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F0557
D

Failure to Maintain Resident Dignity During Incontinence Care

Rural Retreat, Virginia Survey Completed on 04-08-2025

Penalty

Fine: $135,372
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Facility staff failed to maintain the dignity and respect of a resident during incontinence care. The incident involved a certified nurse's aide (CNA) providing care to a resident with multiple diagnoses, including cerebral infarction, chronic kidney disease, chronic pain syndrome, and anxiety. The resident was assessed as moderately cognitively impaired. During the care, the CNA left the resident's door open and did not fully close the privacy curtain between the resident and her roommate, resulting in the resident's bare bottom being exposed while the roommate was present and the door was open to the hallway. The resident expressed discomfort about the situation, specifically noting concern about men walking in the hallway and potentially entering the room while she was exposed. The CNA acknowledged that the door was not properly closed, and the director of nursing confirmed that both the door and privacy curtain should have been closed during care. The deficiency was identified through observation, staff interview, and resident interview.

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