**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, review of the facility's Census List dated 01/30/2018, review of the facility's policies titled Comfortable and Homelike Environment and Preventative / PRN (as needed) Maintenance Schedule, and review of Job Descriptions for the Maintenance Director and Maintenance Technician, the facility failed to ensure resident rooms and common areas were maintained to provide a safe, clean, comfortable, and/or homelike environment for the residents. Walls, door frames, doors, baseboards, and furniture throughout the facility were observed chipped, scraped, scratched, and with missing paint. Furniture was missing knobs and/or handles, sinks and/or showers did not have faucet fixtures, leaving unfinished exposed pipe, ceiling tiles were stained brown, floor tiles were missing and/or stained. Tube feeding and/or Intravenous (IV) poles were wobbly. These concerns were observed on four of four units in the facility, affecting common areas as well as 72 of 79 resident rooms (as reflected on the facility's Census List dated 01/30/2018). These findings affected Room Locator (RL) #s: 1 through 72, but had the potential to affect all 137 residents residing in the facility at the time of this survey. Findings include: 1) Review of the facility's policy and procedure titled COMFORTABLE AND HOMELIKE ENVIRONMENT, dated 11/28/2017, revealed the following: POLICY It is the policy of this facility to have a homelike environment for residents in our facility . PROCEDURE . 4. Maintenance concerns are addressed through the Maintenance service request logs . Review of the facility's undated Preventative / PRN Maintenance Schedule revealed the following: Daily * Check Maintenance Logs * Walk Through Facility Weekly . *Grand Rounds . - Electrical - Plumbing . - Closet Doors - Flooring/Baseboard . - Furniture - Screens/ Blinds - Walls/ Paint - Ceiling - Others . Review of the job description for Facilities Maintenance Director revealed the following: . Essential Functions: 1. Develop and ensure implementation of a preventative maintenance plan, which describes specific tasks, to be completed and the time frame for completion. 2. Establish an equipment and utilities management program. 14. Inspect building to . detect . needed repair . 15. Perform minor plumbing and electrical maintenance. 16. Perform minor painting, carpentry and masonry work . Review of the job description for Facilities Maintenance Technician revealed the following: . Essential Functions: 1. Inspect building to . detect . needed repair . 2. Performs minor electrical maintenance to include but not limited to replacement or repair of fixtures . 3. Performs minor plumbing maintenance (e.g. (for example) replacement or repair of leaks in drains and faucets .) . 4. Performs minor painting, carpentry, and masonry work . 6. Preparing surfaces and painting various structures and equipment (e.g. walls, ceilings, floors, equipment, and doors, etc. (et cetera)) to preserve wood and metal parts and surfaces from corrosion and maintain a safe, comfortable living environment . On 01/30/18 at 03:12 PM the A Bed of Room Locator (RL) #43 was observed without a handle on the top drawer of a four drawer dresser. At 3:27 PM the B bed of RL #43 was also noted without a handle on the bottom drawer of a four drawer dresser. On 01/30/18 at 4:15 PM, Resident #170 said the facility was a hell hole. The tube feeding/IV (intravenous) pole in his/her room was observed to be wobbly. The ceiling vent was dirty and covered with dark grime. The resident voiced concerns regarding contamination to the air blowing out of the vent. Two water stained ceiling tiles were also observed. The doorway into the room from the sink area was unfinished sheet rock with exposed nail heads, uncaulked gaps, unfinished edges, and was unpainted. The sink was too small for the counter, resulting in the placement of a strip of wood and caulking to fill the void at the back of the sink. During a follow-up with Resident #170 on 02/03/18 at 4:00 PM, the resident said the tube feeding/IV pole was still wobbly. He/she indicated maintenance staff were informed of the concern while they were in the room, but so far it had not been corrected. On 01/31/2018 at 09:23 AM, Resident #170's daughter was interviewed. The daughter indicated she was in the process of getting Resident #170 transferred to another facility; she further indicated she was very concerned about the environment in the facility and described it as awful. On 01/31/18 at 9:44 AM, two of two residents at the Resident Council meeting stated the walls in the hallways needed painting, and it bothered them. They both indicated their rooms also needed painting. On 01/31/18 at 10:57 AM, the hand rail outside of Room Locator (RL) #10 was observed with a nail head