Resident Rooms Below Minimum Square Footage Requirement
Summary
The facility failed to ensure that 11 out of 41 resident rooms met the required minimum square footage of 80 square feet per resident in multiple resident bedrooms, as specified by federal regulations. During an initial observation, it was found that rooms 105, 108, 116, 201, 203, 205, 207, 212, 214, 218, and 222 did not meet this requirement. The measured square footage for these rooms ranged from 143 to 234 square feet, with several rooms housing two or three residents, resulting in less than the required space per resident. The facility's room waiver documentation indicated that these rooms were considered adequate for resident needs and did not adversely affect health and safety, but the actual measurements did not comply with the regulatory standards. Interviews with nursing staff, including a CNA, RNA, and LVN, revealed that they believed there was sufficient space in the rooms to provide care and for residents to move around safely, including those using wheelchairs. Additionally, residents interviewed did not express concerns about the size of their rooms. Despite these observations and staff and resident feedback, the deficiency was cited based on the objective measurements of room size not meeting the federal requirements.
Plan Of Correction
Immediate Corrective Action A request for room waiver was submitted to the CDPH Surveyor Team on 6/9/25 for the following rooms which have less than 80 square feet for multiple residents in a room: 105, 108, 116, 201, 203, 205, 207, 212, 214, 218, and 222. Corrective Action for Others Affected The granting of waiver request will not adversely affect the resident's health and safety and is in accordance with the special needs of the residents. A completed Facility Client Accommodations Analysis indicates all other rooms met the required measurement. Measures Taken to Prevent Reoccurrence Starting 7/01/25, the department heads will conduct Angel Rounds on a daily basis to ensure that the space available for the residents in the affected rooms is sufficient to provide care, provide privacy, and provide adequate space for patient care equipment and personal items. Performance Monitoring Starting 7/01/25, all findings will be presented by the administrator during the monthly QAPI Meeting for the next 3 months to ensure total compliance is achieved.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Shared rooms did not provide the required 80 SF per resident in 23 rooms. A census report showed multiple rooms with three residents or capacity for three residents, and a tour confirmed the room arrangements. The DON stated bed management meetings did not address moving residents to meet the space requirement, and the administrator said current residents were not informed when a bed opened unless they requested a room change. One room measured 230 SF, providing 76.67 SF per resident when occupied by three residents, and a resident stated more space would be helpful for belongings and movement.
The facility failed to ensure that 13 single resident rooms on the A-wing met the required 100 sq ft of usable floor space, and 6 occupied rooms were identified as noncompliant. The DON confirmed the rooms did not meet the standard, while an RN reported no resident complaints about room size and the Administrators stated they had no requests for room moves or complaints from current residents. One resident said staff care was not inhibited by the room size, and the facility reported it had previously moved a resident to a larger room for family visiting needs.
The facility failed to meet regulatory and policy requirements for minimum usable living space in multi-occupancy resident rooms. Policy required at least 80 sq ft of usable floor space per resident in semi-private rooms, but surveyor measurements of multiple bed areas in two rooms, conducted with the maintenance director, DON, and later the administrator, showed bed spaces ranging from about 47 to 75.33 sq ft, even when adjacent common areas were included. The administrator confirmed that these room sizes were below the required minimum.
Room Size Below Required Standard: The facility failed to meet the required 80 sq. ft. per resident in two multi-resident rooms. Census and accommodation records showed Rooms 3 and 4 each had capacity for four residents, and the Client Accommodation Analysis measured each room at 272 sq. ft. During a tour, the ADM confirmed the rooms were below the required space per resident and stated the reduced room size could decrease space for residents, staff, and equipment.
Insufficient Bedroom Square Footage in Multiple Occupancy Rooms: The facility failed to provide the required 80 square feet per resident in 17 of 28 bedrooms. Review of the waiver request showed multiple 2-bed rooms at 78.75 square feet per resident and multiple 3-bed rooms at 75 square feet per resident. During observations and resident interviews, occupants reported no concerns about quality of life, quality of care, or safety related to the room space.
Insufficient square footage was identified in multiple resident rooms after surveyors found that 10 of 23 rooms did not meet the required 80 sq. ft. per resident. The facility’s waiver request and room measurements showed several double- and quadruple-occupancy rooms providing only 77.5 to 78.5 sq. ft. per resident, although residents were observed moving freely and staff had adequate space to provide care.
Shared Rooms Did Not Provide Required Floor Space
Penalty
Summary
The facility failed to ensure shared resident rooms had at least 80 square feet per resident in 23 rooms identified as 101, 102, 107, 108, 109, 208, 212, 213, 214, 215, 216, 217, 301, 302, 307, 308, 309, 312, 313, 314, 315, 316, and 317. A Room Assignment and Census Report dated 4/13/26 showed a census of 64 and identified rooms with current residents and open beds that would be occupied by three residents when full. The report indicated three rooms already housed three residents, two rooms were empty and could take two residents, and five rooms had one resident and could take a second resident. A tour on 5/5/25 verified the listed rooms either had three residents or could accommodate three residents if needed. During interview, the DON stated there had been no discussion in weekly bed management meetings about moving residents to meet the 80 square foot per resident requirement. The DON reviewed the census report and confirmed there were two completely empty rooms and five rooms with only one resident. The maintenance supervisor measured one room at 230 square feet, which provided 76.67 square feet per resident when divided among three residents, and stated all rooms had the same square footage. Observation of room [ROOM NUMBER] showed R25 had belongings on the floor from the back wall to the foot board of the bed and from the side of the bed to the curtain separating him from the roommate in the middle. R25 stated he was not sure why the facility had three residents to a room and said more space would be nice for belongings and movement. The administrator stated the facility discussed behaviors, incident reports, and possible admissions in weekly bed management meetings, but did not discuss moving residents when a bed opened to provide at least 80 square feet of living space. The administrator also stated new admissions were told the room size was less than 80 square feet, but current residents in three-person rooms were not told when a bed opened unless they noticed an open room and requested a bed change.
