Failure to Meet Room Size Requirements
Summary
The facility failed to ensure that all multiple-resident bedrooms provided at least 80 square feet per resident for 16 out of 22 resident rooms observed. The facility's policy, revised in July 2023, mandates that each resident in a multiple-resident bedroom should have at least 80 square feet of space. However, a review of the Client Accommodations Analysis form dated April 12, 2024, revealed that several rooms did not meet this requirement, with some rooms providing as little as 71.7 square feet per resident. Despite this, observations during the recertification survey indicated that the room sizes did not restrict the provision of care, and residents did not voice any concerns regarding their space or room size. Maintenance staff confirmed the measurements, and the Director of Nursing and the Administrator both stated that the facility had a room size waiver for these rooms. During interviews, the Director of Nursing and the Administrator emphasized that staff were expected to respect resident privacy and ensure comfort despite the smaller room sizes. The Administrator also mentioned that staff were mindful of equipment needs to ensure that the room sizes did not impact the residents' quality of life. However, the facility's failure to comply with the required room size standards constitutes a deficiency, as it did not meet the regulatory requirements for resident living space.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.



