Failure to Maintain Resident Privacy Due to Broken Window Blinds
Summary
The facility failed to maintain visual privacy for a resident by not repairing broken window blinds, which resulted in feelings of disrespect and the potential for exposure during care. The resident, who was observed in bed covered with a sheet and not wearing a gown, expressed dissatisfaction with the broken blinds that had been covered with a soiled sheet for some time. The resident was concerned about being visible from the outside, especially at night, and was frustrated that the staff had not addressed the issue. The blinds had several broken slats, preventing them from closing properly, which compromised the resident's privacy. The resident, who requires substantial to maximal assistance with activities of daily living, was admitted to the facility with multiple diagnoses, including cerebrovascular disease, epilepsy, hypertension, osteoporosis, and chronic kidney disease. Interviews with the Director of Maintenance and the Director of Nursing revealed that the nursing staff was responsible for notifying maintenance about repairs needed in residents' rooms. However, the facility's policy on resident room maintenance was not followed, as the broken blinds were not repaired, leading to the deficiency in maintaining the resident's privacy.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Incomplete Privacy Curtain in Resident Bedroom: A resident's bedroom had a wrong-size privacy curtain that did not provide full visual privacy for all occupants. The resident had intact cognition, was independent with toileting, bathing, and lower body dressing, and had the capacity to make decisions. Staff stated the curtain was the wrong size and that privacy curtains are important to protect privacy and dignity during care.
Privacy Curtain Track Not Repaired: A resident with moderate cognitive impairment had a privacy curtain that would not fully close, and the issue remained unchanged on repeated observation. A NA said the curtain had not been closing all the way for a couple weeks and was unsure whether a work order had been submitted, while the Maintenance Manager, an RN, and the Administrator were unaware the track needed repair or whether a work order had been entered.
A resident with severe cognitive impairment did not have a privacy curtain in his room after curtains were taken down for deep cleaning and his curtain was not put back up. Observations confirmed the bed-A area lacked a privacy curtain, and the HKS acknowledged the curtain was missed.
Insufficient Privacy Curtains in Multiple Resident Rooms: Surveyors observed that 17 of 33 rooms lacked enough privacy curtains to provide full visual privacy for all occupants, with several multi-occupancy rooms having only one or two curtains on the track at the foot of the beds. CNA and HS interviews confirmed that privacy curtains are essential for resident dignity during care, and the HS stated the facility was aware the rooms did not have enough curtains to ensure each resident full visual privacy.
Surveyors found that two residents sharing a double-occupancy room did not have privacy curtains, preventing visual privacy when needed. An MT confirmed the absence of curtains, and review of the facility’s Resident Rights policy showed that residents were entitled to visual privacy. This failure affected two of three residents reviewed for the physical environment in a facility with a census of 137 residents and was cited under a complaint investigation.
Missing privacy curtains were found in three resident rooms, including rooms with ceiling-mounted tracks and hanger clips already in place but no curtain installed. Surveyors observed the missing curtains in rooms #115, #116, and #119, and staff interviews confirmed that resident privacy was important for dignity and that nursing, housekeeping, and maintenance each had roles related to curtain replacement and room upkeep. The DON was unaware of the issue, and the Administrator could not provide a policy on resident privacy or privacy curtains.
Incomplete Privacy Curtain in Resident Bedroom
Penalty
Summary
The facility failed to ensure that Resident 65's bedroom had a privacy curtain that provided full visual privacy. During observation on 5/4/2026 at 10:52 a.m., a wrong-size privacy curtain was seen on the horizontal track along the foot of Resident 65's bed, and it only provided full visual privacy for two of the room's three occupants. Resident 65 was admitted and later readmitted to the facility, and his diagnoses included spinal stenosis and muscle weakness. Resident 65's MDS dated 2/3/2026 indicated his cognition was intact and that he was independent with toileting, bathing, and lower body dressing. His H&P dated 4/11/2026 stated he had the capacity to understand and make decisions. During interview, Resident 65 stated the incomplete privacy curtain did not bother him. The Housekeeper stated the curtain was the wrong size and may affect the resident's visual privacy and dignity, and the RNS stated privacy curtains are important to protect privacy and dignity during care and may cause the resident to feel uncomfortable. The facility policy titled Resident Rights stated employees were to treat all residents with respect and dignity and that all residents and staff are continually informed and aware of resident rights.
