Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Waters Of Princeton, The during CMS and state inspections, most recent first.
Improper medication labeling, storage, and expired drug handling were observed in multiple med carts. Surveyors found unlabeled inhalers, insulin, liquid meds, and loose tablets; an unopened insulin pen that was not refrigerated as required; open insulin pens with no open date; expired meds; and a narcotic tablet in a resident-labeled cup that an RN could not account for in the narcotic book.
Meals Served at Inappropriate Temperatures: Residents reported that meals were cold or lukewarm, and all residents at a Resident Council meeting said food was not hot when served. Surveyors observed hot items on the steam table, but a test tray from the 200-hall was much cooler and tasted cool. The Kitchen Manager said a heating element on the heating plates had failed and a replacement was pending.
Incomplete documentation affected resident weights, insulin administration, and wound care. A resident had a charted wt loss that was not supported by follow-up documentation, while multiple residents had insulin and BG checks recorded outside ordered time parameters or not documented at all. