The incident occurred at Creekside Village on September 26 when CNA A entered the resident's room at 11:30 AM to change her heavily soiled brief. The resident's roommate was sitting in a recliner chair on the left side of the bed as the aide transferred the woman from her wheelchair and began removing her urine-soaked pants and undergarments.
The resident, identified only as a woman in her 80s, suffers from complete paralysis on one side of her body following a stroke, along with epilepsy, anxiety and an overactive bladder. Despite these conditions, her cognitive function remains intact with a perfect score on mental status testing.
CNA A acknowledged the violation immediately after the incident. "She should have pulled Resident #1's privacy curtains when providing care," the aide told inspectors 15 minutes later. "She was nervous and therefore made a mistake."
The aide had worked full-time at the facility for over two years on the 6 AM to 6 PM shift.
The resident herself expressed clear preferences about privacy during such care. "When she was being provided with incontinent care, she preferred that the staff pulled her curtain for her privacy," she told inspectors four days later. "It was important to pull her privacy curtain because she never knew when someone might come into the room leaving her exposed."
She said if someone saw her during such moments, "she would be embarrassed."
The facility's Director of Nursing confirmed that privacy curtains should be pulled during all resident care, including incontinence care, "due to most of the residents having roommates." The DON said pulling curtains "not only promotes resident dignity, but it also promotes a sense of security."
Creekside Village's own policy on resident rights, dated February 2021, states that "employees shall treat all residents with kindness, respect, and dignity."
The violation occurred during a complaint investigation by state inspectors who observed five residents receiving personal care. Only one resident experienced the privacy breach.
The resident had been admitted to Creekside Village twice, most recently in May 2024. Her comprehensive care plan, revised in August, specifically addressed her bladder incontinence issues.
Federal inspectors classified the violation as causing "minimal harm or potential for actual harm" but noted it placed residents at risk for "loss of dignity, respect, and psychological distress."
The incident highlights ongoing challenges nursing homes face in maintaining basic dignity standards during intimate care procedures. For residents like this woman, who retain full mental capacity despite severe physical limitations, such breaches can cause lasting psychological impact.
The resident's medical complexity required careful attention during transfers and personal care. Her combination of complete paralysis on one side, partial weakness, seizure disorder and anxiety made her particularly vulnerable during care procedures.
CNA A's admission that nervousness caused the mistake raises questions about training and supervision protocols for staff providing intimate care to vulnerable residents. The aide's two years of experience at the facility suggested familiarity with proper procedures.
The roommate's proximity during the incident, sitting in a recliner chair directly beside the bed where the care occurred, made the privacy violation particularly egregious. The layout required only a simple curtain pull to provide appropriate screening.
State inspectors found that few residents were affected by privacy violations during their review, suggesting this was an isolated incident rather than systemic practice. However, the resident's own statements about preferring privacy and fearing embarrassment indicate she had experienced proper curtain use during previous care episodes.
The violation underscores the importance of maintaining dignity standards even during routine care procedures that staff perform multiple times daily. For residents maintaining cognitive awareness while dealing with physical limitations and incontinence, privacy protection becomes essential to psychological well-being.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Creekside Village from 2025-12-01 including all violations, facility responses, and corrective action plans.