Resident Bedrooms Below Required Square Footage
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
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Resident rooms failed to meet required square footage standards for 2 of 10 rooms reviewed. One room certified for 4 residents measured 74 sq ft per resident, and a private room measured 81 sq ft instead of 100 sq ft. Surveyors observed no residents in the rooms, and the ADM said she was unaware of current room waivers, noted one room was being used as a staff break room, and could not find paperwork showing a waiver had been filed.
Insufficient bedroom square footage for double occupancy: The facility placed two residents in rooms that measured only 72.265 sq ft per resident, below the required 80 sq ft per resident. Record review showed multiple rooms below the required size, and several unoccupied rooms were available or being used for non-resident purposes. The ADM said the facility knew the rooms were licensed for 2 residents but chose to keep residents in the front halls and did not apply for a room-size waiver; the VCSP said there was no policy for room size requirements.
Resident Room Size Deficiency: An observation with the Maintenance Director found 4 of 17 sampled resident rooms did not meet the required square footage per resident. One room occupied by two residents measured 137.04 sq. ft. total, two rooms occupied by four residents each measured 260.6 sq. ft. usable space, and one room occupied by five residents measured 158.63 sq. ft. total. The Administrator stated prior inspections had not cited the issue and asked that the room size issues be grandfathered in.
Insufficient Resident Room Square Footage: The facility failed to provide the required 80 sq ft per resident in all 48 resident rooms. Surveyors reviewed the bed classification form, measured the rooms with a laser device, and found that the 2-bed rooms measured 151 to 160 sq ft and the 3-bed rooms measured 219 to 234 sq ft, which did not meet the required space per resident. The ADM provided a waiver request and stated there had been no changes to the rooms.
Resident rooms 107, 108, 110, 302, 305, 306, and 307 did not meet the required square footage standards for multiple-occupancy rooms. Census review showed each room had 2 beds, and repeated observations confirmed the rooms remained set up with 2 beds each. The Administrator stated an exemption had been requested from the state but had not yet been granted.
Bedroom Space Requirements Not Met in Multiple Occupancy Rooms: Multiple resident rooms were measured below the required 80 square feet per resident, with several rooms ranging from 61.9 to 79.3 square feet per resident. The Administrator stated a room waiver was in effect and that the room measurements had not changed. Record review showed the waiver criteria were met for the identified rooms, and 21 residents were living in most of those rooms during the annual survey.
Resident Rooms Did Not Meet Required Square Footage
Penalty
Summary
The facility failed to ensure that resident rooms measured at least 80 square feet per resident in multiple resident rooms and at least 100 square feet in a single resident room for 2 of 10 resident rooms reviewed for square footage. One room certified for 4 residents measured 74 square feet per resident, and one room certified as a private room measured 81 square feet instead of 100 square feet. The report also states that room [ROOM NUMBER] was used as a staff break room, and no residents were residing in the rooms at the time of observation. During observation, surveyors noted that no residents were residing in the rooms in question. During interview, the Administrator said she was not aware the facility had any rooms with room waivers and stated she had been at the facility about a week. She was informed that the rooms had room waivers in previous years and that the rooms still required waivers. She also said she had not found any physical papers indicating a room waiver had been filed last year and stated she had been told by life safety code that she only needed to indicate on the plan of correction that she was requesting the waiver and that there should be no end date so it would continue indefinitely. Record review of the bed classification form dated 07/13/2026 indicated one room was certified for 4 residents and another room was certified for 1 resident.
Insufficient Bedroom Square Footage for Double Occupancy
Penalty
Summary
The facility failed to provide rooms that measured at least 80 square feet per resident in multiple resident bedrooms for 2 of 39 rooms reviewed for the physical environment. Record review of the facility document titled ROOMS LESS THAN REQUIRED SQUARE FEET showed rooms 102, 104, 106, 108, 110, 202, 204, 206, 208, 210, 301, 302, 303, 304, 306, 307, 308, 309, 310, 311, 312, 313, 314, 315, 317, and 319 as rooms below the required square footage. Record review of the Residents by Hall document showed the identified rooms were occupied by two residents, while the other rooms on the list were occupied by one resident each. Observation and measurement of the rooms showed room [ROOM NUMBER] measured 15 feet 7.5 inches by 9 feet 3 inches, totaling 144.53 square feet, or 72.265 square feet per resident, and room [ROOM NUMBER] measured the same dimensions and square footage per resident. The ADM stated the facility knew the listed rooms were licensed for two residents but were below 80 square feet per resident, and said the facility chose to admit residents to the front halls first and keep the back of the facility closed until census grew. The ADM also stated the unoccupied rooms could have been occupied, but it was convenient for staff to keep residents physically closer together. The facility had not applied for a room size waiver when the rooms became dually occupied, and the VCSP stated the facility did not have a policy related to room size requirements.
