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F0583
D

Failure to Ensure Resident Privacy 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 ensure personal privacy for a resident during incontinence care. During an observation, a certified nurse's aide (CNA) was providing care to a resident with the room door open and the privacy curtain only partially pulled, leaving the resident's buttocks exposed. The resident's roommate was present in the room and facing toward the resident receiving care. The CNA acknowledged that the door did not latch properly and believed it was closed, but it was not. The surveyor entered the room after knocking and was able to see the resident exposed, prompting an immediate exit and closure of the door. The resident involved had diagnoses including cerebral infarction, chronic kidney disease, and chronic pain syndrome, and was assessed as moderately cognitively impaired with frequent urinary incontinence and occasional bowel incontinence. The resident later expressed discomfort about the lack of privacy, specifically noting concern about people in the hallway and the need for the door to be closed during personal care. The director of nursing confirmed that both the door and privacy curtain should have been closed during such care.

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