Resident Rooms Below Minimum Square Footage Requirement
Summary
The facility failed to ensure that 11 out of 41 resident rooms met the required minimum square footage of 80 square feet per resident in multiple resident bedrooms, as specified by federal regulations. During an initial observation, it was found that rooms 105, 108, 116, 201, 203, 205, 207, 212, 214, 218, and 222 did not meet this requirement. The measured square footage for these rooms ranged from 143 to 234 square feet, with several rooms housing two or three residents, resulting in less than the required space per resident. The facility's room waiver documentation indicated that these rooms were considered adequate for resident needs and did not adversely affect health and safety, but the actual measurements did not comply with the regulatory standards. Interviews with nursing staff, including a CNA, RNA, and LVN, revealed that they believed there was sufficient space in the rooms to provide care and for residents to move around safely, including those using wheelchairs. Additionally, residents interviewed did not express concerns about the size of their rooms. Despite these observations and staff and resident feedback, the deficiency was cited based on the objective measurements of room size not meeting the federal requirements.
Plan Of Correction
Immediate Corrective Action A request for room waiver was submitted to the CDPH Surveyor Team on 6/9/25 for the following rooms which have less than 80 square feet for multiple residents in a room: 105, 108, 116, 201, 203, 205, 207, 212, 214, 218, and 222. Corrective Action for Others Affected The granting of waiver request will not adversely affect the resident's health and safety and is in accordance with the special needs of the residents. A completed Facility Client Accommodations Analysis indicates all other rooms met the required measurement. Measures Taken to Prevent Reoccurrence Starting 7/01/25, the department heads will conduct Angel Rounds on a daily basis to ensure that the space available for the residents in the affected rooms is sufficient to provide care, provide privacy, and provide adequate space for patient care equipment and personal items. Performance Monitoring Starting 7/01/25, all findings will be presented by the administrator during the monthly QAPI Meeting for the next 3 months to ensure total compliance is achieved.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
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.
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.
Shared rooms did not provide the required 80 SF per resident in 23 rooms. A census report showed multiple rooms with three residents or capacity for three residents, and a tour confirmed the room arrangements. The DON stated bed management meetings did not address moving residents to meet the space requirement, and the administrator said current residents were not informed when a bed opened unless they requested a room change. One room measured 230 SF, providing 76.67 SF per resident when occupied by three residents, and a resident stated more space would be helpful for belongings and movement.
A facility failed to ensure 14 of 33 resident rooms met the required 80 sq ft per resident for multiple-bed rooms. Although the ADM requested a room waiver and staff, residents, and the ADON, DON, DOR, and ADOR stated there was enough room for care, movement, ADLs, and therapy, the Client Accommodation Analysis showed several three-bed rooms measured only 72.1 to 79.8 sq ft per resident, below the required standard.
The facility failed to ensure that 13 single resident rooms on the A-wing met the required 100 sq ft of usable floor space, and 6 occupied rooms were identified as noncompliant. The DON confirmed the rooms did not meet the standard, while an RN reported no resident complaints about room size and the Administrators stated they had no requests for room moves or complaints from current residents. One resident said staff care was not inhibited by the room size, and the facility reported it had previously moved a resident to a larger room for family visiting needs.
The facility failed to meet regulatory and policy requirements for minimum usable living space in multi-occupancy resident rooms. Policy required at least 80 sq ft of usable floor space per resident in semi-private rooms, but surveyor measurements of multiple bed areas in two rooms, conducted with the maintenance director, DON, and later the administrator, showed bed spaces ranging from about 47 to 75.33 sq ft, even when adjacent common areas were included. The administrator confirmed that these room sizes were below the required minimum.
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.
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.