extending out from the rail; Multiple concerns were observed on Unit Locator #1, including scraped baseboards with missing paint down the entire length of the hall, scraped doorframes to resident rooms, and scraped/scratched kick plates on resident doors. On 01/31/18 at 11:28 AM, the nurses station on Unit Locator #1 was observed with two vertical beams that were grey, discolored and scratched. The bottom portion of the wall across from the nurses station had a dark build-up, visible despite the dark paint on the bottom of the wall. On 02/01/18 beginning at 04:55 PM, Employee Identifier (EI) #3, Corporate Maintenance, and EI #1, the owner, made walking rounds with the surveyor starting on Unit Locator #1. EI #2, the Administrator, and EI #5, Maintenance Director, rounded with another surveyor on the opposite side of the facility, starting at Unit Locator #4. The following concerns were noted: Unit #1 - At the Nurses Station on Unit Locator #1, the cove basing along wall was partially detached and baseboards were scratched and missing paint. A pillar at the front corner of the nurses station had a large area of plaster missing, with scraped paint and baseboards. The trim around the chart area at the nurses station (visible to residents) had a grey discoloration. EI #1 said the area needed to be repainted. The cove basing along the wall beside the nurses station was coming loose, and a large area, measuring approximately 1 inch x 3 inches (confirmed by EI #3) had patch work but had not been repainted; an overhead beam was patched and sanded but not repainted. Knicks and scratches in the paint were observed running along the length of the hallway baseboards that were not covered with cove basing. RL #1: laminate on bathroom vanity peeled loose and held on with tape; faucet with steady stream of water, unable to turn off; baseboards around interior of room with scraped, missing paint, grey discoloration and exposed wood RL #2: plastic shield on the bottom, inside of the doorframe coming loose; wall behind bed A and bed B with paint scrapes allowing green colored paint to show through the tan paint, of which the room was finished; per EI #1 the room was previously painted green RL #3: cove basing outside the door coming loose; entry door frame with plastic shield coming loose; scarred dresser inside room RL #4: plastic shield on the doorframe coming loose on the right hand side RL #5: doorframe and door to room with multiple scratched and chipped areas of paint covering approximately half the length of the door; missing knob on dresser; baseboards around interior of room with scraped, missing paint, and grey discoloration; windowsill in room is broken (confirmed by EI #3) and wood is exposed RL #6: per EI #3 the kickplate on the entry door was painted and paint has since been scratched off; large areas of missing paint on the door; dresser with scarred wood; baseboards around the interior of the room with scraped, missing paint, and grey discoloration; built-in dresser in room with scuffs along the edges and the drawers RL #7: cove base coming loose outside of room; doorframe with chipped and scratched areas of paint extending about half the length of the door; kickplate with multiple horizontal scratches; baseboards around the interior of the room with scraped, missing paint, and grey discoloration; bathroom door with multiple chipped areas, exposing wood; dresser with missing paint along the edges RL #8: cove basing on the front left of the entryway was about an inch short; a plastic shield on the doorframe was coming loose at the bottom; door with multiple chipped areas and a large area of missing paint; baseboards around the interior of the room with scratched and missing paint RL #9: cove basing outside of the room torn and wood exposed; doorframe with chipped paint almost half the length of the door; no knob on the closet; chipped paint behind the sink; baseboards around the interior of the room with scraped, missing paint, and grey discoloration RL #10: the entry door had chipped and missing paint extending approximately half the length of door; the kick plate had horizontal scrapes; scraped paint on the dresser and trim broken off of the dresser; the resident in B bed reported the dresser had been like that since before he/she came to the facility; EI #3 said the front of the dresser needed to be replaced; commode bolts about one inch long in the bathroom were not capped; patchwork approximately 4 inches x 4 inches (confirmed by EI #3) behind the sink was not repainted RL #11: the entry door was scarred and had chipped paint approximately half the length of the doorway; the kickplate had multiple horizontal scratches; the doorframe had scraped, missing paint; two of four closet knobs were loose; baseboards around the interior of the room with