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DEPARTMENT OF HEALTH AND HUMAN SERVICES


CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

OMB NO. 0938-0391


(X2) MULTIPLE CONSTRUCTION
A. BUILDING ______________________

(X3) DATE SURVEY


COMPLETED

C
015131

B. WING _____________________________

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

119 WATTERSON PARKWAY

GOLDEN LIVING CENTER - TRUSSVILLE


(X4) ID
PREFIX
TAG

11/07/2014

TRUSSVILLE, AL 35173

SUMMARY STATEMENT OF DEFICIENCIES


(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

F 000 INITIAL COMMENTS

PROVIDER'S PLAN OF CORRECTION


(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

(X5)
COMPLETION
DATE

F 000

An Abbreviated and Partial Extended Survey was


conducted from 11/5/14 to 11/7/14 for the
investigation of complaint/report number
AL00032227. On 11/7/14 at 12:23 PM, the
facility's Executive Director, Director of Nursing
Service, Field Service Clinical Director and Area
Vice President were notified of the findings of
substandard quality of care at the immediate
jeopardy level of "J" in the area of Resident
Behavior & Facility Practices, F 223, F 226 and in
the area of Administration, F 490, based on the
results of the investigation of complaint/report
number AL00032227. The immediate jeopardy
began on 10/25/14 and was relieved onsite on
11/7/14 at 6:00 PM. The scope and severity of all
cited deficiencies was lowered to a "D" level to
allow the facility time to monitor and revise their
corrective actions as needed to achieve
substantial compliance.
Golden Living Center - Trussville is not in
compliance with applicable requirements of 42
CFR Part 483, Health Standard Requirements for
Long Term Care Facilities.
F 223 483.13(b), 483.13(c)(1)(i) FREE FROM
SS=J ABUSE/INVOLUNTARY SECLUSION

F 223

12/9/14

The resident has the right to be free from verbal,


sexual, physical, and mental abuse, corporal
punishment, and involuntary seclusion.
The facility must not use verbal, mental, sexual,
or physical abuse, corporal punishment, or
involuntary seclusion.

This REQUIREMENT is not met as evidenced


LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

(X6) DATE

TITLE

Electronically Signed

12/03/2014

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: 72DP11

Facility ID: 3717301NH

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DEPARTMENT OF HEALTH AND HUMAN SERVICES


CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

OMB NO. 0938-0391


(X2) MULTIPLE CONSTRUCTION
A. BUILDING ______________________

(X3) DATE SURVEY


COMPLETED

C
015131

B. WING _____________________________

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

119 WATTERSON PARKWAY

GOLDEN LIVING CENTER - TRUSSVILLE


(X4) ID
PREFIX
TAG

TRUSSVILLE, AL 35173

SUMMARY STATEMENT OF DEFICIENCIES


(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

F 223 Continued From page 1

PROVIDER'S PLAN OF CORRECTION


(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

(X5)
COMPLETION
DATE

F 223

by:
Based on observation, interviews, medical record
review, hospital records, the facility's investigative
report and police report, the facility failed to
prevent a male visitor, Resident Identifier (RI)
#1's son from sexually abusing RI #1, a
cognitively impaired resident. On 10/25/14, the
male visitor entered the facility intoxicated at
approximately 1:30 PM. Around 3:30 PM/4:15
PM, Employee Identifier (EI) #5, a Certified
Nursing Assistant (CNA) noticed RI #1's room
door was closed. EI #5 opened the door to find a
cold, dark room with the lights off and both
shades down. When EI #5 turned the lights on,
the male visitor's shoes were off, his pants were
unzipped and unbuckled and he was holding his
pants up at his waist. EI #5 turned the lights
back off, closed the door and left the room.
Without reporting any of her observations, EI #5
continued on with her rounds.
Later that afternoon, EI #1, the Licensed Practical
Nurse (LPN) Treatment Nurse entered RI #1's
room to perform a skin assessment on RI #1's
roommate, RI #2. The room door was closed.
After entering the room, EI #1 observed the room
was pitch black, all the lights were off, the curtain
in the middle of the room was pulled and the
room smelled of alcohol. The male visitor, whose
right shoe and sock was off, moved very quickly
into a wheelchair positioned by RI #1's bed. RI
#1's roommate, RI #2, informed EI #1 twice that
the male visitor was messing with RI #1. After
hearing this, EI #1 left the room leaving the male
visitor with the residents. Upon her return to the
room, EI #1 noticed the male visitor was at the
end of RI #1's bed holding his pants up at the
waist, his belt was located on the floor and he sat
very quickly again back into the wheelchair.
FORM CMS-2567(02-99) Previous Versions Obsolete

11/07/2014

Event ID: 72DP11

Preperation, submission and


implementaion of this plan of correction
does not constitute an admission of or
agreement with the facts and conclusions
set forth on the survey report. Our plan of
correction is prepared and executed as a
means to continuously improve the quality
of care and to comply with all applicable
state and federal regulatory requirements.
"This plan of correction constitutes a
writen allegation of substantial compliance
with federal Medicare and Medicaid
requirements."
I.
RI # 1 was transferred to the hospital on
10/25/14 for further evaluation. RI #1's
son was removed/arrested from the
facility ob local Police Department on
10/25/14. RI # 1 did not return to the
facility.
EI # 1 was provided 1-on-1 re-education
on Prevention, Identification, Protection,
Reporting, and Investigation. Training
focused on identification of potential risk
and immediate protection of
patient/resident. Training was conducted
by Director of Nursing Services on
11/7/14.
EI # 5 was provided 1-on-1 re-education
on Prevention, Identification, Protection,
Reporting, and Investigation. Training
focused on identification of potential risk
and immediate protection of
Facility ID: 3717301NH

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DEPARTMENT OF HEALTH AND HUMAN SERVICES


CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

OMB NO. 0938-0391


(X2) MULTIPLE CONSTRUCTION

(X3) DATE SURVEY


COMPLETED

A. BUILDING ______________________

C
015131

B. WING _____________________________

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

119 WATTERSON PARKWAY

GOLDEN LIVING CENTER - TRUSSVILLE


(X4) ID
PREFIX
TAG

TRUSSVILLE, AL 35173

SUMMARY STATEMENT OF DEFICIENCIES


(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

F 223 Continued From page 2

PROVIDER'S PLAN OF CORRECTION


(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

(X5)
COMPLETION
DATE

F 223

Again after observing suspicious activity, EI #1


left the room and walked approximately 350 feet
to find her supervisor because she was
uncomfortable with the situation. EI #1 stated
she was uncomfortable because she entered a
completely dark room to find a male visitor was
holding his pants up at the waist, his belt off, the
room smelled of alcohol and RI #2's roommate
stated, "he's messing with her."
EI #2, the weekend Registered Nurse (RN)
Supervisor, arrived at RI #1's room and found
that the male visitor had been drinking because
the room smelled of alcohol. The male visitor's
shoe was off; his pants were unzipped and wide
opened. RI #1 was observed in bed, naked from
the waist down, with her vaginal area completely
exposed for viewing.
Upon examination, RI #1 complained of back and
vaginal pain and was transferred to a local
hospital for possible sexual assault. The
Emergency Room (ER) record indicated RI #1
had bruising noted on her hymen, a membrane
that partially closes the opening of the vagina,
with several scratches and bruises on the
bilateral lower extremities. RI #1's discharge
summary chief complaint included assault.
The male visitor was arrested at the nursing
facility for public intoxication and later charged
with rape and sexual assault in the first degree,
with two additional charges of elder abuse and
incest.
The facility's investigation substantiated that RI
#1 was sexually abused by the male visitor.
This deficient practice affected RI #1, one of one
FORM CMS-2567(02-99) Previous Versions Obsolete

11/07/2014

Event ID: 72DP11

patient/resident. Training was conducted


by Director of Nursing Services on
11/7/14.

II
All residents/patients have the potential
risk of being affected.

III
Director of Nursing Services / Designee
provided education to all active staff on
Prevention, Identification, Protection,
Reporting, and Investigation. Training
focused on identification of potential risk
and immediate protection of
patient/resident. 100% of active staff
completed 11/7/14. All staff on medical
leave, vacation, scheduled off day will
receive retraining prior to returning to
work. This training has been added to,
and will be emphasized, during new
employee orientation, and no new
employees will be assigned duties until
this training is completed.
IV
Director of Nursing Services / Designee to
interview 10 staff members weekly x 2
weeks then monthly times 3 months to
ensure staff can correctly articulate the
requirements for the identification and
protection of residents from abuse. Any
negative findings will result in immediate
corrective action including relief of duties,
Facility ID: 3717301NH

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DEPARTMENT OF HEALTH AND HUMAN SERVICES


CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

OMB NO. 0938-0391


(X2) MULTIPLE CONSTRUCTION
A. BUILDING ______________________

(X3) DATE SURVEY


COMPLETED

C
015131

B. WING _____________________________

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

119 WATTERSON PARKWAY

GOLDEN LIVING CENTER - TRUSSVILLE


(X4) ID
PREFIX
TAG

11/07/2014

TRUSSVILLE, AL 35173

SUMMARY STATEMENT OF DEFICIENCIES


(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

F 223 Continued From page 3

PROVIDER'S PLAN OF CORRECTION


(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

(X5)
COMPLETION
DATE

F 223

resident, identified by facility as being sexually


abused. This deficient practice posed an
immediate threat to the health and safety of RI
#1, as it was likely to cause serious harm, injury,
impairment, or death.
On 11/7/14 at 12:23 PM, the facility's Executive
Director, Director of Nursing Service, Field
Service Clinical Director and Area Vice President
were notified of the findings of substandard
quality of care at the immediate jeopardy level of
"J" in the area of Resident Behavior & Facility
Practices, F 223.
Findings include:
RI #1, an 83 year old resident, was admitted to
the facility on 10/14/14.
RI #1's Admission "CLINICAL HEALTH STATUS"
dated 10/14/14 9:50 PM, indicated RI #1 had
short and long term memory problems and
needed assistance with decisions at this time. RI
#1 was assessed as being occasionally
incontinent of bladder and used liners/briefs.
RI #1's Minimum Data Set, with an assessment
reference date of 10/21/14, identified the resident
as being moderately impaired in cognitive skills
for daily decision making, with a Brief Interview
for Mental Status (BIMS) score of 11. The MDS
indicated RI #1 was not steady and only able to
stabilize with staff assistance when moving from
a seated to a standing position.

subject to disciplinary action and not


permitted to return to duties until he/she
has been re-trained and can successfully
do a return demonstration. Interview
results will be kept in a binder in the
Director of Nursing Services office.
Social Services Director / Designee
conducted interviews to determine
whether residents are being treated with
respect and dignity. Interviews began on
11/7/14 and 100% of interviewable
residents/patients have been interviewed.
On 12/2/14 additional interviews were
initiated to detect whether
residents/patients have
witness/encountered any abuse while in
the facility. We will interview 100% of
interviewable residents/patients by
12/8/14. Negative findings will result in
immediate steps to protect the resident,
an investigation and a report to the state
agency if it is a reportable allegation, and
a report to local law enforcement if there
is a reasonable suspicion that a crime has
occurred. Interviews results will be kept in
a binder in the Director of Nursing
Services office.

