Resident Bedrooms Below Required Square Footage
Penalty
Summary
The facility failed to ensure that two of its resident bedrooms met the required minimum square footage per resident, as specified by federal regulations. Specifically, two multi-bed rooms were found to be below the 80 square feet per resident requirement, and two single-bed rooms were below the 100 square feet requirement. This was identified through a review of the facility's Client Accommodations Analysis form and confirmed by direct measurement during an observation with the Maintenance Supervisor, who acknowledged the rooms were small for two beds and was unaware of the correct measurement standards. The Director of Nursing also confirmed that rooms deemed too small could become cluttered, potentially leading to falls due to insufficient space.
Plan Of Correction
F-tag 912 I: Corrective Action for residents found to have been affected: • On 06/09/2025, the Social Services Director/designee conducted a room visit to residents in rooms 5 and 6. No signs or indications of any adverse effects from being in a room with more than occupancy required. Resident's feel safe, privacy not invaded, and no negative outcomes with care and treatment. Current needs are met. II: Facility's identification of other residents having the potential to be affected by the same deficient practice and corrective action taken: • On 06/09/2025, the Maintenance Director updated the room measurements for all rooms to ensure residents have adequate space for care, access and use of assistive devices and furniture and for visitors. • All other rooms are in compliance. III: Measures and systemic changes put in place to ensure deficient practices do not recur: Application for the room waiver was sent to Feven Isaac on 06/10/2025. Department managers will conduct room rounds daily to ensure resident satisfaction and validate through feedback. IV: Facility's plan to monitor corrective actions are achieve & sustain compliance; Integrate the POC to QA Process: • The Social Services Director/designee will report findings of the daily room rounds during the monthly QAA meeting x 3 months for compliance. • Trends and patterns will be discussed for further recommendations and interventions. • The administrator will monitor compliance. V. Corrective Action Completion Date: 6/12/2025