Failure to Provide Adequate Visual Privacy for Residents
Summary
Facility staff failed to ensure adequate visual privacy for multiple residents by not providing sufficient privacy curtains or window coverings in several resident rooms. In several instances, residents did not have curtains that fully extended around their beds, leaving them exposed during personal care activities. For example, one resident with dementia and legal blindness was observed receiving ADL care without any privacy curtain around the bed, and another resident with a history of abuse and mental health diagnoses had only a quarter panel curtain that did not provide full coverage. Staff interviews confirmed that there was a shortage of curtains and hooks, and that curtains were often removed for laundering, leaving rooms without adequate privacy. Another resident reported that the curtains in his room did not fit properly, making it difficult to maintain privacy while using a urinal. He stated that he had to rely on keeping the door closed to avoid being seen, as the curtain could not be pulled to fully cover the bed. Observations confirmed that the curtain did not fit around the bed, and the Director of Housekeeping acknowledged ongoing issues with obtaining enough curtains and hooks for all rooms. Additionally, a resident receiving incontinence and ADL care was only partially shielded by a privacy curtain, and the door to the room was closed but did not prevent staff from entering while the resident was exposed. Staff interviews revealed that some had previously reported the lack of privacy curtains, and that the practice was to close the door if curtains were unavailable. In another case, a resident's window blind was damaged, allowing individuals outside to see into the room. Both nursing and maintenance staff recognized this as a privacy issue, and the blind remained unrepaired during the survey period.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Missing Privacy Curtain in Shared Resident Room: A resident with severe cognitive impairment and total dependence for ADLs was observed in a shared room without the required privacy curtain between beds. Staff, including NAs, an LPN, and leadership, were unaware the curtain was missing for a period of time, and interviews identified a communication breakdown between nursing, housekeeping, and maintenance regarding the missing curtain.
Missing privacy curtains were found in multiple double-occupancy rooms, including rooms with ceiling-suspended tracks and clips already in place but no curtain installed. In one room, a resident said the condition had been that way for months, and another resident did not like having the end of the bed exposed. Staff interviews showed unclear responsibility for replacing or hanging curtains, and the DON, Housekeeper-F, and Director of Plant Operations each described different assumptions about who should notify whom when a curtain was missing.
Failure to maintain privacy during incontinent care: CNAs provided care to a resident with aphasia, hemiplegia, severe cognitive impairment, and total bowel and bladder incontinence without fully closing the privacy curtain. The curtain was too short to surround the bed, leaving the resident visible from the room door and fully exposed during care. CNAs stated the curtain should have been closed, and the DON confirmed privacy must be provided during nursing care.
Shared bedrooms were not equipped to maintain full visual privacy for two pairs of residents. Surveyors observed partial privacy curtains that stopped short of the wall and large mirrors that allowed views of each resident’s sleeping area. Residents and staff stated that roommates and visitors could see into the other resident’s area, including when a resident used the shared bathroom or when care was provided.
A resident with hemiplegia and hemiparesis did not have a privacy curtain around the toilet and sink area in the room. Surveyors observed a ceiling track with empty clips but no curtain, allowing full view of the toilet from the doorway. The resident said this caused embarrassment when using the toilet, and an aide and the assistant administrator confirmed the curtain was missing.
Failed privacy curtain during bed bath: A resident’s privacy curtain would not fully close because multiple hooks were missing, leaving a gap that prevented full visual privacy while the resident’s bare bottom was exposed during ADL care. A nurse opened the room door while care was in progress, and a hospice NA entered and walked past the resident while the resident remained visible. Staff gave conflicting accounts about who was responsible for the curtain and work order process, and no TELS work order was found for the issue.
Missing Privacy Curtain in Shared Resident Room
Penalty
Summary
The facility failed to ensure that a required privacy curtain remained in place in a shared resident room for Resident #73. Resident #73 was admitted with diagnoses including stroke, vascular dementia with agitation, speech and language deficits, and cognitive communication deficit. The annual MDS documented severe cognitive impairment and total dependence on staff for all activities of daily living. During observation on 7/19/26 at 11:09 AM, the privacy curtain between Resident #73’s bed and the roommate’s bed was missing, with only about 12 inches of torn curtain still attached to the track, leaving no curtain separating the two beds. Staff interviews showed that multiple nursing assistants and nurses were unaware the curtain was missing while Resident #73 remained in the room without privacy. Nurse #17 stated she did not know the curtain was missing and said a work order would need to be entered. NA #6 stated shared rooms should have privacy curtains and that issues such as a broken or torn curtain should be reported to the nurse for an emergency work order. The ADON confirmed staff were expected to notify supervision immediately when a privacy curtain was missing and stated the work order process was delayed because of communication breakdown between maintenance and housekeeping. The Housekeeping Director reported he had not been notified by housekeeping staff, and the Maintenance Director stated the first work order was closed prematurely because staff believed housekeeping had already installed the replacement curtain.