On 11/3/14, the State Agency received the


facility's Five Day Investigative Report related to
RI #1. According to the facility's investigative
report, on 10/25/14, RI #1's son was observed in
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: 72DP11

Facility ID: 3717301NH

If continuation sheet Page 4 of 37

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DEPARTMENT OF HEALTH AND HUMAN SERVICES


CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

OMB NO. 0938-0391


(X2) MULTIPLE CONSTRUCTION
A. BUILDING ______________________

(X3) DATE SURVEY


COMPLETED

C
015131

B. WING _____________________________

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

119 WATTERSON PARKWAY

GOLDEN LIVING CENTER - TRUSSVILLE


(X4) ID
PREFIX
TAG

11/07/2014

TRUSSVILLE, AL 35173

SUMMARY STATEMENT OF DEFICIENCIES


(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

F 223 Continued From page 4

PROVIDER'S PLAN OF CORRECTION


(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

(X5)
COMPLETION
DATE

F 223

the resident's room very intoxicated. The son


was observed with his shoes off, belt removed
and pants undone. RI #1's roommate heard RI
#1 saying "no and to stop." RI #1's son was
removed from the resident's room. Police arrived
and RI #1's son was arrested for public
intoxication. RI #1 was assessed and sent to the
local emergency room (ER) for further evaluation.
Based on the investigation, the facility
substantiated that RI #1 was sexually abused by
her son.
In a telephone interview on 11/6/14 at 3:05 PM, EI
#4, the CNA assigned to care for RI #1 on the first
shift (7:00 AM - 3:00 PM) on 10/25/14, stated RI
#1's son came to the facility about 1:30 PM.
When asked if RI #1's room smelled of alcohol,
EI #4 said yes.
In an interview on 11/6/14 at 3:30 PM, EI #5, the
CNA who was assigned to care for RI #1 during
the second shift (3:00 PM - 11:00 PM) on
10/25/14, was asked if she recalled the incident
that occurred on 10/25/14. EI #5 said yes.
According to EI #5, she walked pass RI #1's room
door between 3:30 PM and 4:15 PM, and noticed
the door was closed. EI #5 stated RI #1 was
unsteady when she got up unassisted so she was
a little concerned with the door being closed. EI
#5 opened the door to find a cold, dark room with
the lights off and both window shades down.
Before EI #5 could see RI #1's bed, RI #1's son
came from the area where RI #1's wheelchair
was positioned by the bed. When EI #5 turned
the lights on, she noticed a blue diaper
(incontinent brief) on the floor, RI #1's son's
shoes were off, his pants were unzipped and
unbuckled enough where she could see either RI
#1's son's white t-shirt or white underwear. RI
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: 72DP11

Facility ID: 3717301NH

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DEPARTMENT OF HEALTH AND HUMAN SERVICES


CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

OMB NO. 0938-0391


(X2) MULTIPLE CONSTRUCTION
A. BUILDING ______________________

(X3) DATE SURVEY


COMPLETED

C
015131

B. WING _____________________________

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

119 WATTERSON PARKWAY

GOLDEN LIVING CENTER - TRUSSVILLE


(X4) ID
PREFIX
TAG

11/07/2014

TRUSSVILLE, AL 35173

SUMMARY STATEMENT OF DEFICIENCIES


(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

F 223 Continued From page 5

PROVIDER'S PLAN OF CORRECTION


(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

(X5)
COMPLETION
DATE

F 223

#1's son was holding his pants up at his waist.


Before EI #5 could say anything she was startled
when RI #1's son asked if she was in the room to
see the other resident in the room, RI #2. EI #5
asked RI #2 if she was alright and the resident
said yes. EI #5 observed RI #1 lying in bed with
the covers pulled over the resident neatly. EI #5
stated the mistake she made, was turning the
lights back off, closing the room door and leaving
the room. After leaving the room, EI #5 stated
she stood outside the door not knowing what to
think then, continued with her rounds. About 4:30
PM to 4:45 PM, as EI #5 was continuing her
rounds, she passed by RI #1's room and heard EI
#2, the weekend Registered Nurse (RN)
Supervisor and EI #3, the LPN Charge Nurse
having a conversation inside RI #1's room. When
EI #5 looked in the door, she witnessed water all
over the floor and the back of RI #1's son's pants
was wet. According to EI #5, she heard EI #2
asking RI #1's son to leave. Then she heard EI
#3 say that she didn't want RI #1's son to leave,
she wanted him arrested. EI #5 also stated she
overheard RI #1's son say to RI #1 that he was
going to go now because he was about to be
arrested. EI #5 stated she asked the resident if
she could put a diaper on her, but EI #2 and EI #3
stated not to clean the resident up until the police
arrive. When EI #5 placed a diaper on RI #1, she
found car keys, that she believed belonged to RI
#1's son, between RI #1's legs. EI #5 stated she
gave the keys to EI #3, who in turn gave the keys
to the police officer. EI #5 stated she later found
out staff thought RI #1's son was sexually
abusing his mother. EI #5 stated it was unusual
to find RI #1's son in the room with his pants
unzipped. EI #5 stated she felt guilty for not
leaving the door open, not turning the lights on
and not reporting the incident.
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: 72DP11

Facility ID: 3717301NH

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DEPARTMENT OF HEALTH AND HUMAN SERVICES


CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

OMB NO. 0938-0391


(X2) MULTIPLE CONSTRUCTION
A. BUILDING ______________________

(X3) DATE SURVEY


COMPLETED

C
015131

B. WING _____________________________

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

119 WATTERSON PARKWAY

GOLDEN LIVING CENTER - TRUSSVILLE


(X4) ID
PREFIX
TAG

11/07/2014

TRUSSVILLE, AL 35173

SUMMARY STATEMENT OF DEFICIENCIES


(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

F 223 Continued From page 6

PROVIDER'S PLAN OF CORRECTION


(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

(X5)
COMPLETION
DATE

F 223

In an interview on 11/6/14 at 1:57 PM, EI #7, a


CNA who worked the first shift on 10/25/14,
stated RI #1's son was loud and aggressive to the
nursing staff when he came to the facility. EI #7
stated she would go the other way, when she
would witness RI #1's son being loud and
aggressive.
The LPN Treatment Nurse, EI #1, handwritten
witness statement for the local police department,
found within the facility's investigative report
documented " ... Walked into room to access
resident in B bed. Room completely (completely)
dark. Turn light on. A bed (RI #1) son at side of
bed. Jumps into chair and crosses legs. Right
shoe is off no socks on. Rooms smells like
achool (alcohol). Speak with resident in B bed. B
bed resident states "hes (he's) messing her her".
I asked her to repeat it and she stated "he's
messing with her." Left room to look at chart. I
left the lights on and the door open. I returned to
the room. (RI #1's) son is at the bottom half of the
bed. He moves quickly while holding on to pants
and sits back in wheelchair. His belt is lying on
the floor next to the right outer leg of chair and
half way underneath it. Went to notify supervisor.
Left door open. Supervisor returned to room
ahead of me. Supevisor (Supervisor) with son at
bed side asking him to leave ... 911 called. Son
finally leaves room. Resident examened
(examined). Diaper off of resident ... Diaper
found in bathroom ... ." "This statement reflects
to the best of my knowledge and recollection the
facts involved in this incident." EI #1 signed this
statement and dated it 10/25/14.
In an interview on 11/5/14 at 3:00 PM, EI #1 was
asked what she recalled when she entered RI
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: 72DP11

Facility ID: 3717301NH

If continuation sheet Page 7 of 37

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FORM APPROVED

DEPARTMENT OF HEALTH AND HUMAN SERVICES


CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

OMB NO. 0938-0391


(X2) MULTIPLE CONSTRUCTION
A. BUILDING ______________________

(X3) DATE SURVEY


COMPLETED

C
015131

B. WING _____________________________

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

119 WATTERSON PARKWAY

GOLDEN LIVING CENTER - TRUSSVILLE


(X4) ID
PREFIX
TAG

11/07/2014

TRUSSVILLE, AL 35173

SUMMARY STATEMENT OF DEFICIENCIES


(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

F 223 Continued From page 7

PROVIDER'S PLAN OF CORRECTION


(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

(X5)
COMPLETION
DATE

F 223

#1's room on 10/25/14. EI #1 stated the door


was closed, when she knocked and didn't get an
answer, she opened the door half way,
announced herself and entered the room after
hearing someone say come in, whom she thought
was RI #1's son. Upon entering the room, EI #1
observed the room was dark, all the lights were
off. It was pitch black. The curtain in the middle
of the room (between beds A and B) was pulled.
There was a smell of alcohol in the room. RI #1's
son was observed at the end of RI #1's bed and
he sat very quickly into the wheelchair, positioned
by RI #1's bed. EI #1 informed RI #1's son that
she was going to the other side of the room to
speak with the other resident, RI #2. EI #1 stated
RI #2 was a new resident and she wanted to do a
skin assessment. When EI #1 walked over to RI
#2's side of the room, she noticed RI #1's son
right shoe and sock was off. The shoe was
halfway underneath the bed. According to EI #1,
RI #2 told her "he's messing with her." EI #1
asked RI #2 to repeat her statement and RI #2
repeated, "he's messing with her." When asked
how RI #2 said it, EI #1 described RI #2's
statement as matter of fact, loud enough for EI #1
to hear. EI #1 stated she then left the room with
the door open and the lights on to review RI #2's
medical record because RI #2 was a new
resident and EI #1 wasn't' sure if RI #2 was
confused or not. When asked what she stated to
RI #2 after RI #2 told her "he's messing with her",
EI #1 said she told RI #2 to wait a minute, that
she would be right back. EI #1 left the room (on
11/7/14 at 1:13 PM, EI #12, the Maintenance
Assistant, measured, with a tape measure, the
distance from the door of RI #1's room to the end
of the West Wing nurses' station as 31 feet. The
"Charting" room, where the medical records are
kept, was located behind the nurses' station; not
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: 72DP11

Facility ID: 3717301NH

If continuation sheet Page 8 of 37

PRINTED: 12/22/2014
FORM APPROVED

DEPARTMENT OF HEALTH AND HUMAN SERVICES


CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

OMB NO. 0938-0391


(X2) MULTIPLE CONSTRUCTION
A. BUILDING ______________________

(X3) DATE SURVEY


COMPLETED

C
015131

B. WING _____________________________

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

119 WATTERSON PARKWAY

GOLDEN LIVING CENTER - TRUSSVILLE


(X4) ID
PREFIX
TAG

11/07/2014

TRUSSVILLE, AL 35173

SUMMARY STATEMENT OF DEFICIENCIES


(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

F 223 Continued From page 8

PROVIDER'S PLAN OF CORRECTION


(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

(X5)
COMPLETION
DATE

F 223

visible to RI #1's room). When EI #1 returned,


she found RI #1's son at the end of RI #1's bed
again. He was holding his pants as he sat back in
the wheelchair really fast. EI #1 also noticed that
RI #1's son's belt was on the floor beneath the
wheelchair. EI #1 explained that she then left the
room to go and get the supervisor, EI #2. When
asked what RI #1 was doing when EI #1 entered
the room the second time, EI #1 stated RI #1 was
still lying down, the resident was not uncovered.
According to EI #1, EI #2, the weekend
supervisor was located on the opposite side of
the building, the East Wing (on 11/7/14 at 1:13
PM, EI #12 stated the distance between the West
Wing nurses' station and the East Wing nurses'
station was 350 feet). When asked how she got
there, EI #1 stated she walked around the front of
the building to the East Wing. EI #1 stated EI #2
got back to RI #1's room before her. After
arriving back at RI #1's room, EI #1 stated EI #2
asked RI #1's son to leave. EI #1 asked the
nurses at the nurses' station to call 911. EI #1
stated when she went back into RI #1's room, RI
#1's son was leaving, but he was dropping
everything out of his pockets. After RI #1's son
left, a body audit was performed on RI #1. EI #1
stated the resident was confused and she wanted
to know what was going on. When asked why
she went to get the supervisor, EI #1 stated
because she was uncomfortable with the
situation. When asked what the situation was, EI
#1 stated, she was uncomfortable with RI #1's
son holding his pants, his belt off and the smell of
alcohol in the room. EI #1 was asked, if she was
that uncomfortable, why she left the room with
two residents in there. EI #1 stated she left the
door open and went to get help because she was
uncomfortable with the situation, not knowing
what had or was happening. When asked if there
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: 72DP11

Facility ID: 3717301NH

If continuation sheet Page 9 of 37

PRINTED: 12/22/2014
FORM APPROVED

DEPARTMENT OF HEALTH AND HUMAN SERVICES


CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

OMB NO. 0938-0391


(X2) MULTIPLE CONSTRUCTION
A. BUILDING ______________________

(X3) DATE SURVEY


COMPLETED

C
015131

B. WING _____________________________

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

119 WATTERSON PARKWAY

GOLDEN LIVING CENTER - TRUSSVILLE


(X4) ID
PREFIX
TAG

11/07/2014

TRUSSVILLE, AL 35173

SUMMARY STATEMENT OF DEFICIENCIES


(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

F 223 Continued From page 9

PROVIDER'S PLAN OF CORRECTION


(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
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TAG

(X5)
COMPLETION
DATE

F 223

was any other way she could have gotten help to


come to the room, EI #1 said no. When asked
again, why was she uncomfortable, EI #1 stated
she didn't know what had happened or what was
going to happen, she just zoned out and did what
she thought she had to do. When asked, what
was she trained to do, EI #1 stated to protect the
residents. When asked, how to protect the
resident, EI #1 answered to remove the resident
from the situation. When asked if she removed
RI #1 from the situation, EI #1 said no. When
asked if she was presented again with the same
situation, what she would do, EI #1 stated she
would not leave the room that she would tell
somebody else to go get help.
In an interview on 11/5/14 at 4:30 PM, RI #2, RI
#1's roommate at the time of the incident on
10/25/14, was asked if she recalled a lady (RI #1)
in her room being "messed" with. RI #2 replied,
yes it was a patient. When asked how she knew
the resident was being messed with, RI #2 stated
the man in the room was drunk, she could tell by
his actions. RI #2 stated she thought the man
was RI #1's husband and she kept hearing RI #1
tell the man to leave her alone so she could go to
sleep. When asked if the man ever messed with
her, RI #2 stated he never paid her any attention.
RI #2 stated the man never got violent, he was
just drunk. RI #2 stated she was afraid to go to
sleep because she was afraid he was going to
hurt RI #1.
EI #2's handwritten witness statement for the
local police department, found within the facility's
investigative report documented " ... Treatment
Nurse came to me to report possible situation in
(RI #1's room). States she had entered room
after knocking on closed door, lights off in room
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: 72DP11

Facility ID: 3717301NH

If continuation sheet Page 10 of 37

PRINTED: 12/22/2014
FORM APPROVED

DEPARTMENT OF HEALTH AND HUMAN SERVICES


CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

OMB NO. 0938-0391


(X2) MULTIPLE CONSTRUCTION
A. BUILDING ______________________

(X3) DATE SURVEY


COMPLETED

C
015131

B. WING _____________________________

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

119 WATTERSON PARKWAY

GOLDEN LIVING CENTER - TRUSSVILLE


(X4) ID
PREFIX
TAG

11/07/2014

TRUSSVILLE, AL 35173

SUMMARY STATEMENT OF DEFICIENCIES


(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

F 223 Continued From page 10

PROVIDER'S PLAN OF CORRECTION


(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
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TAG

(X5)
COMPLETION
DATE

F 223

and heard rapid movement in area of A bed, (RI


#1). States son was in wheelchair with one shoe
off. Nurse went to B bed to check on the
roommate. Roommate stated, "He's messing
with her." Nurse walked out room to check chart
leaving door open. Returned and found son
sitting on foot of bed, belt on floor. - I went to
check on ... (RI #1) & assess situation. Upon
entrance to room, noted son in wheelchair,
zipper/pants open wide, pants barely on and belt
loosely around waist, One shoe tied, one shoe
untied. Son looks at me as though all is well. I
ask why is his zipper open? He stands & states,
"Can't tell you how many times I have forgotten to
zip my pants." Noted belt loosely in pants &
pants falling slightly. Asked him, "Why is your
belt loose, your pants loose and one shoe untied."
He states, "What are you trying to say?" I look to
resident who is exposed @ (at) her groin with
sheet over one leg. Bed with hips elevated. I
covered resident and informed son that it would
be best he call it a day and go home. Son states,
"Are you trying to accuse me of something? I call
the police." I stated, "I call them for you, if you
don't go home. This is a semi-private room with a
female you are not related to and you are
disrobing. It's unacceptable behavior. We will
call you on Monday about future visits to see your
mother." At this point he started to leave. I found
cigarettes on the floor and gave them to him,
even though he was unable to say they were his.
I then asked roommate if she was alright and if
she heard anything unusual. Roommate states,
"She said stop, stop, stop." At this time another
nurse (EI #3) went to stop son from exiting the
building due to possible situation that may require
intervention Police notified and Director of
Nursing notified. Full body assessment done and
reported to Medical Doctor and orders to send
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: 72DP11

Facility ID: 3717301NH

If continuation sheet Page 11 of 37

PRINTED: 12/22/2014
FORM APPROVED

DEPARTMENT OF HEALTH AND HUMAN SERVICES


CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

OMB NO. 0938-0391


(X2) MULTIPLE CONSTRUCTION
A. BUILDING ______________________

(X3) DATE SURVEY


COMPLETED

C
015131

B. WING _____________________________

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

119 WATTERSON PARKWAY

GOLDEN LIVING CENTER - TRUSSVILLE


(X4) ID
PREFIX
TAG

11/07/2014

TRUSSVILLE, AL 35173

SUMMARY STATEMENT OF DEFICIENCIES


(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

F 223 Continued From page 11

PROVIDER'S PLAN OF CORRECTION


(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

(X5)
COMPLETION
DATE

F 223

resident to hospital for assessment." EI #2


signed this statement and dated it 10/25/14.
In a telephone interview on 11/6/14 at 9:31 AM, EI
#2, the weekend RN Supervisor, was asked
about the incident on 10/25/14 with RI #1. EI #2
stated she was called to RI #1's room by EI #1,
the LPN Treatment Nurse. According to EI #2, EI
#1 had been in the resident's room twice and
there was increase disrobing by RI #1's son. The
first time EI #1 entered the room, the lights were
off, the door was closed and she witnessed a
gentleman with his shoe off jumping, moving
around. EI #1 left the room and went to the
nurses' station. When she reentered the room,
the gentleman was at the foot of the bed. EI #1
left the room to get the supervisor. EI #2 went to
RI #1's room, knocked on the door and entered.
EI #2 stated the door was partially closed, the
lights were on and the curtain was pulled.
According to EI #2, RI #1's son had been drinking
because the room smelled of alcohol. EI #3
stated she normally saw RI #1's son on the
weekend and stated he was usually loud and
there was a smell of alcohol. RI #1's son was
observed sitting in a wheelchair and there was a
puddle of water on the floor. EI #2 stated it
appeared the water pitcher on the bedside table
had been knocked over. RI #1's son's shoe was
off; his pants were obviously unzipped and wide
open. EI #2 stated RI #1's son looked at her
strangely and she asked him why his pants were
unzipped. RI #1's son stood up and EI #2 again
asked RI #1's son about his pants, shoe and
belt. EI #2 then stated under the circumstances,
she would have to ask RI #1's son to leave,
because it was extremely inappropriate for him to
be in that room with two female residents, one of
which was not a relative. EI #2 stated RI #1's
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: 72DP11

Facility ID: 3717301NH

If continuation sheet Page 12 of 37

PRINTED: 12/22/2014
FORM APPROVED

DEPARTMENT OF HEALTH AND HUMAN SERVICES


CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

OMB NO. 0938-0391


(X2) MULTIPLE CONSTRUCTION
A. BUILDING ______________________

(X3) DATE SURVEY


COMPLETED

C
015131

B. WING _____________________________

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

119 WATTERSON PARKWAY

GOLDEN LIVING CENTER - TRUSSVILLE


(X4) ID
PREFIX
TAG

11/07/2014

TRUSSVILLE, AL 35173

SUMMARY STATEMENT OF DEFICIENCIES


(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

F 223 Continued From page 12

PROVIDER'S PLAN OF CORRECTION


(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
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TAG

(X5)
COMPLETION
DATE

F 223

vaginal area was completely exposed for viewing.


The foot of RI #1's bed was elevated, so that
resident's hips were up and her head was down.
EI #2 pulled a sheet over RI #1. As RI #1's son
gathered his things to leave, EI #2 went over to RI
#1's roommate, RI #2, and asked her if she was
okay. RI #2 told her she woke up to something
going on and she kept hearing RI #1 say no, no,
no, stop, stop, stop. Once EI #3, the LPN Charge
Nurse heard this, she stopped RI #1's son from
leaving the building and everyone was notified per
state guidelines for possible abuse. EI #2 stated
RI #1's diaper was found in the bathroom and
there was urine in the toilet. When asked what
was she trained to do when presented with this
situation, EI #2 stated to remove the threat,
whoever that may be and notify the Executive
Director. EI #2 explained that she would not
leave the room because anything could happen
when you leave the room; the resident was
exposed and there was a smell of alcohol. EI #2
stated, EI #1 didn't want to assume something
was going on, but in that case she had to assume
with everything that was going on, including what
the roommate said twice that "he's messing with
her."
RI #1's "Progress Notes" written by EI #3, the
LPN Charge Nurse dated 10/25/14 10:37 PM,
documented " ... Resident's son arrived to facility
intoxicated. Treatment nurse reports that she
walked into the resident's room in total darkness
with door closed. When she entered, the son
jumped back into the wheelchair from the foot of
the bed with his belt on the floor and pants
undone. Roommate states that the resident's son
had been messing with her, and the resident was
continually telling him no. Notified MOD, DON,
Administrator, head to toe assessment
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: 72DP11

Facility ID: 3717301NH

If continuation sheet Page 13 of 37

PRINTED: 12/22/2014
FORM APPROVED

DEPARTMENT OF HEALTH AND HUMAN SERVICES


CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

OMB NO. 0938-0391


(X2) MULTIPLE CONSTRUCTION
A. BUILDING ______________________

(X3) DATE SURVEY


COMPLETED

C
015131

B. WING _____________________________

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

119 WATTERSON PARKWAY

GOLDEN LIVING CENTER - TRUSSVILLE


(X4) ID
PREFIX
TAG

11/07/2014

TRUSSVILLE, AL 35173

SUMMARY STATEMENT OF DEFICIENCIES


(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

F 223 Continued From page 13

PROVIDER'S PLAN OF CORRECTION


(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
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TAG

(X5)
COMPLETION
DATE

F 223

performed, and police notified. Upon


assessment, noted that brief was off, and in the
restroom trashcan, and her legs were crossed
tight. Resident was only wearing a t-shirt with wet
areas on the back of the t-shirt When asked
resident stated that her back and vaginal area
hurts ... MD notified, and received order to send
resident out for evaluation. Sponsor notified,
report called in to (local hospital) ER, and
transportation arranged ... ."
EI #3's typed statement found within the facility's
investigative report documented, "October 31,
2014 I, (EI #3), LPN, was working on the day of
10/25/14. It was somewhere between 4 PM and
5 PM when (EI #1) entered (RI #1's) room and
the events took place."
In a telephone interview on 11/6/14 at 8:08 AM, EI
#3 was asked about the incident on 10/25/14 with
RI #1. EI #3 stated all she could remember was
the Treatment Nurse, EI #1, came to her between
4:00 PM and 5:00 PM and told her RI #1's son
was acting erratically and she had suspicion that
he was doing something with his mother. EI #3
stated on 10/25/14, RI #1's son was drunk.
According to EI #3, other staff complained that RI
#1's son was intoxicated and they smelled
alcohol. EI #3 stated when she entered the room,
EI #2 was asking RI #1's son to leave and as he
was leaving, RI #2 stated she overheard RI #1
say to her son, no, no, no and that RI #2 believed
RI #1's son was bothering his mother. EI #3
stated the lights were off on RI #1's side of the
room and the privacy curtain was pulled. EI #3
explained that as RI #1's son was leaving, he
jumped up from the chair, put his hoodie (a
hooded sweatshirt) on; it was on the wrong side
and his keys and cigarettes all fell out of his
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: 72DP11

Facility ID: 3717301NH

If continuation sheet Page 14 of 37

PRINTED: 12/22/2014
FORM APPROVED

DEPARTMENT OF HEALTH AND HUMAN SERVICES


CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

OMB NO. 0938-0391


(X2) MULTIPLE CONSTRUCTION
A. BUILDING ______________________

(X3) DATE SURVEY


COMPLETED

C
015131

B. WING _____________________________

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

119 WATTERSON PARKWAY

GOLDEN LIVING CENTER - TRUSSVILLE


(X4) ID
PREFIX
TAG

11/07/2014

TRUSSVILLE, AL 35173

SUMMARY STATEMENT OF DEFICIENCIES


(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

F 223 Continued From page 14

PROVIDER'S PLAN OF CORRECTION


(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

(X5)
COMPLETION
DATE

F 223

hoodie. EI #3 walked around RI #1's bed and


observed liquid all over the floor. EI #3 stated
when RI #2 stated what she believed happen, she
ran after RI #1's son, who was in the parking lot
and asked him to come back into the facility. RI
#1's son said no, but eventually came back in the
facility. EI #3 stated his keys had fallen out so he
couldn't leave. According to EI #3, two staff
members in the parking lot overheard RI #1's son
yelling that he was not a pedophile. EI #3 came
back into the facility to assess RI #1. Once EI #3
removed the covers, RI #1 was observed with
nothing on but a t-shirt that stopped right above
her vaginal area. RI #1 had a bruise on her left
lower leg that resembled thumb pressure being
applied. When asked to describe the bruise, EI
#3 stated she had not seen the bruise before. EI
#3 also noticed three drops of some type of liquid
on the back of RI #1's shirt at the hem. EI #3
stated she felt the resident's stomach and asked
her if it hurt. RI #1 said no. According to EI #3
when she asked RI #1 to show her where it hurt,
RI #1 pointed to her right side, down her right
side, across the right groin area and then across
the top part of her vagina and stated that hurts.
EI #3 stated she covered the resident up and
exited the room. As EI #3 left the room, she
noticed an incontinent brief (diaper) in garbage
can in the bathroom; the toilet seat was up and
urine was in the toilet. When asked what she
thought happened, EI #3 stated she believed RI
#1's son may have been touching RI #1. EI #3
based this on what RI #1 said no, no, no, stop,
stop, stop, and what EI #1 stated that RI #1's son
was acting erratically and she had a suspicion
that he was doing something with RI #1 because
the lights were off, RI #1's son's belt was off and
his pants were unzipped.
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: 72DP11

Facility ID: 3717301NH

If continuation sheet Page 15 of 37

PRINTED: 12/22/2014
FORM APPROVED

DEPARTMENT OF HEALTH AND HUMAN SERVICES


CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

OMB NO. 0938-0391


(X2) MULTIPLE CONSTRUCTION
A. BUILDING ______________________

(X3) DATE SURVEY


COMPLETED

C
015131

B. WING _____________________________

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

119 WATTERSON PARKWAY

GOLDEN LIVING CENTER - TRUSSVILLE


(X4) ID
PREFIX
TAG

11/07/2014

TRUSSVILLE, AL 35173

SUMMARY STATEMENT OF DEFICIENCIES


(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

F 223 Continued From page 15

PROVIDER'S PLAN OF CORRECTION


(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

(X5)
COMPLETION
DATE

F 223

RI #1's Admission "CLINICAL HEALTH STATUS"


dated 10/14/14 9:50 PM, indicated on admission,
RI #1 had no bruising to the left lower leg. A
review of RI #1's medical record further indicated
there were no other skin assessments done on
the resident after 10/14/14 and prior to 10/25/14.
In a follow-up interview on 11/7/14 at 11:19 AM,
the State Surveyor informed EI #3, the LPN
Charge Nurse that EI #5, the CNA assigned to
care for RI #1 on the second shift, stated when
she placed the diaper on RI #1, she found car
keys between the resident's legs and she gave
the keys to EI #3. EI #3 was asked if this was
correct. EI #3 stated EI #5 did give her the keys,
but EI #5 did not tell EI #3 where the keys were
found. EI #3 acknowledged that she gave the
keys to the police officer. When asked why she
didn't see the keys during her body audit, EI #1
stated EI #5 may have removed the keys before
the body audit. When asked if it was normal for
RI #1 to lie in bed with no incontinent brief on, EI
#3 answered no, RI #1 always had a brief on. EI
#3 stated she called the hospital and her rationale
for sending RI #1 to the hospital was for possible
inappropriate touching or molestation.
RI #1 was transferred and admitted to a local
hospital on 10/25/14. On 10/28/14, RI #1 was
discharged from a local hospital and admitted to
another nursing facility.
On 11/6/14 at 11:45 AM, RI #1 was observed at
another nursing facility in bed watching television.
When asked about the incident, RI #1 explained,
it was just an evening out and that she and her
son had had many over the years, but that he
would never touch her inappropriate. According
to RI #1, her memory started to get fuzzy
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: 72DP11

Facility ID: 3717301NH

If continuation sheet Page 16 of 37

PRINTED: 12/22/2014
FORM APPROVED

DEPARTMENT OF HEALTH AND HUMAN SERVICES


CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

OMB NO. 0938-0391


(X2) MULTIPLE CONSTRUCTION
A. BUILDING ______________________

(X3) DATE SURVEY


COMPLETED

C
015131

B. WING _____________________________

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

119 WATTERSON PARKWAY

GOLDEN LIVING CENTER - TRUSSVILLE


(X4) ID
PREFIX
TAG

11/07/2014

TRUSSVILLE, AL 35173

SUMMARY STATEMENT OF DEFICIENCIES


(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

F 223 Continued From page 16

PROVIDER'S PLAN OF CORRECTION


(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

(X5)
COMPLETION
DATE

F 223

because she believed she had a mild seizure


that's how she ended up in the hospital. RI #1
stated that place (Golden Living Center Trussville) didn't like her; they got together and
concocted that story.
In a follow-up interview on 11/7/14 at 8:28 AM, EI
#1, the LPN Treatment Nurse was asked, what
was her rationale for leaving the door opened
when she left RI #1's room the first time. EI #1
replied that she wanted to check the cognitive
status of RI #2. EI #1 further stated when she
reentered the room; she left again to get the
supervisor to handle the situation. According to
EI #1, all she was thinking was alcohol and she
knew it was going to take two people to handle
something like that. When asked if RI #1's room
had a call light, EI #1 said yes. When asked, why
she did not use the call light to call for assistance,
EI #1 stated sometimes it takes a minute for
someone to come. She thought it would be faster
to go and get somebody. EI #1 was asked could
the resident have become completely exposed in
the time it took her to get the supervisor and
return to the room. EI #1 replied she guessed so.
The local hospital's "Emergency Physician
Record" indicated on 10/25/14 RI #1 arrived in
the ER from a local nursing home with a chief
complaint of questionable assault, with an
onset/duration of one hour prior to arrival. The
ER record indicated RI #1 had a history of
dementia, displayed intermittent lethargy, was
non-ambulatory and had complaints of abdominal
pain. The clinical impression was listed as
abdominal pain and alleged assault. The ER
record indicated a family member of RI #1 agreed
(gave consent) for a rape exam. The ER record
further indicated " ... Nursing Continuation Notes
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: 72DP11

Facility ID: 3717301NH

If continuation sheet Page 17 of 37

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FORM APPROVED

DEPARTMENT OF HEALTH AND HUMAN SERVICES


CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

OMB NO. 0938-0391


(X2) MULTIPLE CONSTRUCTION
A. BUILDING ______________________

(X3) DATE SURVEY


COMPLETED

C
015131

B. WING _____________________________

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

119 WATTERSON PARKWAY

GOLDEN LIVING CENTER - TRUSSVILLE


(X4) ID
PREFIX
TAG

11/07/2014

TRUSSVILLE, AL 35173

SUMMARY STATEMENT OF DEFICIENCIES


(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

F 223 Continued From page 17

PROVIDER'S PLAN OF CORRECTION


(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

(X5)
COMPLETION
DATE

F 223

... patient (RI #1) has a bruise noted on left


forearm ... spoke with nursing home staff and
stated that patients son was at bedside with his
pants half on, belt in the floor, and patients
vaginal area expose. nursing home staff states
son comes to the nursing home intoxicated
frequently. assault nurse at bedside ... crisis
nurse left the er at this time with a completed
rape kit. nurse notified me that patient had
bruising noted on her hymen (a membrane that
partially closes the opening of the vagina) with
several scratches and bruises on bilateral lower
extremities ... patient is alert at this time and able
to communicate appropriately at this time. patient
states "I can't believe that the nursing home
would think that my son (name) would do those
things to me." patient was also unaware that her
son drinks and did not remember son being at the
nursing home today ... Discharge Summary Chief
Complaint: Assault ... ."
According to the crisis nurse, RI #1 was very
sleepy when she was examined. On observation,
RI #1's genital area had redness below the clitoris
area at the junction where the labia minor met.
There was petechia, which are broken blood
vessels at the hymen. On physical examination,
the resident had a ton of bruises located on the
left side below the pelvic bone, the top part of the
thigh, around the knee, left wrist and there were
finger print like bruising on the left leg.
The "ALABAMA UNIFORM INCIDENT/OFFENSE
REPORT" dated 10/25/14 indicated an officer
responded to Golden Living Center - Trussville
regarding a disorderly person, identified as RI
#1's son. According to the report's narrative " ...
WHEN OFFICER MADE CONTACT WITH THE
SUSPECT HE WAS LEAVING OUT OF THE
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: 72DP11

