluation. The incident occurred late at night, and both residents' medical records documented the altercation and subsequent medical interventions. Despite the severity of the incident and resulting harm, the facility did not notify the State Agency within the mandated two-hour window. Staff interviews confirmed uncertainty about the delay, and the responsible supervisor was no longer employed at the facility. In the second case, a resident with multiple fractures, substance use history, and chronic pain was found unresponsive and administered Naloxone for a suspected drug overdose. The incident occurred on a weekend, and the report to the State Agency was not submitted until two days later, outside the required timeframe. The unit manager acknowledged that the facility's policy was not followed, attributing the delay to the incident occurring over the weekend and the report being sent on the next business day.
Failure to Timely Report Allegations of Abuse, Neglect, and Unusual Incidents
Penalty
Summary
Facility staff failed to notify the State Agency of allegations of abuse or neglect for four residents, as required by policy and regulation. In one incident, two residents were involved in a resident-to-resident altercation resulting in injuries, including bruising, lacerations, and a hospital transfer. Documentation showed that the incident was not reported to the State Agency within the required two-hour timeframe, despite clear evidence of physical harm and police involvement. Staff interviews revealed uncertainty about the reporting process and a lack of clarity regarding responsibility for timely notification. In another case, a resident was found unresponsive and was administered Naloxone by staff, indicating a possible drug overdose. The incident occurred on a weekend, but the report to the State Agency was not submitted until two days later, outside the required reporting window. Staff acknowledged that the facility policy was not followed, attributing the delay to the incident occurring over the weekend and the report being submitted when management returned. A further deficiency was identified when a resident alleged being handled roughly by a CNA during ADL care. The complaint was documented, and staff provided reassurance and education, but did not consider the allegation as abuse and therefore did not report it to the State Agency or conduct a full investigation. Staff interviews confirmed that they did not attempt to identify the aide involved or interview other witnesses, and did not view the resident's report as meeting the threshold for abuse reporting.
Failure to Implement Fall Prevention Care Plan Intervention
Penalty
Summary
Facility staff failed to implement a comprehensive, person-centered care plan for a resident with a history of repeated falls, muscle weakness, and significant medical conditions including a displaced femoral neck fracture and hemiplegia. The resident's care plan, initiated on 03/27/24, included specific interventions such as keeping the bed in the lowest position to mitigate fall risk. Despite this, observations revealed that the resident's bed was found elevated at its highest position during a survey, contrary to the care plan intervention. The resident experienced multiple falls during their stay, including incidents that resulted in a laceration requiring hospital transfer and a subsequent acute right femoral neck fracture. Documentation and staff interviews confirmed that the intervention to keep the bed in the lowest position was not consistently implemented, directly contributing to the resident's ongoing risk and actual occurrences of falls.
Failure to Follow Physician's Order for Narcotic Pain Medication
Penalty
Summary
Facility staff failed to follow a physician's order regarding the administration of narcotic pain medication for a resident with multiple diagnoses, including pain and malignant neoplasm of the left breast. The resident had an active physician's order for Hydromorphone 2 mg, to be given as one tablet by mouth every four hours as needed for chronic pain. During a narcotic count, it was discovered that the resident was administered two tablets of Hydromorphone 2 mg at one time, instead of the ordered one tablet. Review of the medication administration record and the resident's physician orders confirmed that there was no order for the administration of two tablets at once. When questioned, the LPN who administered the medication was unable to provide an explanation for the deviation from the physician's order. The resident did not experience any harm or adverse effects as a result of receiving the incorrect dosage.
Failure to Provide Required Abuse Education Following Allegation
Penalty
Summary
Facility staff failed to provide ongoing in-service training related to abuse, neglect, and exploitation for an employee involved in an allegation of abuse, as required by facility policy. The policy specifies that any employee suspended during an abuse investigation must receive education on abuse prior to returning to work. In this case, a CNA was suspended following an allegation by a resident with dementia, aphasia, and seizure disorder, who accused the CNA of abuse. Documentation review revealed no evidence that the CNA received the required education before returning to work. Interviews with the CNA and the facility educator confirmed that the CNA did not recall receiving any education on abuse prior to resuming duties. The educator acknowledged that education should be provided before the staff member returns to work after suspension during an investigation. The lack of documented evidence and staff recollection indicates that the facility did not follow its own policy for in-service training in response to an abuse allegation.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Washington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bridgepoint Subacute And Rehab Capitol Hill | 1.1 mi | — | 0 | 0 |
| Inspire Rehabilitation And Health Center Llc | 2 mi | — | 17 | 0 |
| Washington Ctr For Aging Svcs | 2.3 mi | — | 0 | 0 |
| Jeanne Jugan Residence | 2.6 mi | — | 0 | 0 |
| Stoddard Baptist Nursing Home | 2.8 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.