Missing Privacy Curtains in Multiple Resident Rooms
Penalty
Summary
The facility failed to equip privacy curtains to ensure full visual privacy for residents in Rooms 114, 301, 303, 307, and 402. During observations, surveyors found that these rooms were double rooms with ceiling-suspended curtain tracks and clips in place, but no privacy curtains were present in several rooms, and in one room a curtain provided only partial privacy. In Room 303, a resident stated the condition had been that way for months, and the resident in the W bed did not like having the end of the bed exposed. In Room 114, the resident did not know how long the curtain had been missing. The deficiency continued across multiple observations, including a later check showing Rooms 114, 301, 303, 307, and 402 still did not have privacy curtains in place. During interviews, the Housekeeper-F stated she did not know who was responsible for replacing privacy curtains and thought it would be Maintenance. The Director of Plant Operations stated he would hang any privacy curtain he was asked to, but relied on nursing staff and housekeeping to let him know when they were needed. The DON stated she was not sure who was responsible, assumed nursing staff would notify housekeeping when a curtain needed replacement because it was dirty, thought housekeeping should notice if a curtain was missing, and believed maintenance needed to be notified when a curtain needed to be hung. The facility's guidance stated that all resident rooms must be arranged and maintained to protect resident privacy and dignity and that rooms with more than one resident must have a privacy curtain that allows complete visual separation between residents.
Failure to Maintain Privacy During Incontinent Care
Penalty
Summary
The facility failed to ensure resident privacy during incontinent care for 1 of 2 residents reviewed for resident rights. During observation, CNAs A and B provided incontinent care to a resident with aphasia, hemiplegia, osteoarthritis, depression, severe cognitive impairment, and total bowel and bladder incontinence, but they did not completely close the privacy curtain on the left side of the bed because the curtain was too short to surround the bed. The observation showed the resident could have been seen by someone opening the room door, and the resident's genitals were fully exposed. Record review showed the resident was admitted with diagnoses including aphasia, hemiplegia, osteoarthritis, and depression, and the quarterly MDS indicated a BIMS score of 03 with severe cognitive impairment and that the resident was always incontinent of bowel and bladder. The care plan identified bladder incontinence related to functional incontinence and included providing proper perineal care and barrier creams. During interview, CNAs A and B stated the curtain was not closed while they provided care but should have been, and they reported the curtain was too short. The DON stated privacy must be provided during nursing care and that the privacy curtain should have been closed completely.
Shared Bedrooms Did Not Provide Full Visual Privacy
Penalty
Summary
The facility failed to ensure that shared resident bedrooms were designed and equipped to maintain full visual privacy when privacy was needed. The Regional Director of Operations stated the facility did not have a policy related to resident privacy, while the Resident’s Rights and Family Handbook stated residents have the right to privacy, including private telephone calls, meetings, and mail. Surveyors identified four residents affected by privacy curtain concerns in two shared bedrooms. For Residents #43 and #35, both with diagnoses including anxiety and depression, observation of their shared room showed a partial privacy curtain that separated the beds only partway across the room and stopped about 4 feet before the opposite wall. A large mirror on the wall opposite the beds allowed a view of each resident’s sleeping area, and there was no wrap-around capability to block visibility. Resident #43 stated that when leaving the room, they lowered their head and looked at their wheelchair wheels so they would not look at their roommate. Resident #35 was not available for interview. For Residents #24 and #14, both with shared-room privacy concerns and diagnoses including schizophrenia, anxiety, and depression, observation showed the same room setup with a partial curtain that did not fully close off the sleeping areas and a large mirror that allowed a view of both residents’ sleeping areas. Resident #24 stated they could see their roommate’s bedroom area whenever entering or exiting the shared bathroom. CNA #7, CMA #8, the DON, and the Administrator all stated that the curtain placement, mirror placement, and room layout allowed residents and visitors to see into the roommate’s area, and that privacy could not be fully provided in these rooms as configured.
Missing Privacy Curtain Prevented Full Visual Privacy
Penalty
Summary
The facility failed to ensure full visual privacy for Resident R9 by not providing a privacy curtain around the toilet and sink area in the resident's room. Resident R9 was admitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side. Observation of the room revealed no privacy curtain extending around the toilet area, even though a ceiling track with empty metal clips was present. The toilet was fully visible to anyone entering the room. During interview, Resident R9 stated being embarrassed about using the toilet because someone might come in while the toilet was in use and reported that there had been no privacy curtain since admission. A nurse aide and the assistant administrator both confirmed that the privacy curtain was missing and that a curtain should have been in place around the toilet area for privacy.
Failed Privacy Curtain During Bed Bath
Penalty
Summary
The facility failed to provide a working privacy curtain that allowed full visual privacy for a resident during ADL care while bathing. During an observation of care for one resident, the resident was receiving a bed bath with the door closed and the privacy curtain pulled between the resident and a roommate who was resting in bed. While the resident’s bare bottom was exposed during washing, a nurse knocked on and opened the room door, and the resident remained visible from the hallway. The privacy curtain next to the door could not be closed because multiple hooks were missing, leaving an approximately 2-foot span that prevented the curtain from moving properly. The NA providing care stated the curtain would not pull all the way around, so privacy could not be given to the resident, and said housekeeping was responsible for replacing privacy curtains when needed. Housekeeping staff stated curtains were changed when dirty and that maintenance was responsible for installing hooks when needed. The Housekeeping Director stated nurses were responsible for entering a work order in the TELS system when the curtain was not working, but no work order for this resident’s curtain was found. The DON stated housekeeping should have checked the curtain and changed it if defective, and the Administrator stated the curtain should have been maintained in functional order and a work order should have been entered in TELS.
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