**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to provide a safe, clean, comfortable, and homelike environment for its residents. The findings include: Review of the facility's policy titled Floor Care procedures, dated September 5, 2017, revealed the facility would ensure floors would be cleaned, stripped and six to eight coats of finish applied; allowing each coat to dry completely before applying the next coat. Review of the facility's policy titled Housekeeping Procedures (HP), dated September 5, 2017, revealed the facility would ensure every room would be cleaned as it was the resident's home and should be treated as such. Further review revealed each resident's room would be deep cleaned at least once monthly. This would include to clean behind furniture, sanitize commode, tank, bowl, and base. Also sanitize sinks, light fixtures, mirrors, vents, cords, refrigerators, wheelchairs, and the curtains as needed. Review of the facility's Maintenance Technician (MT) job description, dated April 19,2024, revealed the Maintenance Department was responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner. Further review revealed maintenance was to protect the assets of the facility by diagnosing and performing preventative maintenance and repairs to the physical structures which may include ceilings, light bulbs, walls, doors, windows, floors, beds and miscellaneous. Review of the facility's Maintenance Director (MD) job description, dated April 19, 2024, revealed the MD was responsible for managing and supervising maintenance staff, coordinating, and performing activities of the Maintenance Department to ensure the center was attractive and maintained in good repair. The MD was responsible for work orders. Review of the facility's Administrator job description not dated revealed the Administrator was responsible for the direct day-to-day functions of the facility. Further review revealed the Administrator worked with and supervised personnel in the facility providing instruction, guidance, and counseling as necessary to ensure complete understanding of responsibilities. Review of the facility's Unit Manager (UM), job description revealed UM duties included conducted frequent rounds and maintained awareness of comfort and safety needs of the residents. Also, to investigate complaints and take necessary action to resolve problems. And to perform additional duties, which included submitting repair orders for the Maintenance Department. Observation on 06/06/2024 at 2:28 PM, of the Hallway E Shower Door revealed the kick plate towards the bottom had numerous blackish scuff marks across the bottom section. Continued observation of the E Hall revealed a thumb size hole in wall about 10 inches above the handrail between the shower door and Room E 11 door, that had been wallpapered and painted over to cover try to cover the hole. Further observation of the E Hall revealed the entire E Hallway had scuff marks on the tile all down the hallway. Additional observations of the E Hall revealed Room E 8 had a linear one-inch-long by two-foot area of black marring behind the door, approximately a foot off the floor, traveled about two feet linear along the wall. During an interview with the Housekeeping Supervisor (HS), on 06/06/2024 at 1:50 PM, she stated the facility had contracted through Health Care Services to provide housekeeping services, and Hallway E had not been stripped and waxed since last year. She stated stripping and waxing was routinely completed on the weekends and it was often pushed back because something else would come up. During continued interview, she stated she was responsible for overseeing the housekeeping needs of the facility and would participate in room rounds with the Administrator about three times a week to see what needed completed. In addition, she stated each unit supervisor was responsible for letting her know what needed to be cleaned and she added it to the work week schedule. She continued to state, each supervisor was responsible for checking to make sure the work was acceptable. During an interview with Maintenance Director (MD), on 06/06/2024 at 2:10 PM, he stated he was responsible for reviewing facility work orders and making needed repairs. The MD stated staff would let him know when repairs were needed when passing them in the halls, by calling him on his cell phone, or they placed work orders in TELS (the facility's computerized system). He stated he then would assess needed materials, go over the needed repairs with his team and made repairs as needed. He also stated a corporate representative came to the facility two or three times a month and made rounds with him, formulating a work list of needed repairs. After that list was completed, another round was done to look for other needed repairs. Review of Resident (R) 77's admission Face Sheet revealed R 77 had been admitted to the facility on [DATE] with diagnosis to include progressive supranuclear ophthalmoplegia, unspecified anxiety disorder, and type 2 diabetes mellitus. Review of R 77's admission Minimum Data Set (MDS), dated [DATE], revealed R 77 had a Brief Interview for Mental Status (BIMS) score of 15/15, which indicated the resident was cognitively intact. Observation of Resident (R) 77's room on 06/03/2024 at 6:50 PM revealed a stained, scuffed wall with ripped wallpaper behind the bed. Continued observation of R 77's room on 06/04/2024 at 9:15 AM, on 06/05/2024 at 3:28 PM, and on 06/06/2024 at 11:05 AM revealed the scuffed area behind the bed was still there and had not been repaired. During an Interview with R 77 on 06/03/2024 at 6:55 PM, she stated the stained, scuffed marks had been there since she was brought into the room. R 77 stated when she asked staff about it, the solution was to put a sign up on the wall for staff to not put the bed against the wall. R 77 stated some management staff (she would not name those staff members) had seen the area behind her bed but had done nothing about it. R 77 stated this really doesn't seem to be very home-like to me. During an Interview with the Housekeeping Supervisor on 06/06/2024 at 1:33 PM, she stated each manager had a room rounding sheet which was completed daily. The Housekeeping Supervisor stated if something needed to be cleaned in a resident's room, the manager would complete the daily rounding form and give it to her in morning meeting. She stated when the areas were cleaned, the managers would follow back up on the next room round to ensure the area had been cleaned. She stated if repairs were needed, such as holes in the walls, peeling wallpaper, or scuffed area on walls, the housekeeping staff would report the issue to her and the nursing staff so they could put a work order in for maintenance staff to make the repairs. The Housekeeping Supervisor stated the housekeeping staff was unable to put in work orders to maintenance due to being contracted and unable to access the TELS computer system. During an Interview with the Maintenance Director on 06/06/2024 at 2:00 PM, he stated he was not sure which staff could put work orders into TELS computer system, but all staff could verbally let his staff know if repairs need to be made so any issues with floors, walls, and ceilings could be fixed in a timely manner. The Maintenance Director stated his staff tried to check the resident rooms frequently, but acknowledged it was a problem. The Maintenance Director stated a sister facility had put hard plastic on the walls behind resident's beds to prevent scuffing of the walls and the facility was currently looking into a similar solution but had not decided on how to correct the problem at this time. The Maintenance Director stated his staff tried to keep a rod behind the headboard to prevent the bed from bumping the wall but stated he was not aware if R 77's bed had a rod or not. The Maintenance Director stated he would expect to find any scuffed walls put in TELS so the needed repairs could be made, put on a room round sheet, or at the very least, verbally let his staff so the issue could be repaired. Interview with the Administrator on 06/06/2024 at 2:54 PM, she stated housekeeping were a contracted company. She stated if staff observed any areas needing repair, they should report it to the maintenance personnel or a member of management. The Administrator stated maintenance personnel were employed by the facility and were responsible for completing all needed repairs to include repairing environmental concerns such as walls, door facings, or anything else that needed repair. She continued to state all staff, except contracted staff had access to a computer and was able to put in a work order for maintenance to fix whatever was needed and maintenance staff should check it daily. The Administrator stated maintenance staff were responsible for conducting weekly, monthly, and yearly checks on all areas of the facility to include inspections on electric, plumbing, and fire alarms. Additionally, maintenance was responsible for performing fire drills on all shifts, checking the fire sprinkler system, beds, bathtubs, and performing disaster drills. The Administrator stated the disaster and emergency preparedness manual was updated at least annually to ensure the building was compliant. The Administrator further stated she expected the facility to be clean, and she expected all staff to be observing for any issues and to report those issues to maintenance so any problems could be repaired. She stated it was the responsibility of all staff to report any issues to maintenance personnel.