Based upon observations, interviews, and policy review, the facility failed to meet the requirements for resident council by not providing a private space for the resident council meetings. The findings include: An observation of the resident council meeting was made on 03/26/2025 at 11:00 AM. The meeting area designated by the facility was the dining room. Seven residents were in attendance for the meeting, including the resident council president and two staff members. Prior to the meeting beginning, the facility liaison, who is the Activities Director, asked what topics should be discussed and informed that she always conducts the meetings. The Activities Director was then asked to exit the meeting so they could discuss resident council topics without staff present. After the meeting began, a staff member from maintenance entered the meeting room without knocking, walked into the room for approximately 5 minutes, and looked around the room. The residents in attendance immediately stopped speaking while staff member was present. When the staff member was informed of the meeting taking place, he stopped, turned around, and left the meeting area. After approximately 20 minutes, another staff member entered the meeting room without knocking and spoke to a resident in attendance. The residents immediately stopped speaking while the staff member was present. The staff member assisted a resident from the meeting in progress. On 3/27/25 at 11:30 AM, an interview was conducted with the Activities Director (AD). The AD stated that she begins each meeting with welcoming the council members in attendance, discussing the activity calendar, and any new changes in the facility such as the rules and policies. The council members in attendance are given an opportunity to discuss any concerns they may have and are given the opportunity to suggest any activities they would like to see occur at the facility. The AD stated that the resident council has 10 residents all together, which includes the three officers. The AD stated that the council have never asked to meet without staff being present. She stated she usually leads the meetings. The Ad was asked if residents can express their concerns without fear of retaliation. The AD stated that no one has expressed their fear or concerns about staff getting back at them for voicing any concerns they may have. Usually, if a concern is brought up during the meeting, she will get the appropriate supervisory staff and their concerns are immediately heard and addressed during the meetings. The AD stated that the meetings are listed on the monthly calendar posted on all the units and they announce the meetings approximately fifteen minutes before the meeting begins. Staff will assist the residents who want to attend the meetings. The AD stated they hold the meetings in the dining room and there is always staff coming in and out of the meetings bringing things to the kitchen. Some of the staff will come and get the residents from the meeting to check and change them as needed. The AD acknowledged that there should not be any interruptions from the staff while the council meetings are in progress. The facility procedural guideline for resident council (effective date 1/2/2023) states, .the purpose of meetings is for the resident council provides a formal organized means of resident input into center operations. Under the general guidelines section states, the center will allow residents to organize into a council group without interference. The center will provide the group with space, privacy for meetings and staff support.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** room [ROOM NUMBER] An observation of room [ROOM NUMBER] was conducted in the presence of the Maintenance Director on 3/27/25 at 2:40 PM. The windowsill was observed to be damaged with depressed areas in the wood and peeling paint. The Maintenance Director confirmed the windowsill was damaged with some rotten areas and the issue had not been reported to him. room [ROOM NUMBER] An observation of room [ROOM NUMBER] was conducted on 3/27/25 at 2:44 PM in the presence of the Maintenance Director. A hole in the wall was observed behind Bed A. The Maintenance Director estimated the hole in the wall to be approximately 8 inches long and 4 inches high. He stated he was not aware of the hole and the bed had probably been pushed into the wall. An interview was conducted with the Administrator on 3/27/25 at 2:49 PM. The Administrator stated the facility had a rounding program to check residents and rooms daily. Rooms are divided among management staff, and they check the rooms daily, then turn in a document weekly to him. If anything needs attention, they let maintenance know, place the item in the maintenance work order book and then check off the item once the repair is complete. Based on observations, interviews and review of the maintenance request logs, the facility failed to maintain a comfortable and safe home like environment for 3 of 24 rooms investigated for environment (Rooms 106, 114 & 212). The findings include: room [ROOM NUMBER] On 03/24/25 at approximately 1:39 PM and on 3/27/25 at approximately 1:33 PM, observations of the bathroom door in Resident room [ROOM NUMBER] revealed peeling wood at the base of the door and the door dragging and scratching the floor. On 03/27/25 at approximately 2:26 PM, the Maintenance Director (MD) stated, we use a ledger system, each maintenance book is kept in the nurses station of that unit, any staff can write work orders in this book, the maintenance techs check theses logs daily, I follow behind to check for completion. I also do a monthly walkthrough of the entire facility and generate a report of work that needs to be completed. We do not have any outstanding work orders for room [ROOM NUMBER] at this time. The MD inspected the bathroom door in room [ROOM NUMBER]. He agreed that the wood was peeling at the bottom of the bathroom door and the hinge appeared to be loose at the top, causing the door to drag on the ground. On 03/27/25 at approximately 2:30 PM, the maintenance log was reviewed and no maintenance requests were found for room [ROOM NUMBER].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to provide or offer adequate grooming of facial hair for 1 of 3 residents sampled for activities of daily living (ADL). (Resident #75) The findings include: Observations of Resident #75 were conducted on 3/26/25 at 10:24 AM and 3/27/25 at 10:35 AM. The resident was observed to have gray facial hair to her chin approximately 1/2 cm long in some areas. On 3/27/25 at 10:35 AM, the resident was asked if staff ever offer to remove her facial hair. She could not recall. A review of Resident #75's electronic medical record revealed the resident had a diagnosis of dementia and was admitted to the facility on [DATE]. The admission minimum data set (MDS) with an assessment reference date of 2/7/25 revealed the resident required partial/moderate assistance with bathing and set-up or clean up assistance with personal hygiene. A review of the resident's care plan for ADL self- care performance deficit initiated 2/1/25 revealed the resident required set up or clean up assistance of one person for personal hygiene. A review of the ADL personal hygiene documentation from 3/18/25- 3/26/25 revealed no documented refusals of personal hygiene. An interview was conducted with Employee B (Certified Nursing Assistant) on 3/27/25 at 11:46 AM. Employee B stated she had worked with Resident #75 since she was admitted to the facility. She stated the resident was not capable of shaving herself and the resident had always had hair on her chin. She stated, when the resident was admitted in early February, she had asked a nurse to assist in removing the hair from the resident's chin because the resident had a bump on her chin and she was scared to use a razor. She did not know if the nurse removed any hair. She had not mentioned the chin hair to any other nurse since then. She stated when they shower residents they will attempt to remove any facial hair. If the resident refuses this service, they let the nurse know. An interview was conducted with the Director of Nursing (DON) on 3/27/25 at 11:57 AM. She stated staff should attempt to remove facial hair daily or when they observe it.

Based upon observations and interviews, the facility failed to report nurse staffing data at the beginning of each shift. The findings include: During observations of the nurse staffing data on 3/24/25, 3/25/25, and 3/27/25, it was observed that the facility had posted all staff for the entire day during the beginning of day shift, which included all staff for the day, evening, and night shifts. On 3/27/25 at approximately 02:20 PM, an interview was conducted with the Administrator and Regional Clinical Manager was conducted. They stated that they have always posted our nursing staffing data for a 24-hour period, then update it at the beginning of each shift and as needed when changes occur, such as call ins.