Room Exceeded Maximum Resident Occupancy
Summary
The facility failed to ensure that one of its resident rooms did not accommodate more than four residents, as required by regulations. During an initial tour, surveyors observed that room [ROOM NUMBER] contained five beds, although only four residents were present at the time of observation. The facility had previously submitted a waiver request to the Department of Public Health, stating that the room had ample space for wheelchairs, medical equipment, and resident mobility, and that it did not impede the ability of residents to achieve their highest practicable wellbeing. Interviews with two residents in the room revealed that they did not have complaints regarding the available space. Throughout the survey period, nursing staff were observed to have full access to provide care, administer medications, and assist residents with activities of daily living. Despite these observations and the facility's waiver request, the presence of five beds in the room constituted a failure to comply with the requirement that no more than four residents occupy a room.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Excess Resident Occupancy in Multiple Rooms: Surveyors found 13 resident rooms configured for five residents each, with a shared bathroom and one exit door, exceeding the limit of no more than four residents per room. The rooms were divided by a floor-to-ceiling wall, with two beds on one side and three on the other, and privacy curtains around each bed. A Maintenance Supervisor confirmed the room layouts and measured resident space, while a resident, an LPN, and a CNA reported no issues with room space or maneuvering.
Overcrowded Resident Room: A room contained six residents, with two beds in one section and four beds in another, while sharing a common entrance door and bathroom. Surveyors observed the room and later measured it at 581 square feet, and the ADM was informed of the finding.
A facility failed to ensure that three resident rooms held no more than 4 residents per room. During a tour, Rooms 3 and 4 each had six beds and Room 5 had five beds, all with curtains. A resident stated there were no problems with the number of residents in the room and that everyone comes and goes as they please. The facility’s waiver request letter stated that residents have chronic and persistent mental illnesses and are generally ambulatory, physically stable, and able to exit independently.
Excessive Resident Occupancy in Multiple Rooms: The facility failed to keep four resident rooms within the required occupancy limit, with rooms identified as 12-bed, 7-bed, and 6-bed rooms housing more than four residents each. The ADM stated the facility had a waiver and wanted an additional waiver, while records confirmed the over-occupied rooms. Residents and CNA reported adequate space, and surveyors observed room for mobility devices and care activities, but the rooms still exceeded the standard limit.
Excessive Residents in Shared Bedrooms: The facility failed to ensure eight sampled bedrooms had no more than four residents each. Eight rooms in Building Two each had eight beds, although the report notes the room arrangements were based on residents’ care needs and comfort, with accessible wheelchairs and toilet facilities, reasonable privacy, adequate storage space, and sufficient room for residents and staff to provide care.
Excess Residents in a Shared Room: A room was found to have 6 beds in 543.98 sq ft, exceeding the 4-resident limit. The waiver request acknowledged the room did not meet the regulation, though observations showed adequate space, privacy curtains, working call lights, and furniture for each resident. An LVN and a resident both stated they had no concerns with the room size or ability to provide care.
Excess Resident Occupancy in Multiple Rooms
Penalty
Summary
The facility failed to ensure 13 of 32 resident rooms accommodated no more than four residents in each room. A facility letter dated 4/24/26 stated that 13 rooms would accommodate five residents each with one shared bathroom, and that each resident would have reasonable privacy, appropriate furnishings and storage, and sufficient space for staff to provide care and for residents to ambulate and use assistive devices. During observation on 4/21/26 at 8:07 a.m., surveyors found rooms 100/102, 101/103, 104/106, 105/107, 108/110, 112/114, 200/202, 201/203, 204/206, 205/207, 208/210, 209/211, and 212/214 configured with a solid wall from floor to ceiling dividing the space, a shared bathroom, and one exit door shared by five residents. Two beds were on one side of the wall and three beds were on the other side, with privacy curtains around each bed. During a concurrent observation and interview on 4/24/26 at 10:42 a.m., the Maintenance Supervisor confirmed room [ROOM NUMBER]/110 was configured with two beds and a shared bathroom, and that the measured living space per resident was 117.5 sq. ft.; room [ROOM NUMBER] was configured with three beds and the measured living space per resident was 88 sq. ft. Resident 86 stated she did not have problems with her space and could move about easily. Resident 7 stated she could maneuver her wheelchair, get into the bathroom, and transfer in and out of bed with assistance and had no problems with room space. An LPN stated she provided care in rooms accommodating five residents and had sufficient space to maneuver beds, equipment, wheelchairs, and walkers. A CNA stated he was assigned to rooms accommodating five residents and did not have issues maneuvering residents. The Department recommended granting a room waiver per the facility request.
