Non-Compliance with Resident Room Capacity Regulations
Summary
The facility failed to comply with federal regulations by accommodating more than four residents in five of its rooms, specifically rooms 32, 33, 34, and 35, each containing six beds. This was observed during a survey conducted on October 21, 2024. The Director of Nurses (DON) acknowledged the non-compliance and mentioned that the facility had a Room Variance Waiver in place and intended to request an additional waiver. Despite the waiver, the facility's policy from May 2017 stated that all resident rooms should accommodate no more than two residents, indicating a discrepancy between practice and policy. During observations and interviews with residents in the affected rooms, it was noted that residents did not express concerns about the space or their ability to move around. Residents reported being able to ambulate without difficulty and having enough space for their belongings. However, the facility's Client Accommodations Analysis confirmed the presence of more than four residents per room, and the facility's request for a room waiver indicated that the current arrangement did not adversely affect residents' health, safety, or well-being. The facility also outlined measures to ensure residents' needs were met, such as ensuring wheelchair accessibility and space for visitors and personal belongings.
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.
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.
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.
Surveyors found that a room contained five beds, exceeding the maximum allowed occupancy of four. Although only four residents were present and both residents and staff reported sufficient space for care and mobility, the room setup did not comply with regulatory requirements.
Surveyors found that several rooms in the facility housed more than four residents per room, with some rooms containing five or six beds and being fully occupied. Although residents reported no concerns about space and rooms were equipped with necessary furniture and equipment, the facility did not comply with federal regulations limiting room occupancy.
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.
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.
Room Exceeded Maximum Resident Occupancy
Penalty
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.
Resident Rooms Exceed Maximum Occupancy Requirements
Penalty
Summary
The facility failed to ensure that resident bedrooms accommodated no more than four residents per room, as required by federal regulations. During a recertification survey, it was observed that eight rooms contained either five or six beds, with several of these rooms fully occupied. The Client Accommodation Analysis and direct observations confirmed that these rooms exceeded the maximum occupancy limit. The surveyors noted that all rooms in question had individualized beds, bedside tables, overbed tables, and resident care equipment, and residents did not report concerns about room size or space during interviews. Despite the presence of adequate space for beds and equipment, the facility's practice of housing more than four residents per room in multiple-resident rooms did not comply with federal requirements. The facility had submitted a waiver letter and had policies in place for management to observe and ensure rooms met residents' needs without adversely affecting health and safety. However, the survey findings indicated that the number of beds and occupants in these rooms exceeded the regulatory limit, constituting a deficiency.
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