Carteret House

The facility failed to meet required staffing levels for its census of 21 residents. Specifically, the facility did not provide the minimum required aide duty hours mandated for facilities with a census of 21 or more residents.

The facility failed to ensure the required staffing hours for the Assisted Living unit. Based on a census of 38 residents, the facility failed to meet required staffing hours for 8 out of 21 sampled shifts.

The facility failed to ensure medications were administered according to provider orders for several residents. Specifically, a resident did not receive their prescribed dose of Toujeo Solostar insulin because the medication pen was empty and no replacement was available on the cart. Additionally, the facility failed to ensure proper medication administration for residents with diabetes and those requiring pain management.

The facility failed to ensure medications were administered as ordered for several residents. Specifically, during an 8:00am medication pass, an error occurred where an insulin pen dose selector stopped at 13 units instead of the ordered 35 units for a resident with diabetes.

The facility failed to maintain a safe environment by leaving an oxygen tank unsecured on the floor in a resident's room. This practice violated the facility's own policy requiring oxygen tanks to be secured upright in a rack, cart, or holder to prevent hazards.

The provided text contains the header for a medication administration deficiency, but the specific findings and details for this citation were truncated in the provided document.

The facility failed to maintain a safe environment by leaving an oxygen tank unsecured on the floor in a resident's room. This practice violated the facility's own policy requiring oxygen tanks to be secured upright at all times to prevent hazards.

The facility failed to provide supervision according to the resident's assessed needs, as evidenced by a resident who experienced a choking episode and was later found unresponsive. Additionally, the facility failed to adequately address the resident's high risk for falls, noted by 14 documented falls over a 10-week period.

The facility failed to complete a resident assessment/care plan within 30 days of admission for one sampled resident. Records showed the resident was admitted on 06/02/22, but no care plan was present in the medical record.

The facility failed to ensure immediate referral to meet the acute health care needs of a resident following an injury. Specifically, the facility did not provide timely referral for a resident who experienced an unwitnessed fall resulting in injuries to the lower back and right arm.