Interviews with Administrator revealed that housekeeping staff are directed to immediately clean any room that needs extra attention including odors, in addition to the weekly cleaning schedule. Administrator stated that an odor was reported for a specific room recently, 319. In which a Resident (R1) has had a recent change in condition. The condition of R1 was stated to have changed within the last month. R1 is stated to have started to urinate, and defecate in the room, including on the carpet. R1 was approached by Administrator, to see if R1 was aware of incontinence. R1 does not acknowledge to be doing so. R1’s family was made aware of the change observed by the facility. R1 was deemed by the facility, to now require level 2 care, as opposed to the level 1 care previously receiving. Based on the change, Level 2 care requires “Hands On” from staff. Hands on Care, includes help with incontinence, as opposed to prompting. Level 2 care was initiated for R1 effective 10/07/21. An Addendum of Admission Agreement reflecting Level 2 was provided to the family of R1, explaining the difference change in care. The Administrator Provided LPAs with copies of Janitorial estimates for carpet cleaning, and are considering changing the carpet, or relocating R1 to prevent a reoccurrence of Urine smell. LPA’s Toured rooms 319, 320, 219, and 220 in which incontinence care is being provided. LPAs did not observe any urine smells in the room. Residents interviews with Residents 1,3,4 indicated that they have not smelled any strong odors, including Urine in their room, or others. Based on LPA Interviews, Observation, and Record Review the LPAs finds that “Although the allegation may have happened or is valid, there is not preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.”

Administrator Provided LPA’s with an Inventory list from Pest Control Company that they contract with including the dates, and months treated. Record Review indicated that the Pest control company comes out every other Wednesday to treat areas of the facility, to prevent infestation. If sightings are brought to staff’s attention, Administrator is notified, and rooms of sightings or areas throughout the facility are targeted and treated. LPA’s did not observe any active infestation of Roaches throughout the tour of facility, and checked rooms 319,320,219, and 220. Residents Interviews revealed that R1-R3 had witnessed roaches, but generally stated that it had not been more than one or two at a time, and not consistent, or daily basis. Based on LPA Interviews, Observation, and Record Review the LPAs finds that “Although the allegation may have happened or is valid, there is not preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.”

A exit interview was conducted and a copy of this report was provided.