Plan of Correction - | doh

1 DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICESSTATEMENT OF DEFICIENCIESAND PLANOF CORRECTIONNAME OF PROVIDER OR SUPPLIERJEANNE JUGAN RESIDENCE(X4) IDPREFIXTAG09E020 SUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEDED BY FULLREGULATORY OR LSC IDENTIFYING INFORMATION)F 000 INITIALCOMMENTSAn annual recertification survey was conductedJanuary 11 through 12, 2007. The followingdeficiencies were based on record review,observation and interviews with facility staff. Thesample included 10 residents based on a censusof 39 residents on the first day of survey andthree (3) supplemental 253 i (h)(2) HOUSEKEEPING/MAINTENANCESS=DThe facility must provide housekeeping andmaintenance services necessary to maintain asanitary, orderly, and comfortable REQUIREMENT is not met as evidenced byBased on observations during the environmentaltour, it was determined that facility staff failed toprovide housekeeping and maintenance servicesto maintain a sanitary and comfortableenvironment as evidenced by: soiled/dusty bedframes, a mechanical lift, floors, carpets, exteriorwindows, marred doors and dining room chairs,and peeling paint on the windows.

2 Theseobservations were made in the presence of theDirectors of Maintenance and Housekeeping andnursing findings include:1. Horizontal bed frames were dusty and soiledwith debris in the following areas:Rooms 1204, 1206, 1401, 1411, 1415 and 1421in six (6) of 17 observations at 10:55 AM onJanuary 11 and between 9:20 AM and 10:40 AMon January 12, 2007.(X2) MULTIPLE CONSTRUCTIONA. BUILDINGB. WINGSTREET ADDRESS, CITY, STATE, ZIP CODE4200 HAREWOOD ROAD NEWASHINGTON,DC 20017 IDPREFIXTAGF 0001 PRINTED: 01/19/2007 FORM APPROVEDOMB NO. 0938-0391(X3) DATE SURVEYCOMPLETED01/12/2007 PROVIDER'S PLAN OF Correction (EACH CORRECTIVE ACTIONSHOULD BECROSS-COMPLETIONREFERENCEDTO THE APPROPRIATE DEFICIENCY) DATEPlan of CorrectionF253 Finding #1F 253 1. Housekeeping Staff dusted and sanitizedthe bed frames in Rooms 1204, 1206, 1401,1415, and 1421 on 1/12 Housekeeping Staff will dust all bedframes as part of their daily cleaning.

3 Onsheet changing days they will also clean andsanitize the bed frames of all the beds. Thisis part of the routine cleaning plan everyother Contract Housekeeping Manager willmonitor this by inspecting a random sampleof Resident bed frames twice weekly and jwill give a report of the results to These reports will be collected and givento the QI nurse to be referred to the QI andQA Corrective action complete1/12 #21. The handles and foot pedals of the liftson good shepherd and Sacred Heart unitswere cleaned on 1/12 All lifts will be cleaned every night bynight shift nursing staff and checked by thenight nurse to assure that they are A schedule for night shift nursing staffhas been put into place and will bemonitored by the Unit Coordinators on aweekly DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURETITLE(X6) DATE9 07 Any deficiency statement ending with an as isk (*) deno es a deficiency which the institution may be excusede fifromdingscorrectinstatedg proviabove rigJ11'other safeguards provide sufficient protection to the patients.

4 (See instructions.) Except for nursing homes, thn daysare it isdisclosable 90determined thatfollowing the date of survey whether or not a plan of Correction is provided. For nursing homes, the above findings and plans of Correction are disclosable 14days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of Correction is requisite to continuedprogram participation.(X1) PROVIDER/SUPPLIER/CLIAIDENTIFICATIONNUMB ERFORM CMS-2567(02-99) Previous Versions Obsolete Event to: 18D911 Facility ID: JEANNEJUGANIf continuation sheet Page 1 off 14 DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICESSTATEMENT OF DEFICIENCIESAND PLAN OF CORRECTIONNAME OF PROVIDER OR SUPPLIERJEANNE JUGANRESIDENCE(X4) IDPREFIXTAG(X1) PROVIDER/SUPPLIER/CLIAIDENTIFICATIONNUMB ER:09E020 SUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEDED BY FULLREGULATORY OR LSC IDENTIFYING INFORMATION)F 253 Continued From page 12.

5 The foot pedals and handles of the mechanicallift were soiled with debris in the laundry rooms inthree (3) of three (3) observations at 11:15 AM onthe good shepherd unit and two (2) of two (2)observations on the Sacred Heart unit at 10:00AM on January 12, Floor and carpet surfaces were sticky, soiledand/or marred in the following areas:Rooms 1210, 1411, 1419, 1423 and Cafe floorsin five (5) of 18 observations between 10:55 AMand 4:08 PM on January 11, 2007 and between 9:20 AM and 10:40 AM on January 12, The exterior surfaces of windows were soiledand stained in the following areas:Rooms 1204, 1206, 1214, 1421, Cafe area, dayroom and rehabilitation services area in seven (7)of 21 observations between 10:55 AM and 4:08PM on January 11, 2007 and between 9:20 AMand 10:40 AM on January 12, Entrance and bathroom doors were marredand scarred in the following areas: good shepherd Rooms 1204, 1206, 1211, 1214and 1217 in five (5) of nine (9) observationsbetween 10:40 AM and 4:08 PM on January 11, Heart Rooms 1403, 1415 and 1421 inthree (3) of eight (8) observations between 9:20AM and 10:40 AM on January 12, Dining room chairs were marred and scarredon leg and arm surfaces in 18 of 19 observationsat 12:40 PM on January 12, CMS-2567(02-99) Previous Versions Obsolete Event ID: 18D911(X2) MULTIPLE CONSTRUCTIONA.