scraped, missing paint, and grey discoloration; bathroom door scraped and missing paint; cracked caulking around the sink in the room, needing to be cut out and re-caulked per EI #3 RL #12: the cove base on both sides of the door were coming loose from the wall; the entry door had chipped and missing paint RL #13: missing knob on the dresser; loose knob on the dresser; scraped paint on edges of the dresser and drawers; base boards around the interior of the room had scraped, missing paint, and grey discoloration; bathroom door and entry door both with scratches and chipped/missing paint RL #14: baseboards around the interior of the room with scraped, missing paint, and grey discoloration; entry door and kickplate both with scratches and door with chipped/missing paint RL #15: cove base outside of the door coming loose; entry door with gray scratches and chipped paint RL #16: dresser with scraped paint along the edges of drawers; baseboards around the interior of the room scraped and missing paint, with grey build up; bathroom door scraped; entry door with chipped paint RL #17: drawer on dresser off track; missing paint on drawer edges; black build up on filter/vent in bathroom door, which EI #1 indicated was probably a result of a spill; the kick plate on the entry door had multiple scratches in the paint RL #18: missing drawer knob on dresser; paint scraped off of dresser; baseboards scraped and missing paint with grey build-up around the interior of the room; the bathroom door had grey discoloration; a large area of patch work behind the sink in the bathroom was not painted; commode bolts approximately one inch long were not capped; EI #3 said the bolts should be capped to make it look better; the entry door to the room had chipped paint affecting approximately half the length of the door RL #19: cove basing outside of the room was peeling loose from the wall; per EI #3, it was probably from where the glue didn't adhere; vertical scratched areas were noted on paneling behind A bed; EI #3 indicated the paneling does still need painting at times; He also said this room had previously been renovated, but was unsure of the date it was completed; the bottom drawer of the night stand beside bed A was off track; the wall and bathroom door had chipped paint and horizontal scrape marks that obviously could use some paint per EI #3; two missing knobs on drawers in the built-in dresser; the entry door to the room was scarred with chipped paint and scratches on the kickplate, that extended nearly half the length of the doorway RL #20: the wall behind the A bed had large grey scratches, probably due to side rails going up and down per EI #1; an area about 6 inches x 2 inches (confirmed by EI #3) with no paint and two visible television brackets, not in use. RL #21: baseboards around the interior of the room with scraped, missing paint, grey discoloration, and exposed wood; an area around the air conditioning unit needed to be resealed per EI #3; EI #3 said it looked like someone tried to seal off the area around the unit with duct tape and that should not be done RL #22: the baseboards outside of the room were scuffed with exposed wood; the doorframe and entry door had chipped paint, extending approximately half the length of the door RL #23: a board with an affixed hand rail outside of the room entryway with a gap in the back where the board meets the wall, needed caulking per EI #3; the corner protector beside the bathroom inside of the room was coming loose from the wall; to the right of the entry door in the hallway there was a strip of wood holding the hand rail with ten plus visible screw holes that should be replaced per EI #3 RL #24: doorframe and entry door were scarred and missing paint The sitting area inside the entry (after coming through the lobby) had a cracked ceiling. Per EI #3, the Heating Ventilation and Air Conditioning (HVAC) drain was leaking a few months prior. He said they replaced the drain and unit and painted over the stains. He also said the facility had discussed adding a drop ceiling in the area, but no definite decision had been made. Unit Locator #2 The right side of the lower half of the wall had wall paper peeling off. The enteral supply closet was observed with a hole in the bottom left of the door, approximately one inch, that was visible in the hallway. The linen and eye wash station door frames were scuffed with black marks. The floor tiles were stained brown. The housekeeping closet and Activities storage doors were also scuffed. A half dollar sized hole was noted in the wall beside the elevator. One of two shower rooms was observed with missing tiles across the width of the entrance doorway. The bathroom door also had chipped wood on the lower half of the door, and the walls had black scuffed area to the left, when entering