Inadequate Privacy Curtains in Semi-Private Room
Summary
The facility did not ensure that each resident in a semi-private room had ceiling-suspended curtains that extended around the bed to provide total visual privacy. This deficiency was identified for two residents who shared a semi-private room. The privacy curtain separating the two residents was not long enough to allow full visual privacy, resulting in one resident being able to see the other through a gap between the bottom of the curtain and the floor. This issue was observed during the survey, and interviews with the residents and staff confirmed the inadequacy of the privacy curtain. One resident, who had a history of Cerebral Vascular Accident, Congestive Heart Failure, and Hypertension, reported feeling uncomfortable and grossed out by their roommate's behavior of touching themselves. Despite reporting this concern to staff members, there was no documented evidence in the resident's Comprehensive Care Plan addressing the issue. The other resident, who had diagnoses including Respiratory Failure, Aphasia, and Encephalopathy, also had no documented evidence in their Comprehensive Care Plan regarding their behavior of touching their genitals. Interviews with various staff members, including Certified Nursing Assistants, Licensed Practical Nurses, the Social Worker, the unit manager, and the Director of Environmental Services, revealed that the staff was either unaware of the privacy curtain issue or the discomfort it caused the resident. The Director of Nursing Services acknowledged that the privacy curtain should ensure full privacy for each resident and that staff should be aware of and address residents' privacy needs during care. The facility's policy on privacy curtains, effective April 2024, stated that the curtains should cover the entire length of the resident's bed area to provide full privacy, which was not adhered to in this case.
Penalty
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Surveyors found that all reviewed dual-occupancy rooms used a single ceiling-to-floor curtain that divided the room but did not extend around each bed or fully cover the area near the door, resulting in a lack of full visual privacy for residents. The DON acknowledged being unaware that the curtains did not provide full visual privacy and noted that residents could be exposed during care if the door was not closed. The Administrator also recognized the possibility of resident exposure during care and reported that the facility had no policy addressing full visual privacy curtains.
Surveyors found that several dual-occupancy rooms lacked full visual privacy because the ceiling-to-floor divider curtains stopped short of the walls and side curtains left large gaps, preventing complete enclosure of each bed. An interview with the Administrator confirmed awareness that this could result in resident exposure during care and revealed there was no facility policy addressing full visual privacy curtains.
Surveyors identified that three dual-occupancy rooms lacked full visual privacy because the central ceiling-to-floor curtains stopped short of the wall and the side curtains for each bed left significant gaps, preventing complete separation between roommates. An interview with the Administrator confirmed that rooms without full visual privacy curtains could not provide privacy when requested and that there was no existing policy addressing privacy curtains.
A resident in a fully occupied four-bed room was observed without a ceiling-suspended privacy curtain around the bed after the curtain and track had fallen months earlier and were never replaced. The resident reported having no privacy and being unable to change clothes at the bedside. The Administrator stated that all residents should have privacy and window curtains for privacy and a homelike environment, while the Housekeeping Supervisor reported that housekeeping is responsible for replacing privacy curtains. Facility policies and job descriptions assign responsibility for maintaining a safe, comfortable, and homelike environment, including ensuring privacy curtains are present and in good condition.
The facility failed to maintain functional ceiling-suspended privacy curtains in two shared rooms, resulting in inadequate visual privacy for two residents who required assistance with ADLs. One resident, with mental health and physical impairments and partial/moderate ADL dependence, had a curtain that was too short and did not close completely, allowing others to see the resident during care, as reported by a CNA. Another resident, with muscle weakness, hypertension, impaired decision-making capacity, and total ADL dependence, had a shortened curtain with tangled strings that did not provide sufficient privacy, as reported by an LVN. These conditions did not comply with the facility’s written policy requiring resident bedrooms to be equipped to assure full visual privacy with ceiling-suspended curtains around each bed in non-private rooms.
Surveyors found that several rooms housing eight residents lacked privacy curtains, preventing full visual privacy. During a tour of one floor with the LNHA, rooms 511A, 514A, 517A, and 519A were observed without privacy curtains despite being occupied by residents transferred from another facility. When questioned, the LNHA reported that maintenance staff had forgotten to install the curtains. The facility’s Residents Rights policy states that staff must treat residents with dignity and that residents are guaranteed rights to privacy and confidentiality under applicable regulations.
Failure to Provide Full Visual Privacy in Dual-Occupancy Rooms
Penalty
Summary
Surveyors identified that dual-occupancy rooms in the facility were not designed or equipped to assure full visual privacy for residents. Observation of rooms 301, 303, 306, 307, 309, and 310 showed each contained an A and B bed separated only by a single ceiling-to-floor curtain that divided the center of the room but stopped approximately 24 inches from the door, and the curtains did not extend around the entire beds to provide full coverage and privacy. These observations demonstrated that the rooms lacked ceiling-suspended curtains that extended around each bed to provide total visual privacy. During interview, the DON stated she was unaware that the existing curtains failed to provide full visual privacy and acknowledged there was a possibility of residents being exposed during resident care if the door was not closed. In a separate interview, the Administrator similarly acknowledged that if there was no full visual privacy in the resident rooms, there was a possibility of residents being exposed during resident care, and further stated that the facility did not have a policy on full visual privacy curtains.
Inadequate Visual Privacy in Dual-Occupancy Rooms
Penalty
Summary
The facility failed to ensure that dual-occupancy resident rooms were designed or equipped to provide full visual privacy for residents in three of four rooms reviewed (rooms C-8, S-8, and S-18). Observation showed each of these rooms had an A and B bed with a single ceiling-to-floor curtain dividing the center of the room that stopped approximately 24 inches from the wall, leaving a gap. The A beds had side curtains, but each had an approximate 30-inch gap that prevented total visual privacy around the beds. During interview, the Administrator acknowledged that without full visual privacy in resident rooms there was a possibility of residents being exposed during resident care and stated that the facility did not have a policy on full visual privacy curtains. No specific resident medical histories or conditions were described in the report.
