Resident Rooms Below Minimum Square Footage Requirement
Penalty
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.