Deficiency in Resident Room Square Footage
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.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Insufficient bedroom square footage for double occupancy: The facility placed two residents in rooms that measured only 72.265 sq ft per resident, below the required 80 sq ft per resident. Record review showed multiple rooms below the required size, and several unoccupied rooms were available or being used for non-resident purposes. The ADM said the facility knew the rooms were licensed for 2 residents but chose to keep residents in the front halls and did not apply for a room-size waiver; the VCSP said there was no policy for room size requirements.
Resident bedrooms did not meet the required square footage in 16 of 25 rooms. During a floor plan observation, surveyors found multiple 2-, 3-, and 4-bed rooms measuring only 64.92 to 78.40 square feet per resident bed, and the NHA confirmed the rooms were below the required 80 square feet.
Insufficient Room Size in Multiple Occupancy Bedrooms: The facility failed to provide at least 80 sq ft per resident in two double-occupancy rooms occupied by four residents. The Administrator stated several rooms were waivered and did not meet proper room size requirements. Two rooms measured 11 by 14 feet each, totaling 177 sq ft, or 77 sq ft per bed, excluding closets; both rooms contained standard furnishings and residents were present with no concerns voiced.
Insufficient Room Size in Multiple Resident Bedrooms: The facility failed to ensure four semi-private rooms met the required minimum of 80 sq. ft. per resident. The ADM stated the rooms were in an unused area awaiting renovation, but they remained listed on the bed classification form. The ADM also stated the facility had no policy for the room size waiver and confirmed the rooms were not planned to open in the near future.
Insufficient bedroom square footage was identified in four of 27 rooms after surveyors measured multiple-occupancy rooms and found they did not meet the required 80 sq. ft. per resident. The Administrator acknowledged the deficiency, and a resident stated that having fewer residents in the room would make it easier to get in and out. A prior room waiver was requested but could not be provided.
Resident Rooms Did Not Meet Required Square Footage: Based on record review and interviews, 14 of 15 resident rooms inspected did not meet the required square footage per resident for privacy and comfort. The Bed Classification Form showed a 144-bed capacity, and the Administrator stated she was not aware of any room waivers. Measurements identified multiple rooms with less than 80 sq ft per bed, and the Administrator later confirmed the form was accurate and said she could not advise that a waiver request had been submitted previously.
Insufficient Bedroom Square Footage for Double Occupancy
Penalty
Summary
The facility failed to provide rooms that measured at least 80 square feet per resident in multiple resident bedrooms for 2 of 39 rooms reviewed for the physical environment. Record review of the facility document titled ROOMS LESS THAN REQUIRED SQUARE FEET showed rooms 102, 104, 106, 108, 110, 202, 204, 206, 208, 210, 301, 302, 303, 304, 306, 307, 308, 309, 310, 311, 312, 313, 314, 315, 317, and 319 as rooms below the required square footage. Record review of the Residents by Hall document showed the identified rooms were occupied by two residents, while the other rooms on the list were occupied by one resident each. Observation and measurement of the rooms showed room [ROOM NUMBER] measured 15 feet 7.5 inches by 9 feet 3 inches, totaling 144.53 square feet, or 72.265 square feet per resident, and room [ROOM NUMBER] measured the same dimensions and square footage per resident. The ADM stated the facility knew the listed rooms were licensed for two residents but were below 80 square feet per resident, and said the facility chose to admit residents to the front halls first and keep the back of the facility closed until census grew. The ADM also stated the unoccupied rooms could have been occupied, but it was convenient for staff to keep residents physically closer together. The facility had not applied for a room size waiver when the rooms became dually occupied, and the VCSP stated the facility did not have a policy related to room size requirements.
Resident Bedrooms Below Required Square Footage
Penalty
Summary
The facility failed to provide the required 80 square feet of space per resident in 16 of 25 resident rooms. During an observation of the facility floor plan on 6/22/26 at 2:15 p.m., surveyors found multiple rooms with less than the required space per resident bed, including rooms with 2, 3, and 4 beds measuring between 64.92 and 78.40 square feet per resident bed. Specific findings included rooms measuring 72.69, 73.40, 71.37, 69.52, 70.67, 73.70, 74.61, 71.61, 76.52, 77.06, 70.91, 71.90, 66.12, 64.92, 78.40, and 71.56 square feet per resident bed. During an interview on 6/25/26 at 12:02 p.m., the Nursing Home Administrator confirmed that the room sizes were less than 80 square feet as required.
