washington nursing · b. wln(; _ 03/25/2009 name of provider or supplier street city, statio,zip...

PRINTED: 07/1812009DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

OMB NO. 0938-03 CENTERS FOR MEDICARE & MEDICAIO SERVIC S· STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(Xi) PROVIDERlSUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRucnON

A. BUILDING 01 • MAIN BUILD1NG 01

(X3) DATE SURVEY COMPLETED

095022 B. WlN(; _

03/25/2009 NAME OF PROVIDER OR SUPPLIER STREET CITY, STATIO, ZIP CODE

\ WASHINGTON NURSING FACIUTY 2426 26T,", STREET SE WASHINGTON, DC

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES 10 PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL RIoGULATORY PREFIX (EACH CORRECTIVE ACTION SHOULD BE CROSS·

TAG OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THEAPPROPRIATE OEFICIl:NCY)

K 000 INITIAL COMMENTS

Based on observations and interview during the annual Ltfe Safe Code survey on March 25, 2009 the following findings were observed.

K 018 NFPA 101 LIFE SAFETYCODE STANDARD SS=E

Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas are substantial doors, such as those constructed of 1% inch solid-bonded core

: wood. or capable of resisting fire for at least 20 minutes. Doors In sprlnklered buildings are only required to resist the passage of smoke. There is no Impediment to the closing of the doors, Doors are provided with 8 means suitable for keeping the door closed. Dutch doors meeting 19.3.6.3.6 are pennitted. 19.3.6.3

Roller latches are prohibited by CMS regulations in all health care facilities.

ThiS STANDARD is not met as evidenced by:

Based on observations during the Ufe Safety Code Inspectlon It was determined that double swinging fire doors and smoke barrier doors failed to latch into frames when tested in five (5) of 14 observations. These findings were observed in the presence of the Maintenance Director.

The findings include:

xnoo

K018 NFPA 101 Life Safety Code Standard

1. Doors which failed to have a positive latch at the time of the survey have been repaired.

2. All doors in the facility werec"ecked to ensure a positive latch and repairs were made whenever necessary,

3. The Maintenance Supervisor will lead a team which is charged wit" the

, responsibility to routinely check the doors of the facility through the

I Maintenance Quality Improvement Program. The results of that data collection will be forwarded to the Director of Maintenance for review and he will establish an Action Plan for correction whenever appropriate.

4, The Director of Maintenance will present the findings of the Maintenance or Program data collection and action plans to the Quality Improvement Committee which meets quarterly and is chaired by the Administrator.

3/27/09

4/3/09

4/3/09

/3/09

r:y which insliMioll may be excused from correctIng provll1ing it is CleletmineCI af other Ions.) ept for nursing homes, the Iindi"9!l stated above are

PRINTED: 07/18/2009DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO 0938-0391

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(Xl) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

095022

(X2) MULTIPLE CONSTRUCTION

A. BUILDING 01 • MAIN BUILDING 01

B. WING _


03/25/2009 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

2425 25TH STREET SE WASHINGTON NURSING FACILITY

WASHINGTON, DC 20020

(X4)ID PREFIX

TAG

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

OR LSC IDENTIFYING INFORMATION)

ID PREFIX

TAG

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

REFERENCED TO THE APPROPRIATE DEFICIENCy)

(X5) COMPLETION

DATE

K 000 INITIAL COMMENTS K 000

K 018 SS=E

Based on observations and interview during the . annual Life Safe Code survey on March 25, 2009

the following findings were observed. NFPA 101 LIFE SAFETY CODE STANDARD

Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas are substantial doors, such as

K 018 NFPA 101 Life Safety Code Standard

1. Doors which failed to have a positive latch at the time of the survey have been

those constructed of 1Y. inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in sprinklered buildings are only required to resist the passage of smoke. There is

repaired.

2. All doors in the facility were checked to ensure a positive latch and repairs

3/27/09

no impediment to the closing of the doors. Doors are provided with a means suitable for keeping the door closed. Dutch doors meeting are permitted. 19.3.6.3

Roller latches are prohibited by CMS regulations in all health care facilities.

were made whenever necessary.

3. The Maintenance Supervisor will lead a team which is charged with the responsibility to routinely check the doors of the facility through the Maintenance Quality Improvement

4/3109

This STANDARD is not met as evidenced by:

Based on observations during the Life Safety Code

Program. The results of that data collection will be forwarded to the Director of Maintenance for review and he will establish an Action Plan for correction whenever appropriate.

