Facility Fails to Meet Room Size Requirements Despite Waiver
Summary
The facility failed to provide the required square footage of 80 square feet per resident in multiple resident bedrooms for 19 rooms out of 86 in the facility. This deficiency affected 29 residents in the total sample of 75 residents. During the entrance conference, the Administrative Consultant mentioned that the facility has an annual waiver for room sizes, which is renewed every year. The Associate Administrator confirmed that some rooms have less than the required square footage for each resident, but stated that all required furnishings and equipment are provided. The facility has an annual waiver from the State Department of Public Health, allowing them to bypass the federal requirement for room size under 42 CFR 483.90. This waiver is granted for specific rooms and is subject to annual review. The facility's policy on Resident Room Waivers indicates compliance with both IDPH and CMS federal requirements for these waivers. The waiver covers the rooms identified in the report, which do not meet the 80 square feet per bed requirement in multi-patient rooms.
Penalty
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Surveyors found that two three-bed rooms in a secure unit were undersized, providing only about 73–74 sq ft per resident instead of the required 80 sq ft. Facility records classified several rooms as three-bed rooms, but the Administrator lacked documentation authorizing three beds and acknowledged the 80 sq ft per-resident requirement. The Maintenance Director measured the rooms, confirmed the insufficient space, and reported being unaware of the exact square footage requirement, noting potential risks such as falls, trips, clutter, and limited evacuation space.
The facility did not ensure that multiple-occupancy rooms met the minimum 80 square feet per resident requirement, despite housing two residents in several rooms identified as undersized. A CMS census form documented the total number of residents, and a state health department letter granted a waiver for specific rooms, subject to annual review. The administrator acknowledged that certain rooms were below the required size, provided a floor plan listing these rooms, and stated that the waiver is submitted annually while confirming that two residents are placed in these waived rooms and that any resident may be assigned there with a roommate.
A resident room that was converted from a physical therapy space to a four-bed room did not meet the required 80 square feet per resident, and no waiver was obtained for this deficiency. The room's limited space contributed to a resident tripping and falling while moving toward the bathroom, and staff confirmed the room was not included in the facility's approved waiver list.
Three bedrooms were found to house three residents each, but did not meet the required 80 square feet per resident, with actual space ranging from 65.9 to 79.6 square feet per person. Affected residents reported insufficient space for movement and personal activities, and the administrator confirmed no recent changes to room configurations.
Surveyors found that 58 rooms did not meet the required minimum square footage for resident occupancy. All rooms were intended for two residents, but measurements showed they were below the regulatory standard, with some rooms housing one or two residents and one room unoccupied. The NHA confirmed the deficiency during the survey.
The facility did not provide the required minimum of 80 square feet per resident in several multiple occupancy rooms, with some rooms offering as little as 49.5 to 70 square feet per resident. Despite this, interviews and observations indicated that space was adequate for belongings and care, and no complaints were reported.
Noncompliant Room Square Footage in Multi-Occupancy Rooms
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet per resident in two multiple-occupancy rooms. Form 3740 Bed Classifications, signed by the Administrator, listed rooms #311, #312, #313, #314, #315, and #316 as three-bed rooms. During surveyor review, rooms #311 and #314 in the secure unit were measured by the Maintenance Director and found to be approximately 220–221.3 square feet each, which equated to about 73–74 square feet per resident when occupied by three residents. The Administrator acknowledged that each resident was required to have 80 square feet and that these rooms did not meet that standard. During interviews, the Administrator stated she did not have documentation showing that three beds were allowed in these rooms and reported that the corporate office had previously informed her that a waiver was not needed. The Maintenance Director reported being unsure of the required amount of space per resident and stated that no concerns had been brought to her about room size or number of beds. She identified that risks associated with inadequate space could include falls, trips, clutter, and insufficient space for evacuation. These observations, interviews, and record reviews established that rooms #311 and #314 did not meet the minimum square footage requirement per resident.
