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FORM APPROVED
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
C
015131
B. WING _____________________________
11/07/2014
TRUSSVILLE, AL 35173
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
F 000
F 223
12/9/14
(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
PRINTED: 12/22/2014
FORM APPROVED
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
C
015131
B. WING _____________________________
TRUSSVILLE, AL 35173
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
PRINTED: 12/22/2014
FORM APPROVED
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
A. BUILDING ______________________
C
015131
B. WING _____________________________
TRUSSVILLE, AL 35173
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
F 223
11/07/2014
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
PRINTED: 12/22/2014
FORM APPROVED
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
C
015131
B. WING _____________________________
11/07/2014
TRUSSVILLE, AL 35173
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
F 223
PRINTED: 12/22/2014
FORM APPROVED
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
C
015131
B. WING _____________________________
11/07/2014
TRUSSVILLE, AL 35173
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
F 223
PRINTED: 12/22/2014
FORM APPROVED
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
C
015131
B. WING _____________________________
11/07/2014
TRUSSVILLE, AL 35173
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
F 223
PRINTED: 12/22/2014
FORM APPROVED
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
C
015131
B. WING _____________________________
11/07/2014
TRUSSVILLE, AL 35173
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
F 223
PRINTED: 12/22/2014
FORM APPROVED
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
C
015131
B. WING _____________________________
11/07/2014
TRUSSVILLE, AL 35173
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
F 223
PRINTED: 12/22/2014
FORM APPROVED
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
C
015131
B. WING _____________________________
11/07/2014
TRUSSVILLE, AL 35173
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
F 223
PRINTED: 12/22/2014
FORM APPROVED
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
C
015131
B. WING _____________________________
11/07/2014
TRUSSVILLE, AL 35173
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
F 223
PRINTED: 12/22/2014
FORM APPROVED
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
C
015131
B. WING _____________________________
11/07/2014
TRUSSVILLE, AL 35173
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
F 223
PRINTED: 12/22/2014
FORM APPROVED
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
C
015131
B. WING _____________________________
11/07/2014
TRUSSVILLE, AL 35173
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
F 223
PRINTED: 12/22/2014
FORM APPROVED
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
C
015131
B. WING _____________________________
11/07/2014
TRUSSVILLE, AL 35173
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
F 223
PRINTED: 12/22/2014
FORM APPROVED
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
C
015131
B. WING _____________________________
11/07/2014
TRUSSVILLE, AL 35173
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
F 223
PRINTED: 12/22/2014
FORM APPROVED
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
C
015131
B. WING _____________________________
11/07/2014
TRUSSVILLE, AL 35173
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
F 223
PRINTED: 12/22/2014
FORM APPROVED
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
C
015131
B. WING _____________________________
11/07/2014
TRUSSVILLE, AL 35173
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
F 223
PRINTED: 12/22/2014
FORM APPROVED
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
C
015131
B. WING _____________________________
11/07/2014
TRUSSVILLE, AL 35173
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
F 223
PRINTED: 12/22/2014
FORM APPROVED
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
C
015131
B. WING _____________________________
11/07/2014
TRUSSVILLE, AL 35173
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
F 223
PRINTED: 12/22/2014
FORM APPROVED
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
C
015131
B. WING _____________________________
11/07/2014
TRUSSVILLE, AL 35173
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
F 223
PRINTED: 12/22/2014
FORM APPROVED
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
C
015131
B. WING _____________________________
11/07/2014
TRUSSVILLE, AL 35173
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
F 223
PRINTED: 12/22/2014
FORM APPROVED
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
C
015131
B. WING _____________________________
11/07/2014
TRUSSVILLE, AL 35173
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
F 223
*************************
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
PRINTED: 12/22/2014
FORM APPROVED
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
A. BUILDING ______________________
C
015131
B. WING _____________________________
11/07/2014
TRUSSVILLE, AL 35173
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
F 226
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
PRINTED: 12/22/2014
FORM APPROVED
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
A. BUILDING ______________________
C
015131
B. WING _____________________________
11/07/2014
TRUSSVILLE, AL 35173
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
F 226
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,
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
PRINTED: 12/22/2014
FORM APPROVED
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
C
015131
B. WING _____________________________
TRUSSVILLE, AL 35173
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
F 226
11/07/2014
PRINTED: 12/22/2014
FORM APPROVED
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
C
015131
B. WING _____________________________
11/07/2014
TRUSSVILLE, AL 35173
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
F 226
PRINTED: 12/22/2014
FORM APPROVED
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
C
015131
B. WING _____________________________
11/07/2014
TRUSSVILLE, AL 35173
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
F 226
PRINTED: 12/22/2014
FORM APPROVED
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
C
015131
B. WING _____________________________
11/07/2014
TRUSSVILLE, AL 35173
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
F 226
PRINTED: 12/22/2014
FORM APPROVED
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
C
015131
B. WING _____________________________
11/07/2014
TRUSSVILLE, AL 35173
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
F 226
PRINTED: 12/22/2014
FORM APPROVED
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
C
015131
B. WING _____________________________
11/07/2014
TRUSSVILLE, AL 35173
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
F 226
PRINTED: 12/22/2014
FORM APPROVED
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
C
015131
B. WING _____________________________
11/07/2014
TRUSSVILLE, AL 35173
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
F 226
PRINTED: 12/22/2014
FORM APPROVED
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
C
015131
B. WING _____________________________
11/07/2014
TRUSSVILLE, AL 35173
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
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
PRINTED: 12/22/2014
FORM APPROVED
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
A. BUILDING ______________________
C
015131
B. WING _____________________________
11/07/2014
TRUSSVILLE, AL 35173
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
F 490
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
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
PRINTED: 12/22/2014
FORM APPROVED
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
C
015131
B. WING _____________________________
TRUSSVILLE, AL 35173
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
F 490
11/07/2014
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
PRINTED: 12/22/2014
FORM APPROVED
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
C
015131
B. WING _____________________________
11/07/2014
TRUSSVILLE, AL 35173
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
F 490
PRINTED: 12/22/2014
FORM APPROVED
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
C
015131
B. WING _____________________________
11/07/2014
TRUSSVILLE, AL 35173
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
F 490
PRINTED: 12/22/2014
FORM APPROVED
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
C
015131
B. WING _____________________________
11/07/2014
TRUSSVILLE, AL 35173
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
F 490
PRINTED: 12/22/2014
FORM APPROVED
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
C
015131
B. WING _____________________________
11/07/2014
TRUSSVILLE, AL 35173
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
F 490