4. The Director of Maintenance will present the findings of the Maintenance QI Program data collection and action plans to the Quality Improvement Committee which meets quarterly and is

4/3/09

Inspection it was determined that double swinging fire doors and smoke barrier doors failed to latch into frames when tested in five (5) of 14 observations. These findings were observed in the presence of the Maintenance Director.


chaired by the Administrator. 4/3/09

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

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days folloWing 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 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

FORM CM5-2567(D2-99) Previous Versions Obsolete Event ID:WPBP2l Facility ID: WASHNURS If continuation sheet Page 1 of 3


(Xl) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION STATEMENT OF DEFICIENCIES (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED


B. WING _095022 03/25/2009

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE


WASHINGTON, DC 20020 PROVIDER'S PLAN OF CORRECTION SUMMARY STATEMENT OF DEFICIENCIES (X5)

PREFIX ID(X4) ID

COMPLETION DATE

(EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY (EACH CORRECTIVE ACTION SHOULD BE CROSS-PREFIX REFERENCED TO THE APPROPRIATE DEFICIENCy)OR LSC IDENTIFYING INFORMATION) TAGTAG

K 018 Continued From page 1 K 018

Double fire doors and single doors failed to close or latch into frames due to damage when tested in the following areas:

1. Basement-A one (1) inch vertical metal strip located on the boiler room entrance door was damaged and failed to seal a qapbetween the entrance doors to the boiler room door located in the basement in one (1) of one (1) observation at 10:05 AM on March 25, 2009.

2. First Floor- Double swinging fire doors located at the entrance to the "B" side and double doors located near the Staffing Office failed to close and latch into frames when tested at 11:40 AM in two (2) of seven (7) observations at 11:40 AM on March 25, 2009.

3. Second Floor-Double swinging fire doors located at the entrance to the dining room failed to close and latch into frames on the "A" side due to damaged door hardware in one (1) of two (2) observations at 1:30 PM on March 25, 2009.

4. Third Floor-The exit door near room 320 failed to close and latch into frames without assistance when tested in one (1) of four (4) observations at 3:10 PM on March 25, 2009.

Based on observations during the survey it was determined that the entrance door to the 3 North lounge was held open with and assistive device. This finding was observed in the presence of the 1. Doors which were held open with Maintenance Director. any assistive device were repaired

and the door stop was removed. 3/27/09The findings include:

2. All doors in the facility were checked During a tour of Unit 3 North it was determined to ensure all door closure devices worked

properly. 4/3/09

FORM CMS-2567(02·99) Previous Versions Obsolete Event ID:WPBP21 Facility ID: WASHNURS If continuation sheet Page 2 of 3

PRINTED: 07/18/2009DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMS NO 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED

A. BUILDING 01 - MAIN BUILDING 01

B. WING _095022 03/25/2009

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE


WASHINGTON, DC 20020 PROVIDER'S PLAN OF CORRECTION SUMMARY STATEMENT OF DEFICIENCIES ID (X5)

COMPLETION (X4) ID

(EACH CORRECTIVE ACTION SHOULD BE CROSS-(EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY PREFIXPREFIX DATEREFERENCED TO THE APPROPRIATE DEFICIENCy) OR LSC IDENTIFYING INFORMATION) TAGTAG

K 018 Continued From page 2 K 018 3. The Maintenance Supervisor will lead that the Lounge entrance door was improperly held a team Which is charged with the open with a metal door stop, prohibiting the door responsibility to routinely check the from closing doors and door closures through the without assistance in one (1) of four (4) Maintenance Quality Improvement observations at,3:15 PM on March 25, 2009, Program. The results of that data 4/3/09

collection will be forwarded to the Director of Maintenance for review and he will establish an Action Plan for correction whenever appropriate.

4, The Director of Maintenance will present the findings of the Maintenance QI Program data collection and action plans to the Quality Improvement Committee which meets quarterly and is chaired by the Administrator. 4/3/09

FORM CMS-2567(02-99) Previous Versions Obsolete EventID:WPBP21 Facility ID: WASHNURS If continuation sheet Page 3 of 3


STATEMENT OF DEFICIENCIES (Xl) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED

A. BUILDING 01 - MAIN BUILDING 01

095022 B. WING _




(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY PREFIX (EACH CORRECTIVE ACTION SHOULD BE CROSS- COMPLETION

TAG OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DEFICIENCy) DATE

K 000 INITIAL COMMENTS K 000

Based on observations and interview during the annual Life Safe Code survey on March 25, 2009 the following findings were observed.