the bathroom. RL #25: dresser scuffed; bathroom door had chipped and missing paint; the ceiling inside the doorway had a cracked area about 6 inches x 4 inches on a 1.5 foot patch (as described by EI #3); EI #3 said someone did not prepare the surface, so the patch did not adhere RL #26: large area behind B bed scraped with missing paint; the resident indicated it had been like that since before he/she came to the facility on [DATE]; the doorframe to the bathroom had chipped paint that was peeling away and exposing wood; approximately 6 inch x 3 inch area of missing paint and plaster on the wall by the shower (in the bathroom) RL #27: accordion window fillers replaced with cardboard and aluminum tape; EI #3 said it needed to be replaced; the far wall in the bathroom had sheetrock paper peeling off at the bottom, running the length of the wall; one nail was protruding about one inch from the windowsill (in the bathroom); EI #3 said the nail could be a hazard and cause a cut RL #28: built-in dresser had scraped paint; paint on windowsills was bubbling and starting to peel back RL #29: doorframe with cracked and chipped paint; broken door seal around entry door; sink vanity with multiple scratches greater than six inches in length RL #30: doorframe had chipped paint about one fourth the length of the door; top of the door with broken rubber seal; baseboards around interior of room with scraped, missing paint, and grey discoloration; crack on wall under the window (EI #3 indicated this was due to settling); windowsill with scraped, missing paint; large area behind the bed with scraped, missing paint RL #31: doorframe with chipped, missing paint; closet doors with gray streaks and chipped, missing paint; baseboards in the room scratched with missing paint RL #32: door to the room and doorframe had chipped paint RL #33: scratches on the wall beside B bed from siderails scraping the wall; closet doors with scraped and peeling paint RL #34: doorframe and door with scuffed, black marks; phone jack with no cover; walls with missing paint RL #35: doorframe and door with scuffed, black marks RL #36: scrapes on doorframe and door RL #37: exposed blue and red wires to the light observed on the wall; scuffed, black areas on walls; closet door and doorframe scuffed; bottom of doorframe with black marks RL #38: the floor outside of the bathroom door had a dark brown stain; two quarter sized holes in the wall in the room; walls scuffed and scraped with black marks; door scraped RL #39: door and doorframe scraped and scuffed with black marks; walls missing paint on both A and B bed sides of the room RL #40: doorframe and door scraped with black marks; closet doors scraped and discolored; missing faucet in shower/tub area; walls in room with black and brown scuffs RL #41: doorframe and door scraped with black marks; closet doors scraped and discolored; bathroom doorframe with rust colored substance at the bottom RL #42: doorframe and door scraped with black marks RL #43-45: doorframes and doors scraped with black marks; room walls with black marks RL #46: wall behind A bed with scuffed areas on the paint; bathroom tiles stained brown RL #47: doorframe and door scraped with black marks; small electrical box on the floor was loose; staff indicated it was no longer in use; bottom portion of walls with scuffed black and brown areas RL #48: resident reports ceiling tiles were stained brown but staff spray painted them just before the surveyor entered the room; no faucet fixtures in the shower area; the sink was chipped on the front left and right sides; bottom portion of walls with black scuff marks; foyer type entryway with unfinished/exposed sheetrock RL #49: doorframes and doors scraped and missing paint; wall behind the bed scraped; bathroom door and walls scraped and missing paint; rust colored material on the bottom of the doorframe in the bathroom; five brown stained ceiling tiles RL #50: doorframe scuffed black; walls in room scraped; missing cover on phone jack Unit Locator #3 RL #51: walls in room with scraped, black areas RL #52: entry door scraped; five brown stained ceiling tiles; black marks on walls in room; two quarter sized holes around the toilet paper holder in the bathroom; bathroom doorframe and door scraped RL #53: doorframe scraped; bottom of room walls scraped, scuffed, and black RL #54: scraped and scuffed doorframe and walls, with black discoloration RL#55: door and doorframe scraped and stained; door has chipped wood on lower half of door RL #56: doorframes scuffed with black marks; wall behind bed B with scuffed areas, black marks, and patched areas without paint; one dark brown stained ceiling tile RL #57: floor tile behind door stained brown; doorframe with black scuff marks RL #58: bottom of wall scraped in the bathroom RL #59: doorframe