Failure to Provide Full Visual Privacy in Dual-Occupancy Rooms
Penalty
Summary
Surveyors found that the facility failed to ensure full visual privacy in three dual-occupancy rooms (Rooms 5, 18, and 21) during a review of 30 such rooms. Observations showed that each of these rooms had an A and B bed separated by a single ceiling-to-floor curtain that divided the center of the room but stopped approximately 12 inches from the wall, leaving a gap. In addition, each bed had its own side curtain, but these side curtains left gaps of approximately 18 inches and 30 inches, preventing total visual privacy for the residents in those beds. During an interview, the Administrator acknowledged that if a resident room did not have a full visual privacy curtain, it would not provide privacy when a resident requested it, and also stated that the facility did not have a policy regarding privacy curtains. The report states that this failure could lead to a lack of privacy for residents, allow residents' private medical treatment to be observed by roommates or others, and lead to a decline in psychosocial well-being.
Failure to Maintain Resident Bed Privacy Curtain in Multi-Occupancy Room
Penalty
Summary
The deficiency involves the facility’s failure to provide full visual privacy for one resident in a four-bed room by not maintaining a ceiling-suspended privacy curtain around the resident’s bed. On 08/03/25, the resident’s privacy curtain and attached track detached from the ceiling and fell while the resident was lying in bed watching television. A progress note from that date documents that the resident immediately notified staff, denied pulling on or laying against the curtain prior to the incident, and that a work order request was placed in the maintenance log. Despite this, on 02/13/26 at 12:00 p.m., surveyors observed the resident sitting in bed in a fully occupied four-person room with no privacy curtain around the bed. During an interview at the same time, the resident reported that the curtain had fallen months earlier and had never been replaced, stating that he had no privacy and could not change clothes at the bedside, and that he wanted some privacy. The Administrator stated that all residents should have privacy curtains and window curtains for privacy, comfort, and a homelike environment, and that maintenance should ensure all curtains are in place and in working order. The Housekeeping Supervisor stated that housekeeping is responsible for replacing privacy curtains and that all residents should have them for privacy. Facility policies and job descriptions reviewed by surveyors indicate that the facility is responsible for maintaining a safe, clean, comfortable, and homelike environment, including having privacy curtains that are clean and in good condition, and that the Maintenance Director is responsible for repairs and routine maintenance of the building and equipment. This failure affected one resident out of 22 residents reviewed.
Failure to Maintain Functional Privacy Curtains in Shared Rooms
Penalty
Summary
The deficiency involves the facility’s failure to provide functional ceiling-suspended privacy curtains in shared resident rooms, resulting in a lack of full visual privacy for two residents. For Resident 1, review of the admission record showed diagnoses including anxiety disorder, paranoid schizophrenia, muscle wasting and atrophy, and lack of coordination. A History and Physical dated 10/9/2025 documented that Resident 1 did not have capacity to understand and make decisions, while an MDS dated 10/16/2025 indicated the resident usually could understand and be understood and required partial/moderate assistance with ADLs such as toileting hygiene, showering, lower body dressing, transfers, and walking. During an observation and interview on 2/10/2026 at 1:50 p.m., CNA 1 stated that Resident 1’s curtain was short, did not close completely, and did not provide enough privacy, allowing another resident to walk in and see the resident being changed. CNA 1 stated the short curtain could not offer full privacy and that it was the facility’s responsibility to ensure full privacy. For Resident 2, the admission record showed diagnoses of muscle weakness and hypertension, and an H&P dated 5/23/2025 indicated the resident did not have capacity to understand and make decisions. An MDS indicated Resident 2 usually was able to understand and be understood and was dependent for ADLs including eating, personal hygiene, toileting hygiene, showering, dressing, footwear, and transfers. During an observation and interview on 2/11/2026 at 1:18 p.m., LVN 2 reported that Resident 2’s curtain was shortened, did not provide enough privacy, and that the curtain strings appeared tangled; LVN 2 did not know how long the curtain had not been functional and stated that not having full privacy with the curtain placed the resident at risk of being exposed to other residents. Review of the facility’s policy titled “Resident Rooms,” dated 1/2025, showed that resident bedrooms must be designed and equipped for comfort and privacy and that all resident bedrooms will be equipped to assure full visual privacy, including ceiling-suspended curtains extending around each bed in non-private bedrooms. The observed conditions for Residents 1 and 2 did not meet this policy requirement.
Failure to Provide Privacy Curtains for Multiple Residents
Penalty
Summary
Surveyors determined that the facility failed to provide privacy curtains in certain resident rooms, resulting in residents not being afforded full visual privacy. On 2/5/26, between 9:00 AM and 10:45 AM, during a tour of the 5th floor with the LNHA, the surveyor observed that rooms 511A, 514A, 517A, and 519A, which housed a total of eight residents recently transferred from another facility, did not have privacy curtains installed. Later that day at 12:55 PM, when the surveyor asked the LNHA why those residents did not have privacy curtains, the LNHA stated that the maintenance staff had forgotten to install them. The deficiency was communicated to the Administrator at 3:28 PM during the Life Safety Code exit conference. The facility’s written Residents Rights policy, provided by the LNHA, states that employees should treat all residents with kindness and dignity and that federal and state laws guarantee residents’ rights to privacy and confidentiality, including visual privacy, as referenced in NJAC 8:39-31.2(e) and 31.8(c)5. No additional clinical details or specific medical histories of the eight affected residents were provided in the report.
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