Privacy Curtain Track Not Repaired
Penalty
Summary
The facility failed to repair a privacy curtain track so that a resident's curtain could fully close and provide total visual privacy. This deficiency was identified for Resident #29, who was admitted on [DATE] and whose quarterly MDS dated [DATE] coded her with moderate cognitive impairment. On 4/28/26 at 9:30 AM, an observation of the resident's room showed the privacy curtain on the track was unable to fully close, and the resident later stated she had not paid attention to the curtain and did not know how long it had not fully closed. On 4/29/26 at 3:20 PM, the curtain track remained unchanged. A NA stated the curtain had not been closing all the way for a couple weeks and she did not know whether a work order had been submitted; she also stated she had not submitted one and assumed another NA or nurse had done so. The Maintenance Manager stated he was new to the facility, was unaware the track needed repair, and did not know whether a work order had been submitted. A nurse stated she was unaware the curtain track could not fully close and said she would put in a work order. The Administrator stated a burst water line in February 2026 may have damaged the track, that the facility had been using paper work orders at that time and later switched to electronic work orders, and that she did not know the track needed repair or whether a work order had been submitted.
Missing Privacy Curtain in Resident Room
Penalty
Summary
The facility failed to ensure a privacy curtain was in place for one resident in room [ROOM NUMBER], bed-A, despite the resident’s need for privacy. The resident, who had a BIMS score of 3 on the annual MDS indicating severe cognitive impairment, stated during interview that he had not had a privacy curtain for a while and reported that a staff member had removed the curtains for cleaning but did not put his curtain back up. Observations on 04/24/2026 and 04/25/2026 confirmed that bed-A in room [ROOM NUMBER] did not have a privacy curtain. The Housekeeping Supervisor acknowledged that the privacy curtain was missing, explained that curtains are taken down for deep cleaning, and stated that bed-A’s curtain was missed and that rounds should be conducted to identify missing privacy curtains.
Insufficient Privacy Curtains in Multiple Resident Rooms
Penalty
Summary
The facility failed to ensure there were adequate privacy curtains available in 17 of 33 rooms, including Rooms 2, 3, 4, 7, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, and 31. During observations, surveyors found multiple rooms with only one or two privacy curtains on the horizontal track along the foot of residents' beds, which did not provide full visual privacy for all occupants in those rooms. In several rooms with three occupants, the curtains only covered one or two residents, and in one room with two occupants, only one privacy curtain was present, providing full visual privacy for only one resident. During interviews, CNA 6 stated privacy curtains were essential for residents' dignity during care, including dressing, bathing, and treatments, and said the curtains should always be fully functional. The Housekeeping Supervisor stated privacy curtains protected residents' dignity and comfort and that without them, residents may feel uneasy receiving care, affecting their emotional well-being. The Housekeeping Supervisor also stated the facility was aware there were not enough privacy curtains in place to allow each resident full visual privacy and that the concern had been brought to the Administrator. The facility policy on Resident Rights stated residents were to be treated with respect and dignity and were guaranteed rights including privacy and a dignified existence.
Failure to Provide Visual Privacy in Shared Bedroom
Penalty
Summary
The deficiency involves the facility’s failure to provide visual privacy for residents in a shared bedroom, as required by its own Resident Rights policy. During an observation on 04/19/26 at 10:18 A.M., surveyors noted that no privacy curtains were in place in the double-occupancy room shared by Residents #15 and #147, meaning the residents could see each other when privacy was needed. At 10:20 A.M. the same day, a Medication Technician (MT #418) confirmed that there were no privacy curtains present in this double room. Review of the facility’s Resident Rights policy showed that residents were entitled to visual privacy, but this was not provided for the two residents in the observed room. This situation affected two of three residents reviewed for the physical environment, in a facility with a total census of 137 residents, and was cited as noncompliance under Complaint Number 2606421.
Missing Privacy Curtains in Resident Rooms
Penalty
Summary
Rooms #115, #116, and #119 did not have privacy curtains in place to provide full visual privacy for residents. During observations on 03/08/26, surveyors found that room #115 had no privacy curtain for the resident in the bed closest to the door, even though a ceiling-mounted track and hanger clips were present. In room #116, there was no privacy curtain at the foot of the bed closest to the window, despite the same curtain track and hanger clips being installed. In room #119, there was also no privacy curtain at the foot of the bed for the bed closest to the window, with the track and hanger clips present but no curtain installed. During interviews, CNA-D, LVN-E, and LVN-F each stated that resident privacy was important for dignity and that privacy curtains were part of that privacy. They also stated that housekeeping was responsible for changing privacy curtains, while maintenance handled window blinds and other maintenance issues. The Housekeeping Supervisor stated nursing staff were responsible for notifying her when a privacy curtain needed to be changed, and she had clean curtains in storage. The Maintenance Supervisor stated nursing staff had to notify him of maintenance issues, and he would usually address them the same day. The DON stated she was unaware of the missing privacy curtains and said she would have a sweep of the facility done to identify rooms needing privacy curtains. The Administrator was unable to provide a policy addressing privacy curtains or resident privacy prior to the end of the survey.
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