The privacy violation at Arlington Residence and Rehabilitation Center became worse when staff discovered the resident's room was missing its privacy curtain entirely. Federal inspectors found the August incident violated the resident's fundamental right to dignity during personal care.
RN A admitted to investigators she "forgot" to close the door while examining Resident #1's briefs. She told inspectors she "normally closed the door when checking the resident's briefs, and she forgot this time."
The nurse said she was "checking Resident #1's brief quickly" and waiting for the assistant director of nursing to bring gloves to the room. She explained they had no gloves on the resident's side of the room and had asked maintenance to stock them, "but he had not done so yet."
CNA B was also present during the privacy breach but failed to close the door.
When inspectors asked about the missing privacy curtain, RN A said she "was not sure why Resident #1 did not have a privacy curtain." She promised to notify laundry to install one.
Assistant Director of Nursing C confirmed she had just delivered gloves to the resident's room because staff said there were none available. She placed "one full box of large and one full box of medium gloves" in the room after RN A and CNA B requested them.
The facility's administrator acknowledged the severity of the privacy violation when interviewed that evening. She told inspectors "the privacy curtains should cover residents, even if their briefs were being checked" and said she hoped proper procedures were being followed.
"It could affect the residents who got their briefs checked may not like being seen by anyone passing their rooms," the administrator said. "Some residents may care and some may not."
She placed responsibility squarely on the nursing staff: "The person providing care was responsible and DON ultimately for ensuring the residents had privacy for personal care including checking the resident's briefs."
The administrator said she was unaware of the missing privacy curtain and would need to contact the laundry department about installing a replacement. She had no reports explaining why the curtain was missing from Resident #1's room.
She outlined proper procedures that staff had failed to follow: "Before touching a resident the nursing staff needed to talk to the resident to let them know what they were about to do and to provide them privacy."
The supply shortage that contributed to the privacy breach reflected broader operational failures. The administrator said nursing staff "needed to look to see if they had gloves in the room before they started" providing care.
"The CNAs, nurses and Central Supply were supposed to look to see what supplies they were out of and replenish it, to prevent having to open the door during resident care," she explained.
The facility's own Resident Rights policy, dated 2025, explicitly states that residents have "the right to a dignified existence." The policy requires staff to inform residents of their rights both orally and in writing.
Federal inspectors classified the violation as causing "minimal harm or potential for actual harm" affecting "few" residents. But the incident exposed systematic failures in basic privacy protections during intimate care.
The privacy breach occurred despite clear facility policies requiring dignity during personal care. Staff left a resident exposed during one of the most vulnerable moments in long-term care — the checking of adult briefs — while they waited for basic supplies that should have been readily available.
RN A's admission that she "forgot" to close the door, combined with the missing privacy curtain and absent supplies, created a perfect storm of dignity violations. The resident remained exposed to hallway traffic during intimate care that should have been completely private.
The administrator's evening interview revealed she learned about the incident hours after it occurred, raising questions about immediate reporting and supervision during personal care procedures.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Arlington Residence and Rehabilitation Center from 2025-08-29 including all violations, facility responses, and corrective action plans.
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