Non-Compliance with Resident Room Capacity Regulations
Summary
The facility failed to comply with federal regulations by accommodating more than four residents in five of its rooms, specifically rooms 32, 33, 34, and 35, each containing six beds. This was observed during a survey conducted on October 21, 2024. The Director of Nurses (DON) acknowledged the non-compliance and mentioned that the facility had a Room Variance Waiver in place and intended to request an additional waiver. Despite the waiver, the facility's policy from May 2017 stated that all resident rooms should accommodate no more than two residents, indicating a discrepancy between practice and policy. During observations and interviews with residents in the affected rooms, it was noted that residents did not express concerns about the space or their ability to move around. Residents reported being able to ambulate without difficulty and having enough space for their belongings. However, the facility's Client Accommodations Analysis confirmed the presence of more than four residents per room, and the facility's request for a room waiver indicated that the current arrangement did not adversely affect residents' health, safety, or well-being. The facility also outlined measures to ensure residents' needs were met, such as ensuring wheelchair accessibility and space for visitors and personal belongings.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Surveyors found that a room contained five beds, exceeding the maximum allowed occupancy of four. Although only four residents were present and both residents and staff reported sufficient space for care and mobility, the room setup did not comply with regulatory requirements.
Surveyors found that several rooms in the facility housed more than four residents per room, with some rooms containing five or six beds and being fully occupied. Although residents reported no concerns about space and rooms were equipped with necessary furniture and equipment, the facility did not comply with federal regulations limiting room occupancy.
A room was found to house more than four residents, exceeding regulatory limits. The room was divided by a wall with two beds on one side and three on the other, but only had a single entry/exit door, making it a single room with five residents. Interviews and observations confirmed that residents and staff had sufficient space and no concerns about care or privacy, but the room did not meet occupancy requirements.
Two rooms were found to house five residents each, surpassing the regulatory limit of four residents per room. Staff interviews indicated no reported issues with providing care, even with several residents using wheelchairs and one requiring a lift. Facility policy stated a maximum of two residents per room, but this was not followed for the affected rooms.
Two resident rooms were found to contain six beds each, exceeding the federal limit of four residents per room. Despite facility documentation and observations indicating sufficient space and freedom of movement for residents and staff, the rooms did not comply with occupancy regulations.
Two rooms were found to exceed the regulatory limit of four residents per room, with one room housing seven beds and another five beds. Observations and interviews with a resident and a CNA indicated that there was adequate space for care and movement, and all residents had privacy curtains, call-lights, dressers, and bedside tables.
Room Exceeded Maximum Resident Occupancy
Penalty
Summary
The facility failed to ensure that one of its resident rooms did not accommodate more than four residents, as required by regulations. During an initial tour, surveyors observed that room [ROOM NUMBER] contained five beds, although only four residents were present at the time of observation. The facility had previously submitted a waiver request to the Department of Public Health, stating that the room had ample space for wheelchairs, medical equipment, and resident mobility, and that it did not impede the ability of residents to achieve their highest practicable wellbeing. Interviews with two residents in the room revealed that they did not have complaints regarding the available space. Throughout the survey period, nursing staff were observed to have full access to provide care, administer medications, and assist residents with activities of daily living. Despite these observations and the facility's waiver request, the presence of five beds in the room constituted a failure to comply with the requirement that no more than four residents occupy a room.
Resident Rooms Exceed Maximum Occupancy Requirements
Penalty
Summary
The facility failed to ensure that resident bedrooms accommodated no more than four residents per room, as required by federal regulations. During a recertification survey, it was observed that eight rooms contained either five or six beds, with several of these rooms fully occupied. The Client Accommodation Analysis and direct observations confirmed that these rooms exceeded the maximum occupancy limit. The surveyors noted that all rooms in question had individualized beds, bedside tables, overbed tables, and resident care equipment, and residents did not report concerns about room size or space during interviews. Despite the presence of adequate space for beds and equipment, the facility's practice of housing more than four residents per room in multiple-resident rooms did not comply with federal requirements. The facility had submitted a waiver letter and had policies in place for management to observe and ensure rooms met residents' needs without adversely affecting health and safety. However, the survey findings indicated that the number of beds and occupants in these rooms exceeded the regulatory limit, constituting a deficiency.
