Deficiency in Resident Room Square Footage
Penalty
Summary
The facility failed to meet the regulatory requirements for minimum square footage in resident rooms, as observed on January 14, 2025. Specifically, one single-bedded resident room measured only 85 square feet, falling short of the required 100 square feet. Additionally, eight two-bedded resident rooms were found to have only 143 square feet each, which does not meet the minimum requirement of 160 square feet for semi-private rooms. These deficiencies were identified in rooms 15, 16, 17, 18, 19, 20, 21, and 23, indicating a significant shortfall in compliance with the space requirements outlined in CFR 483.90(d)(1)(ii) and 28 Pa. Code: 205.20 (d)(f).
Plan Of Correction
This situation poses no threat to the safety or well-being of the residents in these rooms; therefore, the facility has requested a waiver continuation of 42CFR 428.70 (d) (1) (ii) by previously submitted letter. Please note that the facility meets the variation in square footage requirements adopted by the Commonwealth of Pennsylvania at 28 PA Code section 205.20 € and 205.30 (g). The facility is selective in room placement and considers residents' needs and safety when assigning rooms. This facility remains committed to assuring the special needs of the residents in these rooms are met to ensure that their health and safety are not adversely affected. If a resident or family member requests a room change, the facility makes every effort to place the resident in a different room. NHA or designee will discuss room change requests at the Interdisciplinary Team meeting. NHA or designee will audit resident Council meeting minutes to ensure concerns regarding room placement are addressed monthly x 6 months. The results of the audit will be reviewed by the QAPI Committee for review and analysis of need for ongoing monitoring.