Failure to Maintain Functional Privacy Curtains in Shared Rooms
Summary
The deficiency involves the facility’s failure to provide functional ceiling-suspended privacy curtains in shared resident rooms, resulting in a lack of full visual privacy for two residents. For Resident 1, review of the admission record showed diagnoses including anxiety disorder, paranoid schizophrenia, muscle wasting and atrophy, and lack of coordination. A History and Physical dated 10/9/2025 documented that Resident 1 did not have capacity to understand and make decisions, while an MDS dated 10/16/2025 indicated the resident usually could understand and be understood and required partial/moderate assistance with ADLs such as toileting hygiene, showering, lower body dressing, transfers, and walking. During an observation and interview on 2/10/2026 at 1:50 p.m., CNA 1 stated that Resident 1’s curtain was short, did not close completely, and did not provide enough privacy, allowing another resident to walk in and see the resident being changed. CNA 1 stated the short curtain could not offer full privacy and that it was the facility’s responsibility to ensure full privacy. For Resident 2, the admission record showed diagnoses of muscle weakness and hypertension, and an H&P dated 5/23/2025 indicated the resident did not have capacity to understand and make decisions. An MDS indicated Resident 2 usually was able to understand and be understood and was dependent for ADLs including eating, personal hygiene, toileting hygiene, showering, dressing, footwear, and transfers. During an observation and interview on 2/11/2026 at 1:18 p.m., LVN 2 reported that Resident 2’s curtain was shortened, did not provide enough privacy, and that the curtain strings appeared tangled; LVN 2 did not know how long the curtain had not been functional and stated that not having full privacy with the curtain placed the resident at risk of being exposed to other residents. Review of the facility’s policy titled “Resident Rooms,” dated 1/2025, showed that resident bedrooms must be designed and equipped for comfort and privacy and that all resident bedrooms will be equipped to assure full visual privacy, including ceiling-suspended curtains extending around each bed in non-private bedrooms. The observed conditions for Residents 1 and 2 did not meet this policy requirement.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
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.
Surveyors found that all reviewed dual-occupancy rooms used a single ceiling-to-floor curtain that divided the room but did not extend around each bed or fully cover the area near the door, resulting in a lack of full visual privacy for residents. The DON acknowledged being unaware that the curtains did not provide full visual privacy and noted that residents could be exposed during care if the door was not closed. The Administrator also recognized the possibility of resident exposure during care and reported that the facility had no policy addressing full visual privacy curtains.
Missing and Stained Privacy Curtains: The facility failed to provide privacy curtains in several resident bedrooms and failed to keep two privacy curtains free of heavy staining. Multiple residents were observed in rooms without a privacy curtain track or curtain, and two bed curtains were seen with black scratch marks and dark spots. The DON of Housekeeping and Laundry verified the stained curtains, and the facility policy stated residents have the right to dignity, respect, and a safe, clean, comfortable, homelike environment.
Surveyors found that several dual-occupancy rooms lacked full visual privacy because the ceiling-to-floor divider curtains stopped short of the walls and side curtains left large gaps, preventing complete enclosure of each bed. An interview with the Administrator confirmed awareness that this could result in resident exposure during care and revealed there was no facility policy addressing full visual 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.
Failure to Provide Full Visual Privacy in Dual-Occupancy Rooms
Penalty
Summary
Surveyors identified that dual-occupancy rooms in the facility were not designed or equipped to assure full visual privacy for residents. Observation of rooms 301, 303, 306, 307, 309, and 310 showed each contained an A and B bed separated only by a single ceiling-to-floor curtain that divided the center of the room but stopped approximately 24 inches from the door, and the curtains did not extend around the entire beds to provide full coverage and privacy. These observations demonstrated that the rooms lacked ceiling-suspended curtains that extended around each bed to provide total visual privacy. During interview, the DON stated she was unaware that the existing curtains failed to provide full visual privacy and acknowledged there was a possibility of residents being exposed during resident care if the door was not closed. In a separate interview, the Administrator similarly acknowledged that if there was no full visual privacy in the resident rooms, there was a possibility of residents being exposed during resident care, and further stated that the facility did not have a policy on full visual privacy curtains.
Missing and Stained Privacy Curtains
Penalty
Summary
The facility failed to ensure privacy curtains were provided for five residents whose bedrooms lacked a privacy curtain track and privacy curtain. On observation, Resident #82 was seen in a bedroom without a privacy curtain track or curtain, and later Resident #192, Resident #5, Resident #116, and Resident #105 were also observed in bedrooms that lacked a privacy curtain track and privacy curtain. Photographic evidence was obtained during these observations. The facility also failed to ensure privacy curtains were not stained for two beds in one resident room. Curtains for beds 9B and 9D were observed to be heavily stained, including black scratch marks on the lower portion of one curtain and large dark spots on the upper right portion of the other. These conditions were observed on two separate occasions, and the Director of Housekeeping and Laundry verified that the curtains were heavily stained. The facility's Resident Rights Policy stated that each resident has the right to be treated with dignity and respect and to have a safe, clean, comfortable, homelike environment.
Inadequate Visual Privacy in Dual-Occupancy Rooms
Penalty
Summary
The facility failed to ensure that dual-occupancy resident rooms were designed or equipped to provide full visual privacy for residents in three of four rooms reviewed (rooms C-8, S-8, and S-18). Observation showed each of these rooms had an A and B bed with a single ceiling-to-floor curtain dividing the center of the room that stopped approximately 24 inches from the wall, leaving a gap. The A beds had side curtains, but each had an approximate 30-inch gap that prevented total visual privacy around the beds. During interview, the Administrator acknowledged that without full visual privacy in resident rooms there was a possibility of residents being exposed during resident care and stated that the facility did not have a policy on full visual privacy curtains. No specific resident medical histories or conditions were described in the report.
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