Excess Residents in Shared Rooms
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.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
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.
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 Residents in Shared Rooms: Surveyors found two resident rooms that exceeded the allowed occupancy limit, with one room housing five residents and another housing four residents. The ADM confirmed the rooms had five beds each and stated the waiver was requested because the rooms were occupied by more than four residents. During the tour, residents were observed able to move in and out of the rooms, with space for beds, side tables, and care equipment.
Excess Residents in Two Shared Rooms: The facility failed to ensure two rooms held no more than four residents each, as both rooms had 5 beds despite a waiver being discussed by the Admin. During the survey, the rooms were observed to be free of clutter and wheelchair accessible, and the Maintenance Director confirmed the room measurements and bed counts. Staff stated there were no care issues, safety hazards, or resident complaints related to the rooms having more than four residents.
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.
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.
Excess Residents in Shared Rooms
Penalty
Summary
The facility failed to ensure that two of 50 resident rooms accommodated no more than four residents in each room. A review of the facility census dated 3/9/2026 showed one five-resident occupied room and one four-resident occupied room. A review of the Room Variance Waiver letter dated 3/9/2026, submitted by the Administrator, showed that the identified rooms each had five beds and were being used for higher acuity residents requiring more care. During a concurrent facility tour observation and interview on 3/12/2026 at 10:00 a.m. with the Administrator, surveyors observed five residents in one room and four residents in another room. The residents were able to move in and out of the rooms, and there was space for the residents' beds, side tables, and care equipment. The Administrator stated there was a risk of decreased space for the residents, staff, and equipment, and a risk that the residents would feel uncomfortable. The Administrator also stated the room waiver was submitted for the rooms because they were occupied by more than four residents.
Excess Residents in Two Shared Rooms
Penalty
Summary
The facility failed to ensure that two resident rooms accommodated no more than four residents per room. During an interview, the Admin stated that the facility had two rooms approved for a waiver to have more than four residents in each room. However, during an environmental tour, the Maintenance Director confirmed that room [ROOM NUMBER] measured 638.45 square feet and room [ROOM NUMBER] measured 644.08 square feet, and each room had 5 beds. The measurements were documented as 127.69 square feet per resident in one room and 128.81 square feet per resident in the other room. Observations showed that each room was occupied by four residents at the time of the survey, and the rooms were described as free of clutter, wheelchair accessible, and without concerns related to the beds or bedside tables. A CNA stated that the rooms were wheelchair accessible and had sufficient space to provide care to all residents, and the Admin and DON stated there had been no issues with care related to the rooms having more than four residents. The report also states that the rooms were not crowded, did not impose safety hazards, and that there were no complaints from the residents occupying the rooms.
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