Overcrowded Resident Room
Penalty
Summary
The facility failed to ensure resident rooms accommodated no more than four residents in each room when Room 101 had six residents. During an observation on 4/13/26 at 10:30 AM, the room was divided into two sections, with two beds in the right section and four beds in the left section. The room had a common entrance door and a shared bathroom, and there were a total of six residents in the room. On 4/14/26 at 10:00 AM, Room 101 was measured at 581 square feet. During an interview on 4/16/26 at 3:15 PM, the Administrator was made aware of the finding.
Excess Residents in Shared Rooms
Penalty
Summary
The facility failed to ensure that three resident rooms accommodated no more than 4 residents per room. During an initial tour on 3/31/2026 at 10:52 AM, Rooms 3, 4, and 5 were observed; Rooms 3 and 4 each had six beds, and Room 5 had five beds, all with curtains. Resident 28 stated there were no problems with the number of residents in the room and that everyone comes and goes as they please without difficulty. During record review, the facility’s room waiver request letter dated 3/31/2026 stated that the facility serves individuals diagnosed with chronic and persistent mental illnesses, often with significant behavioral and emotional disturbances, and that residents are generally ambulatory, physically stable, and capable of independent egress without staff assistance.
Excessive Resident Occupancy in Multiple Rooms
Penalty
Summary
The facility failed to ensure that four resident rooms accommodated no more than four residents each. During the survey, rooms 1, 5, 20, and 26 were identified as having more than four residents per room, including two 12-bed rooms, one 7-bed room, and one 6-bed room. The Administrator stated during the entrance conference that the facility had a waiver in place for the rooms and wanted to request an additional waiver that year. A review of the facility’s Client Accommodations Analysis form and request for an additional room waiver confirmed that the rooms exceeded the standard room occupancy limits. The waiver request stated that the rooms provided adequate space for nursing care and wheelchair access and that the multiple beds did not adversely affect resident health and safety. During the survey, residents in the affected rooms were observed to have enough space to move freely, with beds and lockers in place and room for wheelchairs, walkers, and canes. Resident 4 stated the room size was okay and that wheelchairs and other equipment were used by other residents without restrictions. CNA 5 stated residents did not complain about room size or having multiple roommates. The resident census review showed that the residents occupying rooms 1, 5, 20, and 26 during this survey were not the same residents who occupied those rooms during the prior recertification survey.
Excessive Residents in Shared Bedrooms
Penalty
Summary
The facility failed to ensure that eight of eight sampled bedrooms accommodated no more than four residents each. During the survey period, eight rooms in Building Two each had more than four residents, with eight beds in each room. The report states that the room arrangements were based on residents’ particular care needs and comfort, and that wheelchairs and toilet facilities were accessible to residents. Survey observations and resident and staff interviews also noted that a reasonable amount of privacy was provided, adequate closet and storage space were available, and there was sufficient space for residents to ambulate and for staff to provide care. Nursing care of the residents was not impacted.
Excess Residents in a Shared Room
Penalty
Summary
The facility failed to meet the requirement for no more than four residents per room in one residential room, room [ROOM NUMBER], which was documented as having 6 beds in 543.98 square feet. During review of the facility’s room waiver request letter dated 3/16/2026, the letter acknowledged that room [ROOM NUMBER] did not meet the 4-bed-per-room regulation. The letter also stated that the room had no projections or obstructions that would interfere with wheelchair movement and that it had enough space to provide each resident’s care, dignity, and privacy. During multiple observations in room [ROOM NUMBER] from 3/16/2026 to 3/19/2026, nursing staff were observed with adequate space to provide care to the residents in the room. Each resident in the room was observed to have curtains for privacy, working call lights, a dresser, television, and a bedside table. In interviews, LVN 5 stated he was assigned to care for the residents in the room, had no concerns with the amount of space, and said wheelchairs were easy to maneuver in and out of the room. Resident 16 stated he had no issues or complaints about the amount of space and said CNAs were able to change and help move him without problems.
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