Failure to Maintain Resident Privacy Due to Broken Window Blinds
Summary
The facility failed to ensure full visual privacy for residents in six rooms, as window blinds in these rooms had multiple broken slats, allowing individuals outside the facility to see into the residents' beds. Observations on several occasions revealed varying numbers of broken slats in the blinds of these rooms, with some residents expressing dissatisfaction and concern about the lack of privacy. One resident specifically stated that the blinds had been broken for a long time and needed replacement for privacy, while another resident disliked the broken blinds because they allowed people to see inside. Interviews with staff, including a medication aide and an LVN, revealed that they were unaware of any blinds needing replacement and that repairs were typically entered into a Maintenance Logbook at each nurses' station. Review of the Maintenance Logbooks showed no requests for blind repair or replacement. The Maintenance Director stated he was responsible for physical plant repairs and relied on staff to report issues, checking the logbooks regularly and conducting monthly room sweeps. He was unaware of the broken blinds but indicated that replacements were available. The facility's policy emphasized the importance of privacy and dignity for residents, including maintaining a homelike environment.
Penalty
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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.
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.
A resident with severe cognitive impairment and frequent bowel and bladder incontinence was found in a shared room without a privacy curtain on his side. Staff observed the missing curtain over multiple days, and interviews showed the curtain had reportedly been absent for about a week because hooks were missing from the track. Nursing, housekeeping, maintenance, and leadership all stated shared rooms should have privacy curtains for care, but the issue was not identified until prompted by the surveyor.
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.
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.
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.
Missing Privacy Curtain in Shared Resident Room
Penalty
Summary
The facility failed to ensure that a shared resident room was equipped with a ceiling-suspended privacy curtain for one resident. Resident #75, an older male admitted in 2024, had severe cognitive impairment with a BIMS score of 3, required substantial to maximal assistance with toileting, showering, dressing, and personal hygiene, and was frequently incontinent of both bladder and bowel. His care plan addressed Alzheimer’s dementia and incontinence, including use of disposable briefs, changing as needed, and checking for incontinence every 2 hours. During observation on 05/04/2026, Resident #75’s side of the shared room did not have a privacy curtain, while the roommate’s side did. The resident was not in the room during the initial observations, and a later observation on 05/04/2026 showed no change. On 05/05/2026, an LVN entered the room and did not recognize the missing curtain until prompted by the surveyor. Staff interviews reflected that privacy curtains were used for incontinent care, clothing changes, repositioning, and transfers, and that a resident in a shared room should have a privacy curtain. Interviews with housekeeping, nursing leadership, maintenance, and administration showed that the curtain had been missing for an extended period, with one housekeeper stating it had been absent for about a week because hooks were missing from the track. The Maintenance Director stated he had no prior work order for the curtain issue and that he completed a work order on 05/06/2026 by replacing the hooks. The DON and Administrator stated shared rooms should have privacy curtains and that the curtain should be replaced immediately if removed, while also acknowledging that weekly walkthroughs had not been completed during the relevant period.
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.
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