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F0912
D

Noncompliant Room Square Footage in Multi-Occupancy Rooms

Houston, Texas Survey Completed on 01-22-2026

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide the required minimum of 80 square feet per resident in two multiple-occupancy rooms. Form 3740 Bed Classifications, signed by the Administrator, listed rooms #311, #312, #313, #314, #315, and #316 as three-bed rooms. During surveyor review, rooms #311 and #314 in the secure unit were measured by the Maintenance Director and found to be approximately 220–221.3 square feet each, which equated to about 73–74 square feet per resident when occupied by three residents. The Administrator acknowledged that each resident was required to have 80 square feet and that these rooms did not meet that standard. During interviews, the Administrator stated she did not have documentation showing that three beds were allowed in these rooms and reported that the corporate office had previously informed her that a waiver was not needed. The Maintenance Director reported being unsure of the required amount of space per resident and stated that no concerns had been brought to her about room size or number of beds. She identified that risks associated with inadequate space could include falls, trips, clutter, and insufficient space for evacuation. These observations, interviews, and record reviews established that rooms #311 and #314 did not meet the minimum square footage requirement per resident.

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