Facility Evaluation Report

Licensing Program Analysts (LPAs) Angela Barutyan and Quoc Huynh conducted an unannounced Case Management - Incident visit at 10:10AM. The purpose of this visit is to conduct an investigation regarding a self-reported incident that occurred on 06/24/2026. LPAs met with Executive Director (ED) Allison Marty and explained the reason for the visit.

During today’s visit, LPAs conducted a physical plant tour and a medication review .

On 07/02/2026, the Department received an incident report stating that on 06/24/2026 around 10:00PM, Resident #1 (R1) was administered an incorrect increased dosage of Buprenorphine. The error was identified during the facility nurse’s narcotic count when it was discovered that the resident had received 16 mg of Buprenorphine, which is beyond their prescribed regimen of 4 mg. Upon notification of the error, R1 was immediately assessed by the two (2) nurses on duty and was alert and stable. ED Marty, who was in the community, also responded to check on R1 and notified R1 of the error. ED also advised R1 that their responsible party and primary care physician (PCP) would be contacted. Per PCP’s recommendation, paramedics evaluated the resident. R1 was awake, alert, verbally responsive, ambulating independently, and no adverse effects noted. ED also observed R1 stable. Following the paramedic’s evaluation, R1 declined transport to the hospital. Frequent nursing assessments were conducted throughout the night for R1. Staff were provided with med-pass retraining and ongoing trainings.

Based on the information obtained during today’s visit, it is determined that no deficiency is warranted at this time due to no immediate health and safety risk to R1 and the facility’s proactive response to rectifying the error. An additional report may follow if warranted. Exit interview conducted. A copy of the report provided.