scraped with missing paint; five brown stained ceiling tiles; closet doors with scuffed, black marks Unit Locator #4 RL #60: bathroom doorframe and door scraped RL #61: bottom of bathroom door scraped; bottom portions of walls in the room with scuffed, black marks RL #62: door with chipped wood from the lower to middle part of the door; closet door, bathroom door, and door frame scraped on the lower half RL #63: lower half of door with chipped wood; bottom of walls scraped with missing paint and exposed sheetrock RL #64: lower half of door with chipped wood; bottom of walls scuffed black RL #65: half dollar and quarter size holes in the wall in the bathroom; lower walls scuffed black RL #66: lower half of entry and bathroom doors with chipped wood RL #67: lower half of door with chipped wood RL #68: walls scraped behind bed, some areas with missing paint and exposed sheetrock; floor stained brown around the toilet in the bathroom; bathroom doorframe and door scraped RL #69: lower half of door with chipped wood; room and bathroom walls scuffed with black marks, with small areas of missing paint and exposed sheetrock; brown stain on floor around toilet in bathroom RL #70: lower half of door with chipped wood; walls with black scuff marks RL #71: bathroom with lower half of door chipped; bottom of bathroom walls with black, scuffed areas RL #72: lower half of entry door chipped; wall outside of room scuffed with black marks The facility's Main Dining Room was observed with a blackened door, and scraped doorframes. Wires were observed hanging from a metal plate (per staff an old computer kiosk had been removed). Tiles and walls outside of the entryway had black scuffed marks. The lower half of the walls inside the dining room were scraped. Walking rounds of the entire facility were completed on 02/01/2018 at 6:50 PM. EI #1, the owner, EI #2, the Administrator, and EI #5, the Maintenance Director, all voiced agreement with the concerns noted by the surveyors. EI #1 agreed the items needed to be corrected. On 02/03/18 at 2:30 PM, Resident #88 said the paint was peeling off the side wall of the shower in his/her room. The surveyor observed an area about 10 inches X 4 inches wide with the plaster/paint peeled off on the left side wall. Resident #88 said, It bothers me as an artist. Resident #88 also indicated he/she would like the facility to look more presentable, and specifically they needed new paint. During a follow-up with Resident #88 on 02/04/18 at 9:50 AM, the ceiling was observed to be slightly buckled, after a hard rain that morning. Resident #88 pointed out a build-up of dark grey residue (build-up of grime over a period of time) on the linoleum in his/her room and said he/she would get a friend to bring in a brillo pad, attach it to his/her scrubber and try to clean the linoleum his/herself. I don't like it to be dirty--if it's the rest of my life. On 02/03/18 at 2:45 PM the resident in RL #68 said all over the facility needed painting, as well as his/her door and walls in the room. A family member present at this time also indicated the entire facility needed painting. The family member also said the door to RL #68 needed to be addressed because the bottom of the door was scuffed/scraped. The spouse indicated when he/she comes in the front door and walks back towards the room, he/she notices the facility needs painting all over the walls and doors. On 02/03/18 at 2:55 PM, a family member of the resident residing in RL #55 said the resident had just been admitted the day before, but stated the room needed painting, the closet doors and the walls needed painting, and there were scuff marks on the floor. On 02/03/18 at 02:58 PM, Resident # 78 was asked what he/she thought about of the appearance of his/her room. Resident #78 said it could use an update, such as painting the walls and replacing the (water stained) ceiling tiles in the room. Resident #78 said the roof had leaked when it rained. On 02/04/18 at 9:55 AM, the ceiling tiles in front of the bathroom in Resident # 78's room were observed with wet stains. The bathroom ceiling vent was not securely attached to the ceiling at one end. On 02/03/18 at 2:30 PM, a family member of the resident in RL #70 said the facility needed painting. On 02/02/18 at 12:42 PM , EI #2, the Administrator, was interviewed regarding the environmental concerns observed throughout the facility. EI #2 was asked why the areas of concern were so widespread. He indicated the facility focused primarily on any potential areas that may have some sort of harm. He said they then focus on painting and touch up work. On 2/2/2018 at 01:21 PM, EI #2, the Administrator, agreed the problems identified by the surveyors did not get that way overnight. He indicated the facility needed to re-purpose . their system of identifying areas