Shared Rooms Did Not Provide Required Floor Space
Penalty
Summary
The facility failed to ensure shared resident rooms had at least 80 square feet per resident in 23 rooms identified as 101, 102, 107, 108, 109, 208, 212, 213, 214, 215, 216, 217, 301, 302, 307, 308, 309, 312, 313, 314, 315, 316, and 317. A Room Assignment and Census Report dated 4/13/26 showed a census of 64 and identified rooms with current residents and open beds that would be occupied by three residents when full. The report indicated three rooms already housed three residents, two rooms were empty and could take two residents, and five rooms had one resident and could take a second resident. A tour on 5/5/25 verified the listed rooms either had three residents or could accommodate three residents if needed. During interview, the DON stated there had been no discussion in weekly bed management meetings about moving residents to meet the 80 square foot per resident requirement. The DON reviewed the census report and confirmed there were two completely empty rooms and five rooms with only one resident. The maintenance supervisor measured one room at 230 square feet, which provided 76.67 square feet per resident when divided among three residents, and stated all rooms had the same square footage. Observation of room [ROOM NUMBER] showed R25 had belongings on the floor from the back wall to the foot board of the bed and from the side of the bed to the curtain separating him from the roommate in the middle. R25 stated he was not sure why the facility had three residents to a room and said more space would be nice for belongings and movement. The administrator stated the facility discussed behaviors, incident reports, and possible admissions in weekly bed management meetings, but did not discuss moving residents when a bed opened to provide at least 80 square feet of living space. The administrator also stated new admissions were told the room size was less than 80 square feet, but current residents in three-person rooms were not told when a bed opened unless they noticed an open room and requested a bed change.
Insufficient Space in Multiple-Resident Rooms
Penalty
Summary
The facility failed to ensure 14 of 33 residents' rooms met the required space standard of at least 80 square feet per resident in multiple-bed rooms. During review of the facility's room waiver request letter dated 4/29/2026, the Administrator requested a waiver for multiple rooms listed on the Client Accommodation Analysis form, stating the rooms had no projections or obstructions that would interfere with wheelchair movement, that there was enough space for care, dignity, and privacy, and that the rooms would not adversely affect residents' health and safety. The waiver request covered rooms with three-bed capacities, and the facility stated the rooms were in accordance with the special needs of the residents. During interviews, CNA 1, Resident 73, Resident 83, CNA 2, LVN 3, the ADON, the DOR, the ADOR, the DON, and the ADM all stated there was enough room in the rooms for care, movement, ADLs, and therapy. However, the concurrent observation and review of the Client Accommodation Analysis dated 4/29/2026 showed the listed rooms measured below the required square footage per resident, ranging from 72.1 to 79.8 square feet per resident in rooms with three beds. The analysis indicated that a three-bed room required at least 240 square feet total, and the Department recommended continuation of the room waiver request.
Insufficient Room Size in A-Wing Single Resident Rooms
Penalty
Summary
The facility failed to ensure that 13 single resident rooms on the A-wing had at least 100 square feet of usable floor space for 6 residents who were occupying those rooms, including A24, A25, A27, A33, A35, and A36. During the entrance conference, the DON confirmed the rooms in hallway A did not meet the required square footage. During the initial screening on the A-wing, those rooms were observed to be occupied by residents. In interviews, one resident stated that staff care was not inhibited by the room size, and an RN reported she was not aware of any resident complaints related to room size. The Administrators stated they had no requests for room moves or complaints that rooms were too small from current residents, and they reported they would accommodate any resident request for more space as allowed. The facility also reported that it had previously moved a resident to a larger room at family request so a large family could visit together. A policy on room size was requested but not received.
Failure to Provide Required Minimum Square Footage in Multi-Occupancy Rooms
Penalty
Summary
The facility failed to ensure that multi-occupancy resident bedrooms provided at least 80 square feet of usable living space per resident, as required by facility policy and 28 Pa. Code: 205.20(f). The facility’s written policy, last revised November 1, 2025, specified that semi-private resident rooms must provide a minimum of 80 square feet of usable floor space per resident. During an observation and measurement process conducted with the maintenance director and the DON, multiple beds in two reviewed rooms were measured and found to be below this standard. Initial measurements showed bed spaces ranging from approximately 47.12 to 65.8 square feet, excluding toilets, bath areas, closets, lockers, wardrobes, alcoves, and vestibules. After these findings were reviewed with the DON and the Administrator, the Administrator requested that the rooms be remeasured to verify the results and to determine whether any alcoves or vestibules could be counted as usable living space. A second set of measurements was then conducted with the maintenance director and the Administrator present. These remeasurements included additional common area space before entering the rooms where applicable, but the total square footage per bed still ranged only from approximately 70 to 75.33 square feet, remaining below the required 80 square feet per resident. The Nursing Home Administrator confirmed that the room sizes did not meet the minimum square footage requirement.
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