Room Occupancy Exceeds Regulatory Limit
Penalty
Summary
The facility failed to ensure that one of its rooms did not exceed the maximum occupancy of four residents per room, as required by regulations. Specifically, the room in question was separated by a wall into two sections, with two beds on one side and three beds on the other, but only had a single door for entry and exit, effectively making it a single room with five residents. This arrangement was confirmed through observation, interviews, and record review, including a review of the facility's room waiver, which acknowledged the configuration and the number of residents in the room. Interviews with the administrator, residents, and nursing staff confirmed the presence of more than four residents in the combined room. Despite the room's size and the ability for residents and staff to move freely and provide care, the room did not meet the regulatory requirement for maximum occupancy. The residents and staff did not express concerns about space, privacy, or the ability to provide care, and observations indicated that the room's configuration did not adversely affect health or safety at the time of the survey.
Exceeding Maximum Resident Occupancy in Shared Rooms
Penalty
Summary
The facility failed to comply with federal requirements limiting the number of residents per room, as two rooms were found to house five residents each, exceeding the maximum of four residents per room. This was identified through observation, interviews, and record review, including the facility's Census List and Client Accommodation Analysis Form, which confirmed the presence of five residents in each of the two rooms. The rooms in question provided between 71.536 and 76.964 square feet per resident. The facility had submitted a waiver request, stating that the rooms had no obstructions and sufficient space for care, dignity, and privacy, but the actual occupancy exceeded regulatory limits. Interviews with staff, including a CNA and an LVN, indicated that they did not experience issues providing care in these rooms, even with multiple residents using wheelchairs and one resident requiring a lift machine. The facility's policy and procedure, last reviewed in July 2024, stated that bedrooms should accommodate no more than two residents at a time, which was not followed in these instances. All ten sampled residents in the affected rooms were impacted by this deficiency.
Resident Rooms Exceed Maximum Occupancy Requirement
Penalty
Summary
The facility failed to comply with federal regulations requiring that resident rooms accommodate no more than four residents per room. During observations, interviews, and record reviews, it was found that two resident rooms each contained six beds, exceeding the allowable maximum. The facility had submitted a Request for Room Size Waiver, indicating that these rooms had six beds and asserting that the room sizes would not interfere with daily nursing care, safety, or residents' dignity and privacy. The waiver letter also stated that the space would not adversely affect residents' health and safety or impede their well-being. A review of the Client Accommodations Analysis confirmed that the two rooms in question measured 466 and 475 square feet, respectively, with each resident having approximately 77.6 square feet of space. Observations during the survey period noted that residents in these rooms had ample space to move freely, and there was sufficient room for beds, side tables, and care equipment. Despite these observations, the rooms did not meet the federal requirement limiting occupancy to four residents per room.
Non-Compliance with Resident Room Occupancy Limits
Penalty
Summary
The facility failed to ensure that two rooms did not accommodate more than four residents, as required by regulations. Review of the facility's room waiver request letter indicated that these rooms exceeded the four-bed limit, with one room containing seven beds and another containing five beds. The waiver letter stated that the rooms had adequate space for each resident and that the arrangement would not adversely affect residents' health and safety. Observations confirmed that each resident had privacy curtains, working call-lights, a dresser, and a bedside table. During multiple observations, nursing staff were seen providing care with adequate space in the affected rooms. Interviews with a resident and a CNA revealed that neither had concerns about the available space, and both felt there was sufficient room for movement and care activities. Despite these observations, the rooms did not comply with the regulation limiting occupancy to four residents per room.
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