Failure to Provide Full Visual Privacy in Dual-Occupancy Rooms
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.
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 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.
Surveyors identified that three dual-occupancy rooms lacked full visual privacy because the central ceiling-to-floor curtains stopped short of the wall and the side curtains for each bed left significant gaps, preventing complete separation between roommates. An interview with the Administrator confirmed that rooms without full visual privacy curtains could not provide privacy when requested and that there was no existing policy addressing privacy curtains.
A resident in a fully occupied four-bed room was observed without a ceiling-suspended privacy curtain around the bed after the curtain and track had fallen months earlier and were never replaced. The resident reported having no privacy and being unable to change clothes at the bedside. The Administrator stated that all residents should have privacy and window curtains for privacy and a homelike environment, while the Housekeeping Supervisor reported that housekeeping is responsible for replacing privacy curtains. Facility policies and job descriptions assign responsibility for maintaining a safe, comfortable, and homelike environment, including ensuring privacy curtains are present and in good condition.
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 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.
Failure to Provide Full Visual Privacy in Dual-Occupancy Rooms
Penalty
Summary
Surveyors found that the facility failed to ensure full visual privacy in three dual-occupancy rooms (Rooms 5, 18, and 21) during a review of 30 such rooms. Observations showed that each of these rooms had an A and B bed separated by a single ceiling-to-floor curtain that divided the center of the room but stopped approximately 12 inches from the wall, leaving a gap. In addition, each bed had its own side curtain, but these side curtains left gaps of approximately 18 inches and 30 inches, preventing total visual privacy for the residents in those beds. During an interview, the Administrator acknowledged that if a resident room did not have a full visual privacy curtain, it would not provide privacy when a resident requested it, and also stated that the facility did not have a policy regarding privacy curtains. The report states that this failure could lead to a lack of privacy for residents, allow residents' private medical treatment to be observed by roommates or others, and lead to a decline in psychosocial well-being.
Failure to Maintain Resident Bed Privacy Curtain in Multi-Occupancy Room
Penalty
Summary
The deficiency involves the facility’s failure to provide full visual privacy for one resident in a four-bed room by not maintaining a ceiling-suspended privacy curtain around the resident’s bed. On 08/03/25, the resident’s privacy curtain and attached track detached from the ceiling and fell while the resident was lying in bed watching television. A progress note from that date documents that the resident immediately notified staff, denied pulling on or laying against the curtain prior to the incident, and that a work order request was placed in the maintenance log. Despite this, on 02/13/26 at 12:00 p.m., surveyors observed the resident sitting in bed in a fully occupied four-person room with no privacy curtain around the bed. During an interview at the same time, the resident reported that the curtain had fallen months earlier and had never been replaced, stating that he had no privacy and could not change clothes at the bedside, and that he wanted some privacy. The Administrator stated that all residents should have privacy curtains and window curtains for privacy, comfort, and a homelike environment, and that maintenance should ensure all curtains are in place and in working order. The Housekeeping Supervisor stated that housekeeping is responsible for replacing privacy curtains and that all residents should have them for privacy. Facility policies and job descriptions reviewed by surveyors indicate that the facility is responsible for maintaining a safe, clean, comfortable, and homelike environment, including having privacy curtains that are clean and in good condition, and that the Maintenance Director is responsible for repairs and routine maintenance of the building and equipment. This failure affected one resident out of 22 residents reviewed.
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