Noncompliance With Minimum Square Footage Requirements in Multiple-Resident Rooms
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Summary
The facility failed to ensure that multiple-resident rooms provided at least 80 square feet per resident, as required, affecting rooms that could house 31 residents. The CMS Form 671 dated 1/4/26, signed by the Administrator (V1), documented that 53 residents resided in the facility. An Illinois Department of Public Health letter dated 4/1/2025 granted a waiver for specific rooms (107-112, 115-119, 201-209, 301-306, 307-311), with the waiver subject to annual review or review at any time the facility did not meet the conditions under which it was granted. During an interview on 1/4/26, the Administrator acknowledged that the facility had rooms that did not meet the 80 square feet per resident requirement and provided a floor plan highlighting rooms 107, 108, 109, 110, 111, 112, 115, 116, 117, 118, 119, 201, 202, 203, 204, 205, 206, 207, 208, 209, 301, 302, 303, 304, 305, 306, 307, 308, 309, 310, and 311 as being under the required size. On 1/5/26, the Administrator further stated that the waiver is sent every year to the State Agency and confirmed that the facility places two residents in the rooms covered by the waiver and that any resident could be moved into those rooms with a roommate. No additional resident-specific medical histories or clinical conditions were documented in relation to this deficiency, and the report focused on the room size measurements, the existence of the waiver, and the Administrator’s statements about room occupancy and use of the waived rooms.
Resident Room Fails to Meet Minimum Size Requirement
Penalty
Summary
The facility failed to ensure that one of its resident rooms, Room A, met the required minimum size of 80 square feet per resident in a multiple occupancy room or to obtain an approved waiver for the deficiency. Room A, previously used as a physical therapy room, was converted to accommodate four residents, but measured only approximately 284.75 square feet, which is less than the required 320 square feet for four residents. The facility's documentation and interviews confirmed that Room A was not included in the list of rooms with approved size waivers, and no waiver request had been submitted for this room in the current year. The facility's policy also requires that resident rooms meet the minimum square footage per resident. During interviews and observations, it was noted that the limited space in Room A contributed to challenges in resident mobility and safety. One resident described an incident where she tripped over a rolling tray table while navigating the cramped space between beds and the bathroom, resulting in a fall. Staff interviews further confirmed that the room's size was insufficient for its current use, and the Director of Nursing acknowledged the importance of adequate space for residents to perform activities of daily living safely and comfortably.
Failure to Meet Minimum Room Size Requirements for Multiple Residents
Penalty
Summary
The facility failed to provide the required minimum square footage per resident in three multi-resident bedrooms, affecting nine residents. Observations revealed that each of these rooms housed three residents but measured less than the mandated 80 square feet per resident, with actual measurements ranging from 65.9 to 79.6 square feet per person. Interviews with affected residents indicated dissatisfaction with the available space, with one resident stating there was not enough room to move around and another expressing difficulty engaging in personal activities such as crafting due to limited space. The administrator confirmed that no changes or updates had been made to the rooms since the previous survey.
Resident Rooms Below Required Square Footage
Penalty
Summary
The facility failed to provide resident rooms that meet the required minimum square footage, as determined by observation, interview, and record review. Specifically, 58 resident rooms were identified as not meeting the standard of at least 80 square feet per resident in multiple occupancy rooms and 100 square feet for single occupancy rooms. Measurements of the rooms showed that all were intended for two residents, but their sizes varied and consistently fell below the required square footage. The Nursing Home Administrator confirmed that 18 rooms had two residents, 39 rooms had one resident, and one room was unoccupied, but all were designed for double occupancy and did not meet the regulatory requirements for space.
Failure to Meet Minimum Square Footage Requirements in Resident Rooms
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet per resident in multiple resident bedrooms, as observed and confirmed through interviews and record review. Specifically, rooms 14, 15, 12, 16, 17, 18, 19, 20, 21, and 22 were identified as not meeting this standard, with some rooms having as little as 49.5 to 70 square feet per resident, and one room with 4 beds providing only 68.5 square feet per resident. Despite these deficiencies, observations and interviews conducted during the survey period indicated that there was adequate space for residents' belongings and for caregivers to provide care, and no complaints were reported by residents or staff regarding room space.
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