needing repairs in such a way it will be better systematically to maintain patient areas. When asked what system was in place to ensure areas that had previously been renovated or repaired were maintained and kept up, EI #2 said they kept maintenance request logs on each unit, but they would need to come up with an action plan to address the concerns. EI #2 said staff on the hall were expected to report all concerns, such as the items identified during walking rounds with surveyors, so actions could be taken to address them. On 02/02/18 at 01:30 PM, EI #1, the owner, agreed major work was needed for environmental concerns on Unit Locator #1, as well as the other side of the facility. EI #1 said there was a need to do touch up work in almost each room. EI #1 explained they had a system of Grand Rounds they complete every Tuesday for about two hours, looking for concerns, including environmental issues, that need to be addressed. He said the system of Grand Rounds was excellent, but had to be done properly. He said they had to teach and train staff on what they should look for. EI #1 then said, to be honest, some people just go through the motions and just check the boxes, and the facility needed to remind staff of the purpose of the system and why it is important to inspect each room. EI #1 said it was embarrassing to go around with the surveyor and see the concerns identified, and indicated he was not happy with what he saw. EI #5, the Maintenance Director, was interviewed on 02/03/18 at 10:28 AM. When asked how he addressed the need for ongoing touch-ups and repairs, EI #5 said they go around and check, stating they started on Unit Locator #4 and have been trying to make their way around the facility. When asked what system was in place to identify and address areas that need attention, EI #5 said he did not really have a system in place, but he addressed as many issues as he could. EI #5 said it was important for him to have a system in place to address concerns because the facility is the residents' home, and they need to beautify it for them. EI #5 said it was an old building, and explained currently they just had himself, a maintenance technician, and Corporate Maintenance that came to assist with big projects.

Based on interviews and review of a facility document titled Hillview Terrace Facility Assessment, the facility failed to evaluate and identify areas of the environment needing to be maintained. This had the potential to affect all 137 of 137 residents residing in the facility at the time of the survey. Findings include: Cross reference F584. During the recertification, the survey team identified multiple environmental concerns, including walls, doorframes, doors, baseboards, plumbing fixtures, ceiling tiles, and furniture in resident rooms and hallways throughout the facility. These concerns were observed on four of four units in the facility, affected common areas as well as 72 of 79 resident rooms reflected on the facility's Census List dated 01/30/2018. Review of the document titled Hillview Terrace Facility Assessment, dated 11/28/2017, revealed the following: . The following criteria were examined and evaluated by our team . : . * Physical environment and physical plant considerations necessary for resident population. F. Building/physical structure and equipment: The physical structure is sound and no areas were identified needing repair. all planned maintenance is documented. On 02/02/2018 at 12:42 PM, EI #2, the Administrator, was interviewed regarding the facility assessment. When asked who was involved in the facility assessment, EI #2 listed a variety of individuals, including himself, corporate staff, maintenance, and environmental staff. EI #2 said the purpose of the facility assessment was to develop an action plan to address any condition, any diagnosis of what the facility provides care for. EI #2 said maintenance was involved in the section of the facility assessment related to building/structure and equipment. When asked why the facility assessment did not reflect needed maintenance and repairs, EI #2 said he did not know. During a follow-up interview with EI #2, the Administrator, on 02/05/18 at 10:24 AM, EI #2 said the facility assessment addressed the physical plant, meaning the plant was physically sound. He said when completing the facility assessment, generator systems, kitchen systems, air conditioner systems, and maintenance schedules were reviewed; however, from his interpretation of the facility assessment,the purpose was to assess the structure of building, major equipment, and ensure it was in good repair. EI #2 said based on his understanding, items such as cosmetics and painting would go through the Quality Assurance and Process Improvement committee instead of being addressed in the facility assessment.