K 018 NFPA 101 LIFE SAFElY CODE STANDARD K 018 SS=E NFPA 101 Life Safety Code Standard

Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or 1. Doors which failed to have a positive hazardous areas are substantial doors, such as latch at the time of the survey have been those constructed of 1% inch solid-bonded core repaired. 3/27/09 wood, or capable of resisting fire for at least 20 minutes. Doors in sprinklered buildings are only 2. All doors in the facility were checked required to resist the passage of smoke. There is to ensure a positive latch and repairs no impediment to the closing of the doors. Doors were made whenever necessary. 4/3109 are provided with a means suitable for keeping the door closed. Dutch doors meeting 19.3.6.3.6 are 3. The Maintenance Supervisor will lead permitted. 19.3.6.3 a team which is charged with the

responsibility to routinely check the Roller latches are prohibited by CMS regulations in doors of the facility through the all health care facilities. Maintenance Quality Improvement

Program. The results of that data 4/3/09 collection will be forwarded to the Director of Maintenance for review and he will establish an Action Plan for correction whenever appropriate.

4. The Director of Maintenance will present the findings of the Maintenance QI Program data collection and action

This STANDARD is not met as evidenced by: plans to the Quality Improvement Based on observations during the Life Safety Code Committee which meets quarterly and is Inspection it was determined that double swinging chaired by the Administrator. 4/3/09 fire doors and smoke barrier doors failed to latch into frames when tested in five (5) of 14 observations. These findings were observed in the presence of the Maintenance Director.


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

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following 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 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:WPBP2l Facility ID: WASHNURS If continuation sheet Page 1 of 3

DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 07/18/2009

FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO 0938-0391

(X2) MULTIPLE CONSTRUCTION STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:



095022

NAME OF PROVIDER OR SUPPLIER

WASHINGTON NURSING FACILITY

B. WING _

STREET ADDRESS, CITY, STATE, ZIP CODE

2425 25TH STREET SE


03/25/2009

(X4) ID PREFIX

TAG



ID PREFIX

TAG



(X5) COMPLETION

DATE

K 018 Continued From page 1 K 018

Double fire doors and single doors failed to close or latch into frames due to damage when tested in the following areas:

1. Basement-A one (1) inch vertical metal strip located on the boiler room entrance door was damaged and failed to seal a gap between the entrance doors to the boiler room door located in the basement in one (1) of one (1) observation at 10:05 AM on March 25, 2009.

2. First Floor- Double swinging fire doors located at the entrance to the .. B" side and double doors located near the Staffing Office failed to close and latch into frames when tested at 11:40 AM in two (2) of seven (7) observations at 11:40 AM on March 25, 2009.

3. Second Floor-Double swinging fire doors located at the entrance to the dining room failed to close and latch into frames on the ..A" side due to damaged door hardware in one (1) of two (2) observations at 1:30 PM on March 25, 2009.

4. Third Floor-The exit door near room 320 failed to close and latch into frames without assistance when tested in one (1) of four (4) observations at 3:10PM on March 25, 2009.

Based on observations during the survey it was determined that the entrance door to the 3 North lounge was held open with and assistive device. This finding was observed in the presence of the Maintenance Director.


During a tour of Unit 3 North it was determined

1. Doors which were held open with any assistive device were repaired and the door stop was removed. 3/27/09

2. All doors in the facility were checked to ensure all door closure devices worked properly. 4/3/09

FORM CMS-2567(02-99) Previous Versions Obsolete EventlD: WPBP21 Facility ID: WASHNURS If continuation sheet Page 2 of 3

PRINTED: 07/18/2009DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMS NO 0938-0391

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(Xl) PROVIDER/SUPPLlER/CLlA IDENTIFICATION NUMBER:

095022

(X2) MULTIPLE CONSTRUCTION


B. WING _



2425 25TH STREET SE . WASHINGTON NURSING FACILITY


(X4) 10 PREFIX

TAG



10 PREFIX

TAG



(X5) COMPLETION

DATE

K 018 Continued From page 2 that the Lounge entrance door was improperly held open with a metal door stop, prohibiting the door from closing without assistance in one (1) of four (4)

K 018 3. The Maintenance Supervisor will lead a team which is charged with the responsibility to routinely check the doors and door closures through the Maintenance Quality Improvement

observations at 3:15 PM on March 25,2009. Program. The results of that data collection will be forwarded to the Director of Maintenance for review and he will establish an Action Plan for correction whenever appropriate.

4. The Director of Maintenance will present the findings of the Maintenance QI Program data collection and action plans to the Quality Improvement Committee which meets quarterly and is

4/3/09

chaired by the Administrator. 4/3/09

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:WPBP2l Facility 10:WASHNURS If continuation sheet Page 3 of 3

washington nursing · b. wln(; _ 03/25/2009 name of provider or supplier street city, statio,zip...

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