**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, residents and staff interviews, a facility document, and policy review, the facility failed to ensure the wall was repaired in one resident's (#41) room. The deficient practice prevented the resident's room from having a homelike environment. Findings include: During an interview conducted on August 24, 2022 at 2:34 p.m. with the resident #41, there were deep cracks observed in the wall approximately 3 inches by 6 inches to the left of the bed behind the recliner. It was also observed that the area was not painted along with two other areas on the left wall adjacent to the wall where the bed was located. The resident stated that no one has come to the room to look at the cracks and missing paint on the wall. The resident's spouse was present at the time of the interview and stated the cracks in the wall and the missing paint were present when the resident was admitted to the facility on [DATE]. Review of a work order with no submission date, stated wall repair was assigned to maintenance on August 24, 2022. The work order also stated that the work was to be completed within 3 business days. Patch was completed on August 24, 2022 and sand and paint to be completed on August 25, 2022. An interview was conducted on August 24, 2022 at 2:35 p.m. with a registered nurse (RN/staff #131). She stated that they submit orders to the front desk when something needs repair and the front desk submits an order to maintenance. The RN stated that an order to repair the wall was submitted to maintenance before the resident was admitted to the room and maintenance is aware of it. An interview was conducted on August 25, 2022 at 8:27 a.m. with the Administrator (staff #200) with the Director of Nursing (DON/staff #18) present. Staff #200 stated the maintenance director inspects the facility daily and completes work orders. She said that staff can identify any repairs needed and put an order in with the front desk. She stated some wall repair and painting is considered general repair and not an emergency. She said that they have had problems with the recliners hitting the wall in the rooms and are currently installing plastic on the wall, so the recliner does not scrape the wall. She said that if a resident is upset about something that is considered a general repair, it would be repaired. She said that she had seen the wall and saw the cracks. She also stated the housekeepers go into the rooms daily and would/should report any repairs needed. At 8:29 a.m., the Facility's Manager (staff #79) joined the interview. He stated that he reviews the facility daily, but he does not do daily rounds in every single room. He stated when he does inspect rooms, he picks them at random. He stated that he does not have an order for the wall repair except for the order that he received yesterday. He stated that he was in the resident's room on Monday and did not see the cracks or missing paint on the walls, but that he inspected the water, lights, and ceiling. He said that after he was informed of the wall damage, he inspected it and it looked like the wall had been damaged by the recliner. He stated he did not ask the resident how long it had been there. During the interview, he reviewed the work order and stated that the wall repair and painting was categorized as repairs that needed to be completed within 3 days. The facility's policy, Work Orders, Maintenance, revised April 2010 states: -In order to establish a priority of maintenance service, work orders must be completed in the work order system. -It shall be the responsibility of the department directors to request or complete work orders that need to be completed to the maintenance department. -Any staff may report a work order needed to the front desk concierge and leave a message after hours. -Work orders are reviewed daily.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure advance directive information was accurate for one resident (#13). The sample size was 2. The deficient practice could result in residents' wishes not being honored. Findings include: Resident #13 was admitted to the facility on [DATE] with diagnoses that included orthostatic hypotension and hip fracture. A physician's order dated [DATE] included full code. The resident's care plan initiated on [DATE] revealed the resident was a full code. Review of the advanced directives with the date [DATE] revealed the resident was a Do Not Resuscitate (DNR). During an interview conducted with the resident on [DATE] at 9:30 am, the resident stated that their code status was full code. During an interview conducted on [DATE] at 8:55 AM with the Director of Social Services (staff #159), she stated that they review advanced directives with the resident and the resident initials and signs the document to execute it. Staff #159 stated the documentation should be consistent. In an interview conducted with a Registered Nurse (RN/staff #97) at approximately 9:05 am on [DATE], the RN stated they would look for a resident's code status on the report sheet first. She stated the report sheet indicated CPR (cardiopulmonary resuscitation) should be initiated. She stated next, they would check the computer to verify. She stated the computer indicates to initiate CPR. She stated they would also check the physical chart, which has a green sheet indicating that CPR should be performed. Continued review of the resident physical chart revealed other forms behind the green sheet. The RN stated the advanced directive statement indicates the resident does not want CPR. She stated the advance care planning tracking form states do not resuscitate. The RN stated that she would notify the Director of Nursing. An interview was conducted with the DON (staff #18) on [DATE] at approximately 9:52 am. She stated her expectation is that the order would be followed. She stated there is a binder at the nurses' station that the nurse would be expected to refer to, and there is also information in the computer. After reviewing the clinical record, the DON stated the advanced directive statement is DNR and was signed by resident's POA (power of attorney) on [DATE]. She stated the advance care planning tracking form indicated DNR was signed by the resident's POA on [DATE]. The DON stated the physician order is for CPR (full code). The DON stated the resident would be treated as full code because the full code sheet is signed by the resident's POA and full code is consistently in the computer. She stated the expectation would be that communication of changes should have happened. The facility's policy Advance Directives revised [DATE] stated advance directives will be respected in accordance with state law and facility policy. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive. The policy stated the attending physician will be notified of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care.