Based on record review and staff interview, the facility's staff failed to have an effective Quality Assurance and Performance Improvement Plan (QAPI). This is evident by the plan's failure to address residents with behaviors or outline safety measures for staff to follow to ensure residents did not possess smoking paraphernalia outside of the designated smoking area. The facility's census on the first day of the survey was 287. The findings included: During the QAPI plan interview conducted on 05/02/24 at approximately 10:00 AM , the plan dated 01/26/23 documented in part, Plan - Smoking Patio Monitoring .Goal- residents will be monitored on smoking patio facility standards .Active Plan- resident will be reminded in residents council meeting that no resident is to have a lighter in their… …
F865 citations in District of Columbia
QAPI program · Administration Deficiencies
Have a plan that describes the process for conducting QAPI and QAA activities.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2024
District of Columbia cites F865 more often than its own record predicts
2.75 times the share F865 takes of citations nationally.
Of every deficiency written in District of Columbia in 2024, this is the portion that was F865.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What District of Columbia surveyors wrote
F865 findings written in District of Columbia, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
The short window
Recent years
| Year | Share of District of Columbia citations | vs expected |
|---|---|---|
| 2023 | 0.45% | 2.64× |
| 2024 | 0.51% | 2.75× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else District of Columbia surveyors cite →
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