DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED: 04/13/2011FORM APPROVED

OMB NO. 0938-0391STATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION

(XI) PROVIDER/SUPPLIER/CLIAIDENTIFICATION NUMBER:

09E020

A. BUILDING 01 - MAIN BUILDING 01

03/29/2011

I(X5)

COMPLETION

I DATE

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEYCOMPLETED

NAME OF PROVIDER OR SUPPLIER

JEANNE JUGAN RESIDENCE

(X4) 10PREFIXTAG

B. WING _

2. Inservicing was done on the importanceOf protecting the residents from any harrPBy educating the staff on our policies andiprocedures for fire and safety so that the I

Facility will be incompliance in followingState and federal regulation andguidelines. The staff was inserviced ontheir roles and responsibilities infollowing the requirements in Fire andSafety Expediently

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

vA I It.,u.~..<,) In La~ ~2 tf,bo Jj I

SUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY

OR LSC IDENTIFYING INFORMATION)

K 000 I INITIAL COMMENTS

STREET ADDRESS, CITY, STATE, ZIP CODE

4200 HAREWOOD ROAD NE

WASHINGTON, DC 20017

10PREFIXTAG

PROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BE

CROSS-REFERENCED TO THE APPROPRIATEDEFICIENCY)

Any deficiency statement ending with an asterisk (0) denotes a deficiency which the institution may be excused from correcting providing it is determined that othersafeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the dateof survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date thesedocuments are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

An annual Recertification (Life Safety Code) Surveywas conducted on March 29, 2011. The findings arebased on observations made during an inspectionof your facility. INFPA 101 LIFE SAFETY CODE STANDARDK050

SS=DFire drills are held at unexpected times undervarying conditions, at least quarterly on each shiftThe staff is familiar with procedures and is awarethat drills are part of established routine.Responsibility for planning and conducting drills isassigned only to competent persons who arequalified to exercise leadership. Where drills areconducted between 9 PM and 6 AM a coded Iannouncement may be used instead of audiblealarms. 19.7.1.2

This STANDARD is not met as evidenced by:

Based on observations during the Life Safety CodeInspection it was determined that staff were notfamiliar with emergency procedures or failed torespond expediently during an unannounced test ofthe fire alarm system in two (2) of two (2)observationsThe findings include:The Fire Alarm Pull Station was manually activatednear the Nurses Station on the Good ShepherdUnit, at approximately 12:05 PM, it was determinedthat staff were unsure of emergency procedures orfailed to act in a timely manner to close doors on thenorth side of the unit, as evidenced by two (2)residents' room doors that remained open duringthe second tour of the Unit and the Second FloorDining Room doors on both sides of the hallwayremained

I

FORM CMS-2567(02-99) Previous Versions Obsolete Event 10: KUYI21

K 000 I Start Typing Here:

K 050 1. No resident was observed or reportedTo have been harmed by this deficientpractice.

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3. All employees will be instructed onFire and safety procedures based onRACE(Remove, Alarm, Contain, EvacuateExtinguish) and facility's policy andProcedure.

All were instructed on the importanceOf closing doors including the diningroom doors and moving residents fromdanger in an expedient manner.

Facility 10: JEANNEJUGAN

DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED: 04/13/2011FORM APPROVED

OMB NO 0938-0391STATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION

(X1) PROVIDERISUPPLIER/CLIAIDENTIFICATION NUMBER:

09E020

(X2) MULTIPLE CONSTRUCTION

01 - MAIN BUILDING 01A. BUILDING

03/29/2011

(X3) DATE SURVEYCOMPLETED

B. WING _

(X4) IDPREFIXTAG

(X5)COMPLETION

DATE

NAME OF PROVIDER OR SUPPLIER

JEANNE JUGAN RESIDENCE

SUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY

OR LSC IDENTIFYING INFORMATION)

K 050 Continued From page 1open through the drill in two (2) of two (2)observations between 12:05PM and 12:15 PM onMarch 29, 2011.

FORM CMS-2S67(02-99) Previous Versions Obsolete Event ID: KUYI21

i

iK 050, i

,I 4. Monthly fire drills will be planned in

order to make sure that our facility isIncompliance with fire and safety andwill be documented. Any in fractionsidentified will be addressed

I

immediately and Followed up at theweekly safety meetings and quarlty QA'

I

meetings to Ensure compliance of Fireand Safety as well as quality of lifeOf our residents.

STREET ADDRESS, CITY, STATE, ZIP CODE

4200 HAREWOOD ROAD NE

WASHINGTON, DC 20017

PROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BE

CROSS-REFERENCED TO THE APPROPRIATEDEFICIENCY)

IDPREFIXTAG

5. All staff was inserviced on Fire andSafety April 20, 2011.4/20/2011

Fire drill and In Service was completedApril 20, 2011. Compliance Met.

Facility ID: JEANNEJUGAN

i4/20/2011

If continuation sheet Page 2 of 2