Insufficient Room Size in A-Wing Single Resident Rooms
Penalty
Summary
The facility failed to ensure that 13 single resident rooms on the A-wing had at least 100 square feet of usable floor space for 6 residents who were occupying those rooms, including A24, A25, A27, A33, A35, and A36. During the entrance conference, the DON confirmed the rooms in hallway A did not meet the required square footage. During the initial screening on the A-wing, those rooms were observed to be occupied by residents. In interviews, one resident stated that staff care was not inhibited by the room size, and an RN reported she was not aware of any resident complaints related to room size. The Administrators stated they had no requests for room moves or complaints that rooms were too small from current residents, and they reported they would accommodate any resident request for more space as allowed. The facility also reported that it had previously moved a resident to a larger room at family request so a large family could visit together. A policy on room size was requested but not received.
Failure to Provide Required Minimum Square Footage in Multi-Occupancy Rooms
Penalty
Summary
The facility failed to ensure that multi-occupancy resident bedrooms provided at least 80 square feet of usable living space per resident, as required by facility policy and 28 Pa. Code: 205.20(f). The facility’s written policy, last revised November 1, 2025, specified that semi-private resident rooms must provide a minimum of 80 square feet of usable floor space per resident. During an observation and measurement process conducted with the maintenance director and the DON, multiple beds in two reviewed rooms were measured and found to be below this standard. Initial measurements showed bed spaces ranging from approximately 47.12 to 65.8 square feet, excluding toilets, bath areas, closets, lockers, wardrobes, alcoves, and vestibules. After these findings were reviewed with the DON and the Administrator, the Administrator requested that the rooms be remeasured to verify the results and to determine whether any alcoves or vestibules could be counted as usable living space. A second set of measurements was then conducted with the maintenance director and the Administrator present. These remeasurements included additional common area space before entering the rooms where applicable, but the total square footage per bed still ranged only from approximately 70 to 75.33 square feet, remaining below the required 80 square feet per resident. The Nursing Home Administrator confirmed that the room sizes did not meet the minimum square footage requirement.
Room Size Below Required Standard
Penalty
Summary
The facility failed to meet the required room size measurement of 80 square feet per resident in rooms with multiple residents. A review of the facility census dated 4/20/2026 showed that Rooms 3 and 4 each had the capacity for four residents. During observations made from 4/20/2026 through 4/23/2026, no adverse effects were observed related to residents' care, privacy, health, or safety in connection with the living space provided. A review of the facility's Client Accommodation Analysis form dated 4/23/2026 showed that two rooms did not meet the 80 square foot requirement, with each room measured at 272 square feet. During a facility tour observation and concurrent interview on 4/23/2026 at 11:25 a.m., the Administrator observed Rooms 3 and 4 and stated that they measured less than 80 square feet per resident. The Administrator also stated that the reduced room size could create a risk of decreased space for residents, staff, and equipment, and could cause residents to feel uncomfortable if the rooms were not properly arranged and monitored.
Insufficient Bedroom Square Footage in Multiple Occupancy Rooms
Penalty
Summary
The facility failed to provide the required square footage per resident in multiple bedrooms for 17 of 28 rooms, including Rooms 101, 102, 103, 104, 105, 106, 107, 108, 111, 115, 126, 127, 131, 132, 134, 136, and 139. Review of the facility’s waiver request dated 4/3/26 showed that these bedrooms did not meet the 80 square feet per resident requirement for multiple-occupancy rooms, with room sizes listed at either 78.75 square feet per resident in 2-bed rooms or 75 square feet per resident in 3-bed rooms. During random observations and interviews with residents occupying these rooms, the residents expressed no concerns about quality of life, quality of care, or safety related to the room space.
Insufficient Square Footage in Multiple Resident Rooms
Penalty
Summary
The facility failed to ensure that at least 80 square feet per resident was provided in ten of 23 resident rooms, including rooms 101, 103, 105, 107, 110, 112, 115, 117, 119, and 121. During the recertification survey from 4/11/2026 to 4/12/2026, surveyors observed that residents in these rooms had sufficient space to move freely inside the rooms, and there was adequate room for the operation and use of wheelchairs, walkers, or canes. The room variance did not affect the care and services provided by nursing staff during the observations. A review of the facility’s Request for Room Variance Waiver letter dated 4/11/2026 showed that the listed rooms did not meet the federal 80 square foot requirement per resident. The facility’s Client Accommodations Analysis documented that rooms 101, 103, 105, and 107 each measured 155 square feet for two beds, rooms 110 and 112 each measured 310 square feet for four beds, and rooms 115, 117, 119, and 121 each measured 157 square feet for two beds, resulting in 77.5 to 78.5 square feet per resident. During the resident council meeting, no concerns were raised about room size, and the facility’s policy stated that multiple resident bedrooms must measure at least 80 square feet per resident and single resident rooms at least 100 square feet.
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