It is alleged that staff did not reorder resident’s medications timely resulting in missed medications. Regarding this allegation it is reported that Client #1’s (C1’s) medication ran out due to Administrator changing pharmacies without making sure that C1 had enough medication during the change, this caused C1 to go without their medication. Interview with Administrator revealed that although there was a change in pharmacies, it was not on purpose. The original pharmacy, Olive Tree Pharmacy, did not have C1’s medication in stock, when Administrator was made aware, the prescription was then transferred to Walmart Pharmacy who did have C1’s medication in stock. According to Administrator, this was not a facility error or delay in reordering but instead, stated that C1’s provider sent the medication to Olive Tree in error instead of Walmart, this is what caused a two (2) day delay. However, once this was discovered, action was taken by the Administrator, and C1 was provided with their medication as soon as it was dispensed. Administrator relayed this information to C1’s provider who then advised that this was ok and to just resume the medication as instructed. Interview with C1 revealed that they did go without medication for two (2) days, but C1 states that from what C1 was told, the original pharmacy did not have the medication in question in stock. Furthermore, C1 states that they have never had concerns with medication being missed or dispensed. Interview with three (3) staff confirmed the information provided by Administrator and stated that this was an issue that was out of facility staff hands since it was a prescription sent in by C1’s doctor’s office directly to the pharmacy. Two (2) additional clients were interviewed, and they collectively stated that they have no concerns regarding their medication, nor do they have concerns with missing any medication. One (1) client refused to be interviewed. LPA interviewed Olive Tree Pharmacy Pharmacist who corroborated that C1’s medication was not in stock and that the order was sent to Walmart Pharmacy instead, clarifying that this was not a facility error, but instead a logistics concern. The Pharmacist also stated that since C1 takes other medications, that a two (2) day delay would not affect C1 and that there was no concern for C1’s health as there was no threat to their safety. The Pharmacist stated that the medication is on automatic refill therefore the reorder was not missed, they simply do not carry the medication to fill it. Additionally, LPA was informed by the Pharmacist that the two (2) days of missed medication 11/16/25 and 11/17/25 coincide with the time that it would take for the transaction to be processed, further confirming that the facility was not at fault. Therefore, based on observations, file review and interviews, this allegation is deemed unsubstantiated.

Exit interview conducted. Copy of report provided to Administrator.

It is alleged that staff do not ensure facility is free from pests. Regarding this allegation, it is reported that the facility has a bed bug problem. Interview with Administrator revealed that there was a visual confirmation by staff of bed bugs on 10/30/25. As soon as this was observed, action was taken, and the facility was fumigated by an exterminator on the same day. A subsequent visit by the exterminator was made on 11/05/25, followed by another visit from the exterminator on 11/11/25. All the clients were relocated to a hotel on 10/30/25 and returned on 11/02/25 when the exterminator stated that there was no longer a threat to the clients and that further extermination would be needed as a precaution. When the exterminator visited for the subsequent visits all the clients were taken on outings while the facility was sprayed. However, during LPA file review of exterminator receipts, it was noted that on 11/11/25 there was still a presence of “many Nymphs” but a follow up exterminator visit was not scheduled. LPA inquired about this, and Administrator stated that a new appointment was made for 12/04/25 on today’s date. Interview with three (3) clients revealed that there were bed bugs and that clients were taken to a hotel to stay for a few days while the facility was being fumigated. One (1) client refused to be interviewed. All clients interviewed denied any bites or skin concerns due to bed bugs. Interview with three (3) staff present in the facility corroborated what clients and Administrator stated, there were bed bugs, and the facility was fumigated. During the file review LPA found that an exterminator treated the home for bed bugs on 10/30/25, 11/05/25 and 11/1/25, with a pending visit on 12/04/25. Therefore, based on observations, file review and interviews this allegation is deemed substantiated.

Citation issued. Exit interview conducted. Copy of report provided to Administrator.