2014 sex abuse case

A. BUILDING ______________________

(X1) PROVIDER/SUPPLIER/CLIA

IDENTIFICATION NUMBER:

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION

(X3) DATE SURVEY

COMPLETED

PRINTED: 12/22/2014FORM APPROVED

(X2) MULTIPLE CONSTRUCTION

B. WING _____________________________

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

015131 11/07/2014

C

STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER

119 WATTERSON PARKWAYGOLDEN LIVING CENTER - TRUSSVILLE

TRUSSVILLE, AL 35173

PROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE

CROSS-REFERENCED TO THE APPROPRIATE

DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG

SUMMARY STATEMENT OF DEFICIENCIES

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION)

F 000 INITIAL COMMENTS 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

SS=J

483.13(b), 483.13(c)(1)(i) FREE FROM

ABUSE/INVOLUNTARY SECLUSION

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

F 223 12/9/14

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

12/03/2014Electronically Signed

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 72DP11Event ID: Facility ID: 3717301NH If continuation sheet of 37

A. BUILDING ______________________





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________



015131 11/07/2014

C







DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG




F 223 Continued From page 1 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.

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.







A. BUILDING ______________________





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________



015131 11/07/2014

C







DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





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



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,




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,


A. BUILDING ______________________





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________



015131 11/07/2014

C







DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





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.

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

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.


A. BUILDING ______________________





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________



015131 11/07/2014

C







DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





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


A. BUILDING ______________________





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________



015131 11/07/2014

C







DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





#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.


A. BUILDING ______________________





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________



015131 11/07/2014

C







DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





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


A. BUILDING ______________________





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________



015131 11/07/2014

C







DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





#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


A. BUILDING ______________________





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________



015131 11/07/2014

C







DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





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


A. BUILDING ______________________





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________



015131 11/07/2014

C







DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





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


A. BUILDING ______________________





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________



015131 11/07/2014

C







DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





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


A. BUILDING ______________________





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________



015131 11/07/2014

C







DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





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


A. BUILDING ______________________





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________



015131 11/07/2014

C







DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





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


A. BUILDING ______________________





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________



015131 11/07/2014

C







DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





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."


#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


A. BUILDING ______________________





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________



015131 11/07/2014

C







DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





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.


A. BUILDING ______________________





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________



015131 11/07/2014

C







DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





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


A. BUILDING ______________________





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________



015131 11/07/2014

C







DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





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


A. BUILDING ______________________





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________



015131 11/07/2014

C







DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





... 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


A. BUILDING ______________________





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________



015131 11/07/2014

C







DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





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


A. BUILDING ______________________





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________



015131 11/07/2014

C







DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





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


implementation of abuse prohibition protocol

steps and reviewed through the OAPI process.


A. BUILDING ______________________





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________



015131 11/07/2014

C







DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





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


AL00032227.

F 226

SS=J

483.13(c) DEVELOP/IMPLMENT

ABUSE/NEGLECT, ETC POLICIES

The facility must develop and implement written

F 226 12/9/14


A. BUILDING ______________________





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________



015131 11/07/2014

C







DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





policies and procedures that prohibit

mistreatment, neglect, and abuse of residents

and misappropriation of resident property.


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.


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.

I.






facility.








11/7/14.








11/7/14.

II



A. BUILDING ______________________





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________



015131 11/07/2014

C







DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG










"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


III
















IV

















A. BUILDING ______________________





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________



015131 11/07/2014

C







DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





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.


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




















Services office.


A. BUILDING ______________________





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________



015131 11/07/2014

C







DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





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.


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


A. BUILDING ______________________





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________



015131 11/07/2014

C







DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





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.


#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


A. BUILDING ______________________





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________



015131 11/07/2014

C







DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





going to hurt RI #1.


#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."


A. BUILDING ______________________





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________



015131 11/07/2014

C







DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG






#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.


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


A. BUILDING ______________________





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________



015131 11/07/2014

C







DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





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

stated that is not what she was told.


#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.

*************************



which documented:

November 07, 2014


1. Beginning on 11.07.2014 at 1:55 PM, no staff


education by the Director of Nursing Services

and/or Designee without education by the


A. BUILDING ______________________





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________



015131 11/07/2014

C







DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





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.


11.07.2014


A. BUILDING ______________________





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________



015131 11/07/2014

C







DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





*************************










AL00032227.

F 490

SS=J

483.75 EFFECTIVE

ADMINISTRATION/RESIDENT WELL-BEING

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.


by:

F 490 12/9/14

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

I.






facility.






A. BUILDING ______________________





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________



015131 11/07/2014

C







DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





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.


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.






"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




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


patient/resident. Training was completed

by Area Vice President and Field Services

Clinical Director on 11/7/14.






patient/resident. Training was completed

by Area Vice President and Field Services

Clinical Director on 11/7/14.

II



III

















A. BUILDING ______________________





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________



015131 11/07/2014

C







DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





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 ... ."


#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) ... ."


DNS was asked what was the staff told to do

IV



































Services office.


A. BUILDING ______________________





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________



015131 11/07/2014

C







DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





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.


#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

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.


A. BUILDING ______________________





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________



015131 11/07/2014

C







DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





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.

*************************



which documented:

November 07, 2014


1. The Executive Director and Director of

Nursing Services was provided re-education on

conducting a thorough investigation to include


A. BUILDING ______________________





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________



015131 11/07/2014

C







DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





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


education by the Director of Nursing Services

and/or Designee without completing education on

the Policy and Procedure for Reporting 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.


A. BUILDING ______________________





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________



015131 11/07/2014

C







DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG






11.07.2014

*************************










AL00032227.


2014 sex abuse case

Documents