6 BUILDINGB. WINGSTREET ADDRESS, CITY, STATE, ZIP CODE4200 HAREWOOD ROAD NEWASHINGTON,DC 20017 IDPREFIXTAGF 253 PRINTED: 01/19/2007 FORM APPROVEDOMB NO. 0938-0391(X3) DATE SURVEYCOMPLETED01/12/2007 PROVIDER'S PLAN OF Correction (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)and QA committee Corrective action taken1/15/07.(X5)COMPLETIONDATE will be given to the QI nurse on4. A reporta monthly basis. Findings will be reported atQI and QA Corrective action taken 1/12 }-10 Finding #31. The carpet in Room 1210 was cafe floor and the floors in rooms 1411,1419, and 1423 were washed on 1/12 The carpet will be vacuumed daily byhousekeeping. Spots will be identified andtreated. Floors will be swept and moppeddaily and as All floors will be inspected andmonitored by the Contract HousekeepingManager daily.

7 Any sticky or soiled floorswill be brought to the attention of theresponsible housekeeper or The Contract Housekeeping Managerwill give a monthly audit report as to thecleanliness of the floors and carpets to theQI nurse. Findings will be referred to the QIFinding #41. Facility has contracted with aprofessional window cleaning service toclean windows in Rooms 1204, 1206, 1214,1421, the cafe area, day room andrehabilitation services area on 3/20 Facility will contract professionalservices to clean all windows annually Housekeeping will be responsible forcleaning windows that may become soiled orstained in-between those services when it isFa I ID'ot;s/6 7l Iy . JEANNEJUGANIf continuation sheet Page 2 of 14F253possible and safe. They will clean inside The exterior surfaces of the windows willbe inspected every six months by theContract Housekeeping Manager and reportof soiled windows given to theAdministrator for review.

8 Findings will bereferred to the QI and QA Corrective action will be completed by3/20 #51. Repair of door surfaces by sanding andstaining will be done in Rooms #1204, 1206,1211, 1214, 1217, 1403, 1415 and 1421 willbe done by 3/20 All of the Residents' rooms' doorsurfaces were inspected to see which oneswere in need of repair and report given These inspections will be added to thequarterly preventive maintenance Results of quarterly maintenance programwill be reported to the Administrator and theQI nurse. Findings will be referred to the QIand QA committee Corrective actions will be completed by3/20 #61. All dining room chairs were inspected on1/12 ID: 18D911 FacilityID: Jeanne Jugan Residence 09E0202AF2532. All chairs will be replaced by new chairsby 3/30 Dining room chairs will be inspected aspart of the quarterly maintenance Results of report of quarterly inspectionof dining room chairs will be given to theAdministrator and QI nurse.

9 Findings willbe referred to the QI and QA Corrective action will be completed by3/20 #71. Window sills and frames in rooms #1204,1206, 1419, 1423, and the Cafe will bepainted by an outside contractor by 3/20 Maintenance will inspect all Residents'rooms for any window sills or frames thatare in need of painting because of peelingpaint and will give a report to These inspections will be added to thequarterly preventative maintenance Results of reports from quarterlyinspections will be reported to theAdministrator and the QI nurse. Findingswill be referred to the QI and QA Corrective actions will be completed byan outside contractor by 3/20/07.'y/a?O^D 7 CMS-2567 Event ID: 18D911 Facility ID: Jeanne Jugan Residence 09E020 2 BDEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICESSTATEMENT OF DEFICIENCIESAND PLAN OF CORRECTIONNAMEOF PROVIDER OR SUPPLIERJEANNE JUGANRESIDENCE(X4) IDPREFIXTAG09E020 SUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEDED BY FULLREGULATORY OR LSC IDENTIFYING INFORMATION)F 253 I Continued From page 2F 279SS=D7.

10 Paint on window sills and frames was peelingin the following areas:Rooms 1204, 1206, Cafe, 1419, 1421 and 1423in six (6) of 21 observations between 10:55 AMand 4:08 PM on January 11, 2007 and between 9-120 AM and 10:20 AM on January 12, (d), (k)(1) COMPREHENSIVECARE PLANSA facility must use the results of the assessmentto develop, review and revise the resident'scomprehensive plan of facility must develop a comprehensive careplan for each resident that includes measurableobjectives and timetables to meet a resident'smedical, nursing, and mental and psychosocialneeds that are identified in the care plan must describe the services that areto be furnished to attain or maintain the resident'shighest practicable physical, mental, andpsychosocial well-being as required under.