Facility Evaluation Report

On 10/14/2025, Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived unannounced at the facility to conduct a case management visit. LPA met with staff, Mereisis Naisausau and explained the purpose of the visit. LPA notified Administrator, Adi Lina Tuiloma of LPA's presence at the facility. Administrator later arrived at the facility.

During today's visit, LPA and Administrator conducted a tour of the facility to ensure the health and safety of residents in care. Storage space was inspected to confirm medications, toxins and sharps are locked and secured.

LPA conducted a medication audit of three (3) residents.

Resident #1 (R1) was prescribed Fluoxetine (40mg), Cyclobenzaprine (5mg) and Oxycodone (5mg) which were not present in the facility. Administrator said they will reach out to R1s doctor.

Resident #2 (R2) was prescribed Clobetasol 0.05% ointment, Mupirocin 2% ointment and Terbinafine 250mg tablet which were not present in the facility. Administrator said they will reach out to R2s doctor.

Resident #3 (R3) was prescribed Doxycycline 100 mg tablet and Levetriacetam 100 mg/ml solution which were not present in the facility. Administrator said they will reach out to R3s doctor.

LPA conducted a file review of residents. All resident files contained required documents. Three (3) out of five (5) residents are non- ambulatory and require full or partial assistances with ADLs. One (1) resident is on hospice. One (1) resident requires a hoyer lift. Administrator stated that facility staff do not use the hoyer lift for R4. It is used for when transportation comes to take the resident to appointments.

As a result of today's visit, deficiencies observed. Please see LIC 809-D.

Copy of report and appeal rights provided during exit interview.