The resident, identified as R108, noticed the inspector watching from the public hallway during the procedure and asked aloud, "What's he doing out there?" Staff responded they didn't know but made no attempt to close the door.
The January 6 incident occurred at 2:04 p.m. when two staff members in disposable gowns were changing a dressing on R108's leg. A mobile cart was placed at a ninety-degree angle in the hallway adjacent to the doorway. Each time one staff member moved to the side, the resident's red-colored tissue and associated bodily drainage became visible from the hallway.
R108's care plan, revised November 27, specifically required keeping her door open "at all times, unless changing brief" due to claustrophobia. The plan stated "Fresh air is very important" and noted the resident "feels Claustrophobic." However, the care plan lacked information about what other privacy options had been attempted or offered.
When interviewed, R108 confirmed she wanted the door open due to severe claustrophobia. She said if anyone saw inside during care, "such was their problem and not mine." R108 stated she lived in a medical care center and "people should expect to see things which may be unsightly," adding "That's reality."
Nobody from the care center had asked or offered other privacy options, R108 told inspectors.
The director of nursing approached during the wound care and questioned why the door would be left open. When asked if it could be closed, the registered nurse manager responded aloud, "She wants it open." R108 then voiced, "I have nothing showing."
Staff later acknowledged the wound tissue would have been "very visible" to passersby. The registered nurse manager admitted "red tissue would have been very visible" and called privacy "a dignity issue for all involved."
Two ceiling-mounted tracks for privacy curtains were installed in R108's room, but no physical curtains hung on them.
Social services staff admitted they "had not thought of" privacy options and said if R108's room had been in a heavier traffic area, "then it would have been addressed." The nurse manager confirmed the facility had portable privacy screens at one time and said turning the mobile cart to cover the door "would be a very easy option."
The facility's privacy policy states it will "safeguard personal privacy" and "protect the resident's privacy regarding medical treatment" and "personal care."
Privacy violations extended beyond wound care. On January 8, inspectors found an unattended medication cart on the second floor containing a patient care sheet with personal information including names, room numbers, preferences, and assistance needs. Six contracted flooring employees were installing laminate in the hallway where the cart sat.
The facility administrator walked by the cart and stated, "This should not be visible. This is private information." The care sheet contained information on 25 residents.
Multiple nurses confirmed care sheets should never be left unattended. "Someone could look at the patient information which they have no business doing," one registered nurse said.
Assessment failures compounded care problems. The facility failed to complete timely quarterly assessments for multiple residents, including R50, whose assessment was overdue by two days when inspectors arrived. Key sections remained incomplete and marked "In Progress."
For resident R108, a completed assessment had entire sections marked as "Not assessed" for cognitive patterns and mood, preventing accurate evaluation of her mental state.
Care planning deficiencies affected daily life for residents with complex needs. R142, who had a prosthetic leg following amputation, told inspectors "the staff doesn't know how to put on my prosthetic leg." He said only two nursing assistants knew the procedure and "nobody knows what they are doing."
R142's care plan, physician orders, and daily instruction sheets made no mention of his prosthetic leg. The physical therapist confirmed training only two staff members on the prosthetic application, despite R142 needing daily assistance.
"I need to tell them what to do," R142 said. He was supposed to walk in the hallway twice daily but this occurred only when the two trained assistants worked.
Another resident, R139, repeatedly expressed wanting to use the toilet instead of incontinence pads. "I don't like to go in my underwear," she told inspectors. Staff never offered toilet use or bedpan assistance, simply changing her pad when soiled.
R139 said she could sense when she needed to urinate and felt confident sitting on a toilet with support. Physical therapists confirmed she could transfer using standing equipment, making toilet use feasible. Her care plan failed to reflect these preferences or abilities.
Basic hygiene suffered from neglect. R47, who had severe cognitive impairment and depended on staff for personal care, was observed over multiple days with fingernails "multiple millimeters in length" containing "visible brown or black-colored debris." His bath audit four days earlier incorrectly indicated nail care was provided and nail beds were clear.
When asked if he wanted his nails clipped, R47 responded "Yea." Staff acknowledged the nails "need to be trimmed" and he "could scratch himself" but had failed to provide routine nail care despite facility policy requiring it.
Activity programming on the short-term care unit left residents isolated. R222, who expressed interest in crafts, beading, and card-making, attended only four activities during her two-month stay. No activity calendar was posted in her room, and staff never offered in-room alternatives despite her initial mobility limitations.
The therapeutic recreation coordinator explained they don't typically program activities on the short-term unit due to poor past attendance, instead expecting residents to attend programs on other floors designed for long-term care residents.
R222 said she would be "receptive" to activities if offered but "nobody ever came and offered any activities to her."
Pressure ulcer prevention failed for residents with previous wounds. R142 reported staff were "supposed to get me up or turn me every two hours, but they don't." He described waiting over an hour to be cleaned after bowel incontinence, raising infection risks for his existing buttock pressure ulcer.
The facility's own policy requires comprehensive, person-centered care plans that "reflect the resident's expressed wishes regarding care and treatment goals." Yet multiple residents' documented preferences went unaddressed, from toilet use to activity participation to basic dignity during medical procedures.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Southview Acres Healthcare Center from 2025-01-09 including all violations, facility responses, and corrective action plans.
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