Facility ID: 3717301NH

If continuation sheet Page 18 of 37

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FORM APPROVED

DEPARTMENT OF HEALTH AND HUMAN SERVICES


CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

OMB NO. 0938-0391


(X2) MULTIPLE CONSTRUCTION
A. BUILDING ______________________

(X3) DATE SURVEY


COMPLETED

C
015131

B. WING _____________________________

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

119 WATTERSON PARKWAY

GOLDEN LIVING CENTER - TRUSSVILLE


(X4) ID
PREFIX
TAG

11/07/2014

TRUSSVILLE, AL 35173

SUMMARY STATEMENT OF DEFICIENCIES


(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

F 223 Continued From page 18

PROVIDER'S PLAN OF CORRECTION


(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

(X5)
COMPLETION
DATE

F 223

FRONT DOOR. (RI #1's son) STAGGERED


WHEN HE WALKED, HAD BLOOD SHOT EYES
AND THE SMELL OF AN ALCOHOLIC
BEVERAGE ABOUT HIS PERSON. WHILE
OFFICE (OFFICER) ATTEMPTED TO IDENTIFY
THE SUSPECT, HE SPONTANEOUSLY
DECLARED "I DON'T KNOW WHY YOU ARE
STOPPING ME, I'M NOT A PEDOPHILE OR
ANYTHING." (RI #1's son) WAS LATER
ARRESTED FOR PUBLIC INTOXICATION ... ."
In an interview on 11/5/14 at 4:42 PM, the primary
investigator with the local police department
stated RI #1's son confessed and had written a
very detailed statement. A warrant was active for
RI #1's son and the charges were first-degree
rape and sexual abuse, with two additional
charges of elder abuse and incest.
RI #1's son statement obtained by the local police
department titled "(NAME) POLICE
DEPARTMENT SUSPECT STATEMENT AND
WAIVER OF RIGHTS" documented " ... I hereby
agree to and make the following written
statement. I had 2 drinks, went inside and got into
bed with my mom started comforting her, petting
hair, and then we fell into position with her
underneath me, ... and had intercourse." This
statement is signed by RI #1's son and dated
10/30/14 10:30 AM.
*************************
On 11/7/14 at 5:26 PM, the facility submitted an
Allegation of Credible Compliance for F 223,
which documented:
November 07,2014
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: 72DP11

Facility ID: 3717301NH

If continuation sheet Page 19 of 37

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DEPARTMENT OF HEALTH AND HUMAN SERVICES


CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

OMB NO. 0938-0391


(X2) MULTIPLE CONSTRUCTION
A. BUILDING ______________________

(X3) DATE SURVEY


COMPLETED

C
015131

B. WING _____________________________

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

119 WATTERSON PARKWAY

GOLDEN LIVING CENTER - TRUSSVILLE


(X4) ID
PREFIX
TAG

11/07/2014

TRUSSVILLE, AL 35173

SUMMARY STATEMENT OF DEFICIENCIES


(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

F 223 Continued From page 19

PROVIDER'S PLAN OF CORRECTION


(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

(X5)
COMPLETION
DATE

F 223

F223 Allegation of Compliance


1. Rl#l was transferred to the hospital on 10.25
.2014 for further evaluation. Rl#l's son was
removed/arrested from the facility by local Police
Department on 10.25.2014
2. Beginning on 11/07/2014 at 1:55PM no staff
members have worked or shall work without
education by the Director of Nursing/or Designee
without completing education on the Policy and
Procedure for Reporting and Investigation of
Alleged Violations of Federal and State Laws
Involving Mistreatment, Neglect, Abuse, Injuries
of Unknown Source and Misappropriation of
Resident's Property. Focus oftraining to include
Prevention,Identification,Protection, Reporting
and Investigation. Training will be completed by
11.07/2014 with 100% of active staff. Any staff on
Medical Leave, vacation, scheduled off day will
receive retraining prior to returning to work .
3. Beginning the week of 11.07.2014,visiting
Field Services Clinical Director, Area Vice
President and/or designee will visit daily x 3 days,
weekly for 3 weeks, then monthly x 3 months to
review any allegation of abuse investigations
conducted. Any negative findings will result in
immediate corrective action and implantation of
abuse prohibition protocol steps.
4. Beginning 11.07.2014,the Social Services
Director/Designee will conduct interviews with a
minimum of 6 residents daily 5 times per week
times 2 weeks, then 6 residents weekly times two
weeks then monthly times 3 months. Any
negative findings will result in immediate
implementation of abuse prohibition protocol
steps and reviewed through the OAPI process.
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: 72DP11

Facility ID: 3717301NH

If continuation sheet Page 20 of 37

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DEPARTMENT OF HEALTH AND HUMAN SERVICES


CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

OMB NO. 0938-0391


(X2) MULTIPLE CONSTRUCTION
A. BUILDING ______________________

(X3) DATE SURVEY


COMPLETED

C
015131

B. WING _____________________________

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

119 WATTERSON PARKWAY

GOLDEN LIVING CENTER - TRUSSVILLE


(X4) ID
PREFIX
TAG

11/07/2014

TRUSSVILLE, AL 35173

SUMMARY STATEMENT OF DEFICIENCIES


(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

F 223 Continued From page 20

PROVIDER'S PLAN OF CORRECTION


(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

(X5)
COMPLETION
DATE

F 223

5. Beginning 11.07.2014,the Director of Clinical


Education/Designee will interview a minimum of
10 staff members weekly times 2 weeks then
monthly times 3 months to ensure staff can
correctly articulate the requirement for the
identification and protection of residents from
abuse. Any negative findings will result in
immediate corrective action and implantation of
abuse prohibition protocol steps.
6. Special QAPI was updated 11/7/14 to have
discussion and review of results of the
investigation of event occurring 10/25/14 at
3:30PM related to possible sexual abuse to
include additional findings.
GLC Trussville alleges compliance as of
11.07.2014

*************************
After reviewing the facility's information provided
in their Allegation of Compliance, inservice
records completed as of 11/7/14 and interviews
with facility staff, it was determined the facility had
implemented their AOC, the immediate jeopardy
was relieved and the scope and severity was
lowered to "D" on 11/7/14 at 6:00 PM.
This deficiency was cited as a result of the
investigation of complaint/report number
AL00032227.
F 226 483.13(c) DEVELOP/IMPLMENT
SS=J ABUSE/NEGLECT, ETC POLICIES

F 226

12/9/14

The facility must develop and implement written


FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: 72DP11

Facility ID: 3717301NH

If continuation sheet Page 21 of 37

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FORM APPROVED

DEPARTMENT OF HEALTH AND HUMAN SERVICES


CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

OMB NO. 0938-0391


(X2) MULTIPLE CONSTRUCTION

(X3) DATE SURVEY


COMPLETED

A. BUILDING ______________________

C
015131

B. WING _____________________________

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

119 WATTERSON PARKWAY

GOLDEN LIVING CENTER - TRUSSVILLE


(X4) ID
PREFIX
TAG

11/07/2014

TRUSSVILLE, AL 35173

SUMMARY STATEMENT OF DEFICIENCIES


(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

F 226 Continued From page 21

PROVIDER'S PLAN OF CORRECTION


(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

(X5)
COMPLETION
DATE

F 226

policies and procedures that prohibit


mistreatment, neglect, and abuse of residents
and misappropriation of resident property.

This REQUIREMENT is not met as evidenced


by:
Based on interviews and record review, the
facility failed to ensure Employee Identifier (EI)
#1, a Licensed Practical Nurse (LPN) Treatment
Nurse and EI #5, a Certified Nursing Assistant
(CNA) implemented the facility's abuse policy on
protection. EI #5 entered Resident Identifier (RI)
#1's room to find a cold, dark room with a male
visitor (RI #1's son) with his shoes off and he was
holding his pants up at the waist, which were
unzipped and unbuckled. EI #1 entered RI #1's
room and found the room to be pitch black, all the
lights were off and the room smelled of alcohol.
The male visitor had his right shoe and sock off
and RI #1's roommate reported to EI #1 that "he's
messing with her." EI #1 left the room and
returned to find the male visitor holding his pants
up at the waist as he sat very quickly back into
the wheelchair; his belt was observed on the
floor. After seeing all this, EI #1 left the room
again. Both EI #1 and EI #5 entered and exited
RI #1's room without removing the suspected
perpetrator as directed by the facility's abuse
policy. RI #1 and her roommate, RI #2 were left
alone in the room, with a male visitor, who was
acting erratically and intoxicated.
This deficient practice affected RI #1, one of one
resident reviewed for sexual abuse. This
deficient practice posed an immediate threat to
the health and safety of RI #1, as it was likely to
cause serious harm, injury, impairment, or death.
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: 72DP11

I.
RI # 1 was transferred to the hospital on
10/25/14 for further evaluation. RI #1's
son was removed/arrested from the
facility ob local Police Department on
10/25/14. RI # 1 did not return to the
facility.
EI # 1 was provided 1-on-1 re-education
on Prevention, Identification, Protection,
Reporting, and Investigation. Training
focused on identification of potential risk
and immediate protection of
patient/resident. Training was conducted
by Director of Nursing Services on
11/7/14.
EI # 5 was provided 1-on-1 re-education
on Prevention, Identification, Protection,
Reporting, and Investigation. Training
focused on identification of potential risk
and immediate protection of
patient/resident. Training was conducted
by Director of Nursing Services on
11/7/14.

II
All residents/patients have the potential
Facility ID: 3717301NH

If continuation sheet Page 22 of 37

PRINTED: 12/22/2014
FORM APPROVED

DEPARTMENT OF HEALTH AND HUMAN SERVICES


CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

OMB NO. 0938-0391


(X2) MULTIPLE CONSTRUCTION

(X3) DATE SURVEY


COMPLETED

A. BUILDING ______________________

C
015131

B. WING _____________________________

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

119 WATTERSON PARKWAY

GOLDEN LIVING CENTER - TRUSSVILLE


(X4) ID
PREFIX
TAG

11/07/2014

TRUSSVILLE, AL 35173

SUMMARY STATEMENT OF DEFICIENCIES


(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

F 226 Continued From page 22

PROVIDER'S PLAN OF CORRECTION


(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

(X5)
COMPLETION
DATE

F 226
risk of being affected.

On 11/7/14 at 12:23 PM, the facility's Executive


Director, Director of Nursing Service, Field
Service Clinical Director and Area Vice President
were notified of the findings of substandard
quality of care at the immediate jeopardy level of
"J" in the area of Resident Behavior & Facility
Practices, F 226.
Findings include:
Cross reference F 223.
The facility's policy titled "HR-408 Reporting and
Investigation of Alleged Violations of Federal and
State Laws Involving Mistreatment, Neglect,
Abuse, Injuries of Unknown Source and
Misappropriation of Resident's Property" revised
3/1/13 documented " ... Protection If the
circumstances require it, the DNS/DOCS
(Director of Nursing Service/Director of Clinical
Service) or ED/DOR (Executive Director/Director
of Rehabilitation) shall remove a resident
suspected of being the subject of an alleged
violation to an environment where the resident's
safety can be protected ... 3. If the suspected
perpetrator is a vendor, visitor, or volunteer the
ED or DOR shall take all appropriate measures
immediately to secure the safety and wellbeing of
the resident ... ."
On 11/3/14, the State Agency received the
facility's Five Day Investigative Report related to
RI #1. According to the facility's investigative
report, on 10/25/14, RI #1's son was observed in
the resident's room very intoxicated. The son
was observed with his shoes off, belt removed
and pants undone. RI #1's roommate heard RI
#1 saying "no and to stop." RI #1's son was
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: 72DP11

III
Director of Nursing Services / Designee
provided education to all active staff on
Prevention, Identification, Protection,
Reporting, and Investigation. Training
focused on identification of potential risk
and immediate protection of
patient/resident. 100% of active staff
completed 11/7/14. All staff on medical
leave, vacation, scheduled off day will
receive retraining prior to returning to
work. This training has been added to,
and will be emphasized, during new
employee orientation, and no new
employees will be assigned duties until
this training is completed.
IV
Director of Nursing Services / Designee to
interview 10 staff members weekly x 2
weeks then monthly times 3 months to
ensure staff can correctly articulate the
requirements for the identification and
protection of residents from abuse. Any
negative findings will result in immediate
corrective action including relief of duties,
subject to disciplinary action and not
permitted to return to duties until he/she
has been re-trained and can successfully
do a return demonstration. Interview
results will be kept in a binder in the
Director of Nursing Services office.
Social Services Director / Designee
Facility ID: 3717301NH

