Resident Bedrooms Below Required Square Footage
Penalty
Summary
The facility failed to ensure that resident bedrooms met the required minimum square footage as specified by federal regulations. Specifically, 33 multi-resident rooms measured less than 80 square feet per resident, and two single-resident rooms measured less than 100 square feet. This was confirmed through a review of the facility's Client Accommodation Analysis form, which listed the square footage of each room, and through interviews with the Maintenance Director and Administrator, both of whom acknowledged awareness of the room size deficiencies. The Administrator also referenced an approved room waiver dated 2025. Observations conducted during the survey period indicated that residents had sufficient space to move freely within their rooms, and there were no complaints from residents or staff regarding room size. Each resident had a bed and side table, and there was adequate space for mobility aids such as walkers, canes, wheelchairs, and shower chairs. The facility's policy and procedures required compliance with the minimum square footage standards, but the actual room sizes did not meet these requirements.
Plan Of Correction
Bedrooms Measure at Least 80 Sq Ft/Resident How Corrective Action(s) will be accomplished for those residents found to have been affected by the deficient practice: On 6/19/25, the facility submitted a formal request for recognition of variation of room space for recertification. (Exhibit #38) How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: - All residents have the potential to be affected by the deficient practice. - Social Services Director will monitor residents for comfort and offer recommendations or alternatives if needed, upon admission, room change, quarterly after admission, annually after admission, and as needed. What measures were put into place or what systematic changes the facility will make to ensure that the deficient practice does not recur: - Social Services Director will monitor residents for comfort and offer recommendations or alternatives if needed, upon admission, room change, quarterly after admission, annually after admission, and as needed. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system: - Administrator will report findings and trends to QA committee meeting on a monthly basis for 3 months then quarterly thereafter. Date of completion: June 20, 2025 How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: - All residents have the potential to be affected by the deficient practice. - Social Services Director will monitor residents for comfort and offer recommendations or alternatives if needed, upon admission, room change, quarterly after admission, annually after admission, and as needed. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system: - Administrator will report findings and trends to QA committee meeting on a monthly basis for 3 months then quarterly thereafter. Date of completion: June 20, 2025