Resident Room Size Deficiency
Penalty
Summary
The facility failed to provide the required square footage per resident in 4 of 17 sampled rooms after an observation and measurement of resident rooms #312, #315, #317, and #301 with the Maintenance Director. Using a metal tape measure, room #312 was occupied by two residents and measured 137.04 square feet total, providing 68.52 square feet per resident. Room #315 was occupied by four residents and had 260.6 square feet of usable space, providing 65.15 square feet per resident. Room #317 was occupied by four residents and also had 260.6 square feet of usable space, providing 65.15 square feet per resident. Room #301 had five residents and measured 158.63 square feet total, providing 79.315 square feet per resident. During interview, the Administrator stated that several inspections had been done in the past and this issue had never been mentioned, and asked that the sampled room size issues be grandfathered in. The report cited the Facility Guidelines Institute 2018 edition for Residential Healthcare and Support Facilities, which states resident rooms shall be sized and arranged to maximize safe resident mobility and related access needs.
Insufficient Resident Room Square Footage
Penalty
Summary
The facility failed to provide the required 80 square feet per resident in 48 of 48 resident rooms. Record review of the Health and Human Services Form 3740 Bed Classifications dated 06/29/26 showed 44 rooms with 2 beds and 4 rooms (23, 24, 51, and 52) with 3 beds. During the survey investigation beginning at 11:30 a.m. on 06/29/26, an agency laser measuring device was used to measure all existing rooms, and the 2-bed rooms measured between 151 and 160 square feet while the 3-bed rooms measured between 219 and 234 square feet. None of the rooms provided the required square footage per resident. During interview and record review at 3:00 p.m. on 06/29/26, the ADM provided a letter requesting a room size waiver for rooms 1 through 52 and stated there had been no changes to the rooms.
Resident Rooms Did Not Meet Required Square Footage
Penalty
Summary
The facility failed to ensure that 7 resident rooms, including Rooms 107, 108, 110, 302, 305, 306, and 307, met the required square footage standards of at least 80 square feet per resident in multiple resident rooms and at least 100 square feet in single resident rooms. Review of the facility census showed that each of these rooms had two beds, and the reported room sizes were 142 sq ft, 143 sq ft, 143 sq ft, 154 sq ft, 154 sq ft, 154 sq ft, and 153 sq ft. Observations on 06/22/2026, 06/23/2026, 06/24/2026, 06/25/2026, and 06/26/2026 confirmed that these rooms each contained two beds. During an interview on 06/26/2026 at 11:30 AM, the Administrator stated that an exemption had been requested from the state for these rooms but had not been granted as of that time.
Bedroom Space Requirements Not Met in Multiple Occupancy Rooms
Penalty
Summary
Rooms 5, 15, 16, 17, 19, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, and 31 did not meet the required bedroom square footage of at least 80 square feet per resident in multiple-occupancy rooms. During interview, the Administrator stated the facility had 16 resident rooms with square footage less than the required amount and identified those rooms as 5, 15, 16, 17, 19, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, and 31. The Administrator also stated there was a room waiver in effect for these rooms and that the room measurements had not changed. Review of the room dimensions showed the identified rooms measured below the required standard, including measurements such as 79.3 square feet per resident in a 3-resident room, 77.9 square feet per resident in a 2-resident room, 61.9 square feet per resident in a 2-resident room, 72.0 square feet per resident in several rooms, 69.6 square feet per resident in several rooms, 74.9 square feet per resident in a 3-resident room, 76.0 square feet per resident in a 2-resident room, and 70.8 square feet per resident in a 2-resident room. Record review of the Room Size Waiver for Facilities documented that these rooms met the justification criteria for waiver, and the Resident Master List Report showed 21 residents resided in Rooms 5, 15, 16, 17, 19, 22, 23, 24, 25, 26, 27, 28, 29, 30, and 31 during the annual survey.
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