Insufficient Room Size in Multiple Occupancy Bedrooms
Penalty
Summary
The facility failed to provide at least 80 square feet per resident in multiple occupancy resident bedrooms for 4 residents, identified as R9, R10, R19, and R24, in a sample of 25. On 6/5/26 at 10:00 AM, the Administrator stated that dementia unit rooms 23 through 31 and main hall rooms 17 through 22 were waivered rooms and did not meet the proper room size requirements. On 6/5/26 at 10:15 AM, R19 and R24's double occupancy room was observed with the Administrator, who stated the room was less than 80 square feet per resident bed. The room measured 11 by 14 feet, totaling 177 square feet, or 77 square feet per bed, not including the closet. The room contained two beds, two nightstands, a recliner, 2 chests of drawers, a wheelchair, 2 walkers, and 2 over-the-bed tables, and both residents were present with no concerns voiced. On 6/5/26 at 10:25 AM, R9 and R10's double occupancy room was also measured at 11 by 14 feet, totaling 177 square feet, or 77 square feet per bed, excluding the closet. That room contained two beds, a chest, two over-the-bed tables, and two nightstands, and R10 was present and voiced no concerns. An undated facility room roster provided by the Administrator documented that R9, R10, R19, and R24 resided in the waivered rooms that were measured.
Insufficient Room Size in Multiple Resident Bedrooms
Penalty
Summary
The facility failed to provide at least 80 square feet per resident in multiple resident bedrooms for Rooms 407, 602, 604, and 611, which were identified as semi-private rooms for two residents on the Texas Health and Human Services Form 3740 Bed Classifications dated 05/20/26. During the entrance conference on 05/19/26, the ADM stated the facility would need the Texas Health and Human Services Form 3762 Room Size Waiver for several rooms at the facility and explained that the rooms were in a part of the facility not in use and awaiting renovations, but were still listed on the bed classification form. During interview on 05/21/26, the ADM stated the facility did not have a policy for the room size waiver and followed state regulations for room sizes. The ADM later confirmed that Rooms 407, 602, 604, and 611 were still listed on the bed classification form and that the facility did not have plans to open the rooms in the near future. The ADM also stated the long-term goals were to renovate and make sure all rooms were up to date. Measurements taken in the unused rooms showed square footage of 141.81, 155.04, 151.59, and 155.1 square feet, respectively, while the rooms were not occupied.
Insufficient Bedroom Square Footage in Multiple Occupancy Rooms
Penalty
Summary
The facility failed to provide the minimum square footage required by regulation in four of 27 bedrooms. During a concurrent observation and interview with the Administrator, the multiple-occupancy rooms were measured and found to be 315 square feet with 4 resident beds, 286 square feet with 2 resident beds, 286 square feet with 4 resident beds, and 390 square feet with 4 resident beds. The Administrator stated these rooms did not meet the required minimum of 80 square feet per bed for multi-occupancy rooms and acknowledged that this was a deficiency. During an interview, Resident 43 stated that if there were 3 residents in the room it would be easier to get in and out. A copy of a previous room waiver was requested but could not be provided.
Resident Rooms Did Not Meet Required Square Footage
Penalty
Summary
The facility failed to maintain resident rooms with at least 80 square feet per resident in 14 of 15 resident rooms inspected for sufficient space for privacy and comfort. Based on record review and interviews, rooms 101, 102, 103, 104, 105, 106, 107, 401, 403, 404, 405, 406, 408, and 409 did not meet the required space per resident. The Bed Classification Form 3740 dated 02/13/24, completed by the Administrator, indicated the facility had a capacity of 144 beds, and the Administrator stated in interview that she was not aware of any room waivers for the facility. Review of measurements provided by the Life Safety Surveyor and identified by the Maintenance Director showed that the bedrooms allocated for multiple beds were below the required square footage per bed, including rooms 101 through 107 and 401 through 406, as well as rooms 408 and 409. In interview on 05/11/2026, the Administrator stated that the Bed Classification Form 3740 she completed was accurate and that she could not advise that a room waiver request had been submitted by the previous Administrator. The Administrator also stated she would like to apply for a room waiver request for the rooms designated by the Life Safety Surveyor as not meeting room space capacity requirements.
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