If continuation sheet Page 23 of 37

PRINTED: 12/22/2014
FORM APPROVED

DEPARTMENT OF HEALTH AND HUMAN SERVICES


CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

OMB NO. 0938-0391


(X2) MULTIPLE CONSTRUCTION
A. BUILDING ______________________

(X3) DATE SURVEY


COMPLETED

C
015131

B. WING _____________________________

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

119 WATTERSON PARKWAY

GOLDEN LIVING CENTER - TRUSSVILLE


(X4) ID
PREFIX
TAG

TRUSSVILLE, AL 35173

SUMMARY STATEMENT OF DEFICIENCIES


(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

F 226 Continued From page 23

PROVIDER'S PLAN OF CORRECTION


(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

(X5)
COMPLETION
DATE

F 226

removed from the resident's room. Police arrived


and RI #1's son was arrested for public
intoxication. RI #1 was assessed and sent to the
local emergency room (ER) for further evaluation.
Based on the investigation, the facility
substantiated that RI #1 was sexually abused by
her son. Refer to F 223.
In an interview on 11/6/14 at 3:30 PM, EI #5, the
CNA who was assigned to care for RI #1 during
the second shift (3:00 PM - 11:00 PM) on
10/25/14, was asked if she recalled the incident
that occurred on 10/25/14. EI #5 said yes.
According to EI #5, she walked pass RI #1's room
door between 3:30 PM and 4:15 PM, and noticed
the door was closed. EI #5 stated RI #1 was
unsteady when she got up unassisted so she was
a little concerned with the door being closed. EI
#5 opened the door to find a cold, dark room with
the lights off and both window shades down.
Before EI #5 could see RI #1's bed, RI #1's son
came from the area where RI #1's wheelchair
was positioned by the bed. When EI #5 turned
the lights on, she noticed a blue diaper
(incontinent brief) on the floor, RI #1's son's
shoes were off, his pants were unzipped and
unbuckled enough where she could see either RI
#1's son's white t-shirt or white underwear. RI
#1's son was holding his pants up at his waist.
Before EI #5 could say anything she was startled
when RI #1's son asked if she was in the room to
see the other resident in the room, RI #2. EI #5
asked RI #2 if she was alright and the resident
said yes. EI #5 observed RI #1 lying in bed with
the covers pulled over the resident neatly. EI #5
stated the mistake she made, was turning the
lights back off, closing the room door and leaving
the room. After leaving the room, EI #5 stated
she stood outside the door not knowing what to
FORM CMS-2567(02-99) Previous Versions Obsolete

11/07/2014

Event ID: 72DP11

conducted interviews to determine


whether residents are being treated with
respect and dignity. Interviews began on
11/7/14 and 100% of interviewable
residents/patients have been interviewed.
On 12/2/14 additional interviews were
initiated to detect whether
residents/patients have
witness/encountered any abuse while in
the facility. We will interview 100% of
interviewable residents/patients by
12/8/14. Negative findings will result in
immediate steps to protect the resident,
an investigation and a report to the state
agency if it is a reportable allegation, and
a report to local law enforcement if there
is a reasonable suspicion that a crime has
occurred. Interviews results will be kept in
a binder in the Director of Nursing
Services office.

Facility ID: 3717301NH

If continuation sheet Page 24 of 37

PRINTED: 12/22/2014
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DEPARTMENT OF HEALTH AND HUMAN SERVICES


CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

OMB NO. 0938-0391


(X2) MULTIPLE CONSTRUCTION
A. BUILDING ______________________

(X3) DATE SURVEY


COMPLETED

C
015131

B. WING _____________________________

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

119 WATTERSON PARKWAY

GOLDEN LIVING CENTER - TRUSSVILLE


(X4) ID
PREFIX
TAG

11/07/2014

TRUSSVILLE, AL 35173

SUMMARY STATEMENT OF DEFICIENCIES


(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

F 226 Continued From page 24

PROVIDER'S PLAN OF CORRECTION


(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

(X5)
COMPLETION
DATE

F 226

think then, continued with her rounds. EI #5


stated she later found out staff thought RI #1's
son was sexually abusing his mother. EI #5
stated she felt guilty for not leaving the door open,
not turning the lights on and not reporting the
incident.
In an interview on 11/5/14 at 3:00 PM, EI #1, the
LPN Treatment Nurse, was asked what she
recalled when she entered RI #1's room on
10/25/14. EI #1 stated the door was closed,
when she knocked and didn't get an answer, she
opened the door half way, announced herself and
entered the room after hearing someone say
come in, whom she thought was RI #1's son.
The room was dark, all the lights were off, it was
pitch black, the curtain in the middle of the room
(between beds A and B) was pulled and there
was a smell of alcohol in the room. RI #1's son
was observed at the end of RI #1's bed and he
sat very quickly into the wheelchair, positioned by
RI #1's bed. EI #1 noticed RI #1's son's right
shoe and sock was off. The shoe was halfway
underneath the bed. According to EI #1, RI #2
told her two times "he's messing with her." EI #1
stated she then left the room with the door open
and the lights on to review RI #2's medical record
because RI #2 was a new resident and EI #1
wasn't' sure if RI #2 was confused or not. EI #1
left the room and when she returned, she found
RI #1's son at the end of RI #1's bed again. He
was holding his pants as he sat back in the
wheelchair really fast. EI #1 also noticed that RI
#1's son's belt was on the floor beneath the
wheelchair. EI #1 explained that she then left the
room to go and get the supervisor, EI #2. EI #1
stated that when she left the room the second
time, RI #1 was still lying down; the resident was
covered. According to EI #1, EI #2, the weekend
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: 72DP11

Facility ID: 3717301NH

If continuation sheet Page 25 of 37

PRINTED: 12/22/2014
FORM APPROVED

DEPARTMENT OF HEALTH AND HUMAN SERVICES


CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

OMB NO. 0938-0391


(X2) MULTIPLE CONSTRUCTION
A. BUILDING ______________________

(X3) DATE SURVEY


COMPLETED

C
015131

B. WING _____________________________

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

119 WATTERSON PARKWAY

GOLDEN LIVING CENTER - TRUSSVILLE


(X4) ID
PREFIX
TAG

11/07/2014

TRUSSVILLE, AL 35173

SUMMARY STATEMENT OF DEFICIENCIES


(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

F 226 Continued From page 25

PROVIDER'S PLAN OF CORRECTION


(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

(X5)
COMPLETION
DATE

F 226

supervisor was located on the opposite side of


the building, the East Wing. When asked why
she went to get the supervisor, EI #1 stated
because she was uncomfortable with the
situation. When asked what the situation was, EI
#1 stated, she was uncomfortable with RI #1's
son holding his pants, his belt off and the smell of
alcohol in the room. EI #1 was asked, if she was
that uncomfortable, why she left the room with
two residents in there. EI #1 stated she left the
door open and went to get help because she was
uncomfortable with the situation, not knowing
what had or was happening. When asked if there
was any other way she could have gotten help to
come to the room, EI #1 said no. When asked
again, why was she uncomfortable, EI #1 stated
she didn't know what had happened or what was
going to happen, she just zoned out and did what
she thought she had to do. When asked, what
was she trained to do, EI #1 stated to protect the
residents. When asked, how to protect the
resident, EI #1 answered to remove the resident
from the situation. When asked if she removed
RI #1 from the situation, EI #1 said no. When
asked if she was presented again with the same
situation, what she would do, EI #1 stated she
would not leave the room that she would tell
somebody else to go get help.
In a follow-up interview on 11/7/14 at 8:28 AM, EI
#1 was asked, could the resident have become
completely exposed in the time it took her to get
the supervisor and return to the room. EI #1
replied she guessed so.
In an interview on 11/5/14 at 4:30 PM, RI #2, RI
#1's roommate at the time of the incident on
10/25/14, stated she was afraid to go to sleep
because she was afraid he (RI #1's son) was
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: 72DP11

Facility ID: 3717301NH

If continuation sheet Page 26 of 37

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DEPARTMENT OF HEALTH AND HUMAN SERVICES


CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

OMB NO. 0938-0391


(X2) MULTIPLE CONSTRUCTION
A. BUILDING ______________________

(X3) DATE SURVEY


COMPLETED

C
015131

B. WING _____________________________

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

119 WATTERSON PARKWAY

GOLDEN LIVING CENTER - TRUSSVILLE


(X4) ID
PREFIX
TAG

11/07/2014

TRUSSVILLE, AL 35173

SUMMARY STATEMENT OF DEFICIENCIES


(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

F 226 Continued From page 26

PROVIDER'S PLAN OF CORRECTION


(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

(X5)
COMPLETION
DATE

F 226

going to hurt RI #1.


In a telephone interview on 11/6/14 at 9:31 AM, EI
#2, the weekend RN Supervisor, was asked
about the incident on 10/25/14 with RI #1. EI #2
stated she was called to RI #1's room by EI #1,
the LPN Treatment Nurse. According to EI #2, EI
#1 had been in the resident's room twice and
there was increase disrobing by RI #1's son. The
first time EI #1 entered the room, the lights were
off, the door was closed and she witnessed a
gentleman with his shoe off jumping, moving
around. EI #1 left the room and went to the
nurses' station. When she reentered the room,
the gentleman was at the foot of the bed. EI #1
left the room to get the supervisor. EI #2 went to
RI #1's room, knocked on the door and entered.
EI #2 stated the door was partially closed, the
lights were on and the curtain was pulled.
According to EI #2, RI #1's son had been drinking
because the room smelled of alcohol. RI #1's
son's shoe was off; his pants were obviously
unzipped and wide open. EI #2 stated RI #1's
vaginal area was completely exposed for viewing.
The foot of RI #1's bed was elevated, so that
resident's hips were up and her head was down.
When asked what was she trained to do when
presented with this situation, EI #2 stated to
remove the threat, whoever that may be and
notify the Executive Director. EI #2 explained that
she would not leave the room because anything
could happen when you leave the room; the
resident was exposed and there was a smell of
alcohol. EI #2 stated, EI #1 didn't want to
assume something was going on, but in that case
she had to assume with everything that was going
on, including what the roommate said twice that
"he's messing with her."
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: 72DP11

Facility ID: 3717301NH

If continuation sheet Page 27 of 37

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DEPARTMENT OF HEALTH AND HUMAN SERVICES


CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

OMB NO. 0938-0391


(X2) MULTIPLE CONSTRUCTION
A. BUILDING ______________________

(X3) DATE SURVEY


COMPLETED

C
015131

B. WING _____________________________

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

119 WATTERSON PARKWAY

GOLDEN LIVING CENTER - TRUSSVILLE


(X4) ID
PREFIX
TAG

11/07/2014

TRUSSVILLE, AL 35173

SUMMARY STATEMENT OF DEFICIENCIES


(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

F 226 Continued From page 27

PROVIDER'S PLAN OF CORRECTION


(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

(X5)
COMPLETION
DATE

F 226

In a telephone interview on 11/6/14 at 8:08 AM, EI


#3 was asked about the incident on 10/25/14 with
RI #1. EI #3 stated all she could remember was
the Treatment Nurse, EI #1, came to her between
4:00 PM and 5:00 PM and told her RI #1's son
was acting erratically and she had suspicion that
he was doing something with his mother.
According to EI #3 when she asked RI #1 to show
her where it hurt, RI #1 pointed to her right side,
down her right side, across the right groin area
and then across the top part of her vagina and
stated that hurts. EI #3 stated she covered the
resident up and exited the room. As EI #3 left the
room, she noticed an incontinent brief (diaper) in
garbage can in the bathroom; the toilet seat was
up and urine was in the toilet. When asked what
she thought happen, EI #3 stated she believed RI
#1's son may have been touching RI #1, based
on what RI #1 said no, no, no, stop, stop, stop,
and what EI #1 stated that RI #1's son was acting
erratically and she had a suspicion that he was
doing something with RI #1 because the lights
were off, RI #1's son's belt was off and his pants
were unzipped.
In an interview on 11/6/14 at 4:33 PM, EI #11, the
Director of Nursing Service (DNS) acknowledged
being notified of the incident surrounding RI #1 on
10/25/14 by EI #2 and EI #3. According to the
facility's policy, " ... If the suspected perpetrator is
a vendor, visitor, or volunteer the ED or DOR
shall take all appropriate measures immediately
to secure the safety and wellbeing of the resident
... ." When asked to explain that statement, EI
#11 stated, secure the resident the perpetrator
away. When asked if her staff followed the
policy, EI #11 said yes. When the State Surveyor
informed EI #11 that EI #1 informed her that RI
#1's son was not removed from the room when
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: 72DP11

Facility ID: 3717301NH

If continuation sheet Page 28 of 37

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FORM APPROVED

DEPARTMENT OF HEALTH AND HUMAN SERVICES


CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

OMB NO. 0938-0391


(X2) MULTIPLE CONSTRUCTION
A. BUILDING ______________________

(X3) DATE SURVEY


COMPLETED

C
015131

B. WING _____________________________

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

119 WATTERSON PARKWAY

GOLDEN LIVING CENTER - TRUSSVILLE


(X4) ID
PREFIX
TAG

11/07/2014

TRUSSVILLE, AL 35173

SUMMARY STATEMENT OF DEFICIENCIES


(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

F 226 Continued From page 28

PROVIDER'S PLAN OF CORRECTION


(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

(X5)
COMPLETION
DATE

F 226

she (EI #1) went to get the supervisor, EI #11


stated that is not what she was told.
In a follow-up interview on 11/7/14 at 8:28 AM, EI
#1 was asked if she told EI #11 she brought RI
#1's son out of RI #1's room while she went to get
the supervisor, EI #2. Initially EI #1 denied saying
this to EI #11 but after informing EI #1 of EI #11's
statement, EI #1 stated she did recall informing
EI #11 that she asked RI #1's son to come out of
RI #1's room. When asked if RI #1's son came
out of the room, EI #1 said no. According to EI
#1, she asked RI #1's son but he didn't come out.
When asked if she told anyone else that she had
asked RI #1's son to come out of the room
besides EI #11, EI #1 said no.
A review of EI #1's statement she provided to the
local police and her nurses' note related to the
incident, all found within the facility's investigative
report, revealed EI #1 did not document or
indicate that she asked RI #1's son to step out of
RI #1's room with her while she went to get the
supervisor, EI #2.
*************************
On 11/7/14 at 5:26 PM, the facility submitted an
Allegation of Credible Compliance for F 226,
which documented:
November 07, 2014
F226 Allegation of Compliance
1. Beginning on 11.07.2014 at 1:55 PM, no staff
members have worked or shall work without
education by the Director of Nursing Services
and/or Designee without education by the
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: 72DP11

Facility ID: 3717301NH

If continuation sheet Page 29 of 37

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FORM APPROVED

DEPARTMENT OF HEALTH AND HUMAN SERVICES


CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

OMB NO. 0938-0391


(X2) MULTIPLE CONSTRUCTION
A. BUILDING ______________________

(X3) DATE SURVEY


COMPLETED

C
015131

B. WING _____________________________

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

119 WATTERSON PARKWAY

GOLDEN LIVING CENTER - TRUSSVILLE


(X4) ID
PREFIX
TAG

11/07/2014

TRUSSVILLE, AL 35173

SUMMARY STATEMENT OF DEFICIENCIES


(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

F 226 Continued From page 29

PROVIDER'S PLAN OF CORRECTION


(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

(X5)
COMPLETION
DATE

F 226

Director of Nursing Services and/or Designee


without completing education on the Policy and
Procedure for Reporting and Investigation of
Alleged Violations of Federal and State Laws
Involving Mistreatment, Neglect, Abuse, Injuries
of Unknown Source and Misappropriation of
Resident's Property. Focus training to include
Prevention, Identification, Protection, Reporting
and Investigation. Training will be completed by
11.7.14 with 100% of active staff. Any staff on
Medical Leave, vacation, scheduled off day will
receive retraining prior to returning to work.
2. Identified CNA present on 3-11 shift on
10.25.14 will be interviewed and provided
education for protection of resident against
suspected perpetrator(abuse). 1.. Take all
measures immediately to secure the safety and
well being of the resident. 2. Remove the
perpetrator from the victim (asked to leave the
room). 3. Use call light to render for help. 4.
Holler down the hall for assistance if needed. Do
not leave the resident alone in the room with the
perpetrator.
3. Treatment Nurse provided with retraining by
Director of Nursing Services on 11.07.14 at 6:09
PM. protection of resident against suspected
perpetrator(abuse). 1.. Take all measures
immediately to secure the safety and well being of
the resident. 2. Remove the perpetrator from the
victim (asked to leave the room). 3. Use call light
to render for help. 4. Holler down the hall for
assistance if needed. Do not leave the resident
alone in the room with the perpetrator.
GLC Trussville alleges compliance as of
11.07.2014
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: 72DP11

Facility ID: 3717301NH

If continuation sheet Page 30 of 37

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FORM APPROVED

DEPARTMENT OF HEALTH AND HUMAN SERVICES


CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

OMB NO. 0938-0391


(X2) MULTIPLE CONSTRUCTION
A. BUILDING ______________________

(X3) DATE SURVEY


COMPLETED

C
015131

B. WING _____________________________

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

119 WATTERSON PARKWAY

GOLDEN LIVING CENTER - TRUSSVILLE


(X4) ID
PREFIX
TAG

11/07/2014

TRUSSVILLE, AL 35173

SUMMARY STATEMENT OF DEFICIENCIES


(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

F 226 Continued From page 30

PROVIDER'S PLAN OF CORRECTION


(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

(X5)
COMPLETION
DATE

F 226

*************************
After reviewing the facility's information provided
in their Allegation of Compliance, inservice
records completed as of 11/7/14 and interviews
with facility staff, it was determined the facility had
implemented their AOC, the immediate jeopardy
was relieved and the scope and severity was
lowered to "D" on 11/7/14 at 6:00 PM.
This deficiency was cited as a result of the
investigation of complaint/report number
AL00032227.
F 490 483.75 EFFECTIVE
SS=J ADMINISTRATION/RESIDENT WELL-BEING

F 490

12/9/14

A facility must be administered in a manner that


enables it to use its resources effectively and
efficiently to attain or maintain the highest
practicable physical, mental, and psychosocial
well-being of each resident.

This REQUIREMENT is not met as evidenced


by:
Based on interview and record review, the
facility's administrative staff, Employee Identifier
(EI) #10, the Executive Director (ED) and EI #11,
the Director of Nursing Service (DNS) failed to
ensure facility staff were aware of what measures
to take when a male visitor, Resident Identifier
(RI) #1's son, was found in RI #1's room partially
dressed, acting erratically with a smell of alcohol
in the room and RI #1's roommate, RI #2,
repeatedly telling staff that he was messing with
RI #1, a cognitively impaired resident. Prior to the
incident, the facility staff had not been trained on
how to immediately secure and protect the safety
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: 72DP11

I.
RI # 1 was transferred to the hospital on
10/25/14 for further evaluation. RI #1's
son was removed/arrested from the
facility ob local Police Department on
10/25/14. RI # 1 did not return to the
facility.
EI # 10 was provided 1-on-1 re-education
on Prevention, Identification, Protection,
Reporting, and Investigation. Training
focused on identification of potential risk
Facility ID: 3717301NH

If continuation sheet Page 31 of 37

PRINTED: 12/22/2014
FORM APPROVED

DEPARTMENT OF HEALTH AND HUMAN SERVICES


CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

OMB NO. 0938-0391


(X2) MULTIPLE CONSTRUCTION

(X3) DATE SURVEY


COMPLETED

A. BUILDING ______________________

C
015131

B. WING _____________________________

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

119 WATTERSON PARKWAY

GOLDEN LIVING CENTER - TRUSSVILLE


(X4) ID
PREFIX
TAG

11/07/2014

TRUSSVILLE, AL 35173

SUMMARY STATEMENT OF DEFICIENCIES


(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

F 490 Continued From page 31

PROVIDER'S PLAN OF CORRECTION


(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

(X5)
COMPLETION
DATE

F 490

and wellbeing of a resident when suspected


abuse was occurring. Both EI #1, a Licensed
Practical Nurse (LPN) Treatment Nurse and EI
#5, a Certified Nursing Assistant (CNA) entered
and exited RI #1's room without removing the
suspected perpetrator as directed by the facility's
abuse policy. RI #1 and her roommate, RI #2
were left alone in the room with a male visitor,
who was acting erratically and intoxicated.
This deficient practice affected RI #1, one of one
resident reviewed for sexual abuse. This
deficient practice posed an immediate threat to
the health and safety of RI #1, as it was likely to
cause serious harm, injury, impairment, or death.

and immediate protection of


patient/resident. Training was completed
by Area Vice President and Field Services
Clinical Director on 11/7/14.
EI # 11 was provided 1-on-1 re-education
on Prevention, Identification, Protection,
Reporting, and Investigation. Training
focused on identification of potential risk
and immediate protection of
patient/resident. Training was completed
by Area Vice President and Field Services
Clinical Director on 11/7/14.

II
On 11/7/14 at 12:23 PM, the facility's Executive
Director, Director of Nursing Service, Field
Service Clinical Director and Area Vice President
were notified of the findings of substandard
quality of care at the immediate jeopardy level of
"J" in the area of Administration, F 490.
Findings include:
Cross reference F 223 and F 226.
The facility's policy titled "HR-408 Reporting and
Investigation of Alleged Violations of Federal and
State Laws Involving Mistreatment, Neglect,
Abuse, Injuries of Unknown Source and
Misappropriation of Resident's Property" revised
3/1/13 documented " ... Policy It is the policy of
the Company to take appropriate steps to prevent
the occurrence of abuse ... Protection If the
circumstances require it, the DNS/DOCS
(Director of Nursing Service/Director of Clinical
Service) or ED/DOR (Executive Director/Director
of Rehabilitation) shall remove a resident
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: 72DP11

All residents/patients have the potential


risk of being affected.

III
Director of Nursing Services / Designee
provided education to all active staff on
Prevention, Identification, Protection,
Reporting, and Investigation. Training
focused on identification of potential risk
and immediate protection of
patient/resident. 100% of active staff
completed 11/7/14. All staff on medical
leave, vacation, scheduled off day will
receive retraining prior to returning to
work. This training has been added to,
and will be emphasized, during new
employee orientation, and no new
employees will be assigned duties until
this training is completed.
Facility ID: 3717301NH

If continuation sheet Page 32 of 37

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FORM APPROVED

DEPARTMENT OF HEALTH AND HUMAN SERVICES


CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

OMB NO. 0938-0391


(X2) MULTIPLE CONSTRUCTION
A. BUILDING ______________________

(X3) DATE SURVEY


COMPLETED

C
015131

B. WING _____________________________

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

119 WATTERSON PARKWAY

GOLDEN LIVING CENTER - TRUSSVILLE


(X4) ID
PREFIX
TAG

TRUSSVILLE, AL 35173

SUMMARY STATEMENT OF DEFICIENCIES


(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

F 490 Continued From page 32

PROVIDER'S PLAN OF CORRECTION


(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

(X5)
COMPLETION
DATE

F 490

suspected of being the subject of an alleged


violation to an environment where the resident's
safety can be protected ... 3. If the suspected
perpetrator is a vendor, visitor, or volunteer the
ED or DOR shall take all appropriate measures
immediately to secure the safety and wellbeing of
the resident ... Reporting Any employee who
suspects an alleged violation shall immediately
notify the ED or DOR ... ."
In a telephone interview on 11/6/14 at 9:31 AM, EI
#2, the weekend Registered Nurse (RN)
Supervisor was asked how had the facility trained
her to handle the situation that occurred in the
facility on 10/25/14 with RI #1. EI #2 stated the
facility had not said a lot about it and further
explained that it may need to be covered.
A review of the facility's training records indicated
on 10/13/14 at 1:00 PM, EI #11, the DNS
presented a lecture/in-service on abuse. A
review of the training documents utilized during
the lecture/in-service, did not include how the
staff should immediately secure the safety and
wellbeing of a resident when the staff suspects
abuse.
A review of the facility's training records indicated
on 10/27/14 (two days after the incident with RI
#1), EI #13, the Director of Clinical Education
(DCE) presented a lecture/in-service on sexual
abuse. A review of the training documents
utilized during the lecture/in-service, indicated " ...
If you witness or suspect any type of abuse you
must stop the abuse and notify our abuse
coordinator (EI #10) ... ."
In an interview on 11/6/14 at 4:33 PM, EI #11, the
DNS was asked what was the staff told to do
FORM CMS-2567(02-99) Previous Versions Obsolete

11/07/2014

Event ID: 72DP11

IV
Director of Nursing Services / Designee to
interview 10 staff members weekly x 2
weeks then monthly times 3 months to
ensure staff can correctly articulate the
requirements for the identification and
protection of residents from abuse. Any
negative findings will result in immediate
corrective action including relief of duties,
subject to disciplinary action and not
permitted to return to duties until he/she
has been re-trained and can successfully
do a return demonstration. Interview
results will be kept in a binder in the
Director of Nursing Services office.
Social Services Director / Designee
conducted interviews to determine
whether residents are being treated with
respect and dignity. Interviews began on
11/7/14 and 100% of interviewable
residents/patients have been interviewed.
On 12/2/14 additional interviews were
initiated to detect whether
residents/patients have
witness/encountered any abuse while in
the facility. We will interview 100% of
interviewable residents/patients by
12/8/14. Negative findings will result in
immediate steps to protect the resident,
an investigation and a report to the state
agency if it is a reportable allegation, and
a report to local law enforcement if there
is a reasonable suspicion that a crime has
occurred. Interviews results will be kept in
a binder in the Director of Nursing
Services office.
Facility ID: 3717301NH

If continuation sheet Page 33 of 37

PRINTED: 12/22/2014
FORM APPROVED

DEPARTMENT OF HEALTH AND HUMAN SERVICES


CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

OMB NO. 0938-0391


(X2) MULTIPLE CONSTRUCTION
A. BUILDING ______________________

(X3) DATE SURVEY


COMPLETED

C
015131

B. WING _____________________________

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

119 WATTERSON PARKWAY

GOLDEN LIVING CENTER - TRUSSVILLE


(X4) ID
PREFIX
TAG

11/07/2014

TRUSSVILLE, AL 35173

SUMMARY STATEMENT OF DEFICIENCIES


(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

F 490 Continued From page 33

PROVIDER'S PLAN OF CORRECTION


(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

(X5)
COMPLETION
DATE

F 490

when they see or suspect abuse. EI #11 stated to


report it to the Abuse Coordinator (EI #10).
According to EI #11, the number one goal was to
protect the resident and that if staff needed help
to go and get the supervisor. EI #11 stated a
supervisor is in the building around the clock.
When asked how was the staff trained to get the
supervisor, EI #11 stated to call, page, or go to
the Charge Nurse. EI #11 acknowledged being
notified of the incident surrounding RI #1 on
10/25/14 by EI #2 and EI #3. When asked since
the 10/25/14 incident, what was the staff told to
do, EI #11 the staff should be more mindful of
their surrounding and visitors and to make sure
family members sign-in, when they come into the
facility. According to the facility's policy, " ... If the
suspected perpetrator is a vendor, visitor, or
volunteer the ED or DOR shall take all
appropriate measures immediately to secure the
safety and wellbeing of the resident ... ." When
asked to explain that statement, EI #11 stated,
secure the resident the perpetrator away. When
asked if her staff followed the policy, EI #11 said
yes. According to EI #11, EI #1 told her she
asked RI #1's son to come out of RI #1's room to
accompany her while she went to get the
supervisor, EI #2. When the State Surveyor
informed EI #11 that EI #1 informed her that RI
#1's son was not removed from the room when
she (EI #1) went to get the supervisor, EI #11
stated that is not what she was told.

Visiting Area Vice President, Field


Services Clinical Director, and/or,
Designee will visit daily x 3 days, weekly x
3 weeks, and monthly x 3 months to
review allegations of abuse investigations.
Any negative outcomes will be reviewed
through the QAPI process. Sign in sheets
will be kept in binder in Director of Nursing
Services office.

In a follow-up interview on 11/7/14 at 8:28 AM, EI


#1 was asked if she told EI #11 she bought RI
#1's son out of RI #1's room while she went to get
the supervisor, EI #2. Initially EI #1 denied saying
this to EI #11 but after informing EI #1 of the EI
#11's statement, EI #1 stated she did recall
informing EI #11 that she asked RI #1's son to
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: 72DP11

Facility ID: 3717301NH

If continuation sheet Page 34 of 37

PRINTED: 12/22/2014
FORM APPROVED

DEPARTMENT OF HEALTH AND HUMAN SERVICES


CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

OMB NO. 0938-0391


(X2) MULTIPLE CONSTRUCTION
A. BUILDING ______________________

(X3) DATE SURVEY


COMPLETED

C
015131

B. WING _____________________________

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

119 WATTERSON PARKWAY

GOLDEN LIVING CENTER - TRUSSVILLE


(X4) ID
PREFIX
TAG

11/07/2014

TRUSSVILLE, AL 35173

SUMMARY STATEMENT OF DEFICIENCIES


(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

F 490 Continued From page 34

PROVIDER'S PLAN OF CORRECTION


(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

(X5)
COMPLETION
DATE

F 490

come out of RI #1's room. When asked if RI #1's


son came out of the room, EI #1 said no.
According to EI #1, she asked RI #1's son but he
didn't come out. When asked if she told anyone
else that she had asked RI #1's son to come out
of the room besides EI #11, EI #1 said no.
A review of EI #1's statement she provided to the
local police and her nurses' note related to the
incident, all found within the facility's investigative
report, revealed EI #1 did not document or
indicate that she asked RI #1's son to step out of
RI #1's room with her while she went to get the
supervisor, EI #2.
During an interview on 11/7/14 at 9:43 AM, EI
#10, the ED stated he and EI #11, the DNS,
conducted the investigation regarding RI #1.
When asked how was the staff trained to protect
the resident, EI #10 stated if the staff physically
saw signs and symptoms they should separate
the resident immediately and then report it to
either him or EI #11, the DNS. EI #10 explained
that was just what EI #1, the LPN Treatment
Nurse, did with RI #1 on 10/25/14.
*************************
On 11/7/14 at 5:26 PM, the facility submitted an
Allegation of Credible Compliance for F 490,
which documented:
November 07, 2014
F490 Allegation of Compliance
1. The Executive Director and Director of
Nursing Services was provided re-education on
conducting a thorough investigation to include
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: 72DP11

Facility ID: 3717301NH

If continuation sheet Page 35 of 37

PRINTED: 12/22/2014
FORM APPROVED

DEPARTMENT OF HEALTH AND HUMAN SERVICES


CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

OMB NO. 0938-0391


(X2) MULTIPLE CONSTRUCTION
A. BUILDING ______________________

(X3) DATE SURVEY


COMPLETED

C
015131

B. WING _____________________________

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

119 WATTERSON PARKWAY

GOLDEN LIVING CENTER - TRUSSVILLE


(X4) ID
PREFIX
TAG

11/07/2014

TRUSSVILLE, AL 35173

SUMMARY STATEMENT OF DEFICIENCIES


(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

F 490 Continued From page 35

PROVIDER'S PLAN OF CORRECTION


(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

(X5)
COMPLETION
DATE

F 490

interviewing with staff, visitors and other residents


that may have knowledge and were present in the
facility around the time of an alleged event by the
Area Vice President and the Field Services
Clinical director on 11.07.2014 at 3:30pm.
2. Beginning on 11.07.2014 at 1:55pm, no staff
members have worked or shall work without
education by the Director of Nursing Services
and/or Designee without completing education on
the Policy and Procedure for Reporting and
Investigation of Alleged Violations of Federal and
State Laws Involving Mistreatment, Neglect,
Abuse, Injuries of Unknown Source and
Misappropriation of Resident's Property. focus of
training to include Prevention, Identification,
Protection, Reporting and Investigation. Training
will be completed by 11.07.2014 with 100% of
active staff. Any staff on medical leave, vacation,
scheduled off day will receive retraining prior to
returning to work.
3. Special QAPI was updated 11.07.2014 at
3:30pm to have discussion and review of results
of the investigation of event occurring 10.25.2014
related to possible sexual abuse to include
additional findings. Meeting held included
Executive Director, Director of Nursing Services,
Medical Director (via phone), and Social
Services.
4. Beginning the week of 11.7.14 visiting Field
Services Clinical Director, Area Vice President,
and/or Designee will visit daily x 3, weekly x 3
weeks, and monthly x 3 months to review any
allegation of abuse investigations conducted.
Any negative outcomes will be corrected
immediately and results will be reviewed through
the QAPI process.
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: 72DP11

Facility ID: 3717301NH

If continuation sheet Page 36 of 37

PRINTED: 12/22/2014
FORM APPROVED

DEPARTMENT OF HEALTH AND HUMAN SERVICES


CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

OMB NO. 0938-0391


(X2) MULTIPLE CONSTRUCTION
A. BUILDING ______________________

(X3) DATE SURVEY


COMPLETED

C
015131

B. WING _____________________________

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

119 WATTERSON PARKWAY

GOLDEN LIVING CENTER - TRUSSVILLE


(X4) ID
PREFIX
TAG

11/07/2014

TRUSSVILLE, AL 35173

SUMMARY STATEMENT OF DEFICIENCIES


(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

F 490 Continued From page 36

PROVIDER'S PLAN OF CORRECTION


(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

(X5)
COMPLETION
DATE

F 490

GLC Trussville alleges compliance as of


11.07.2014
*************************
After reviewing the facility's information provided
in their Allegation of Compliance, inservice
records completed as of 11/7/14 and interviews
with facility staff, it was determined the facility had
implemented their AOC, the immediate jeopardy
was relieved and the scope and severity was
lowered to "D" on 11/7/14 at 6:00 PM.
This deficiency was cited as a result of the
investigation of complaint/report number
AL00032227.

FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: 72DP11

Facility ID: 3717301NH

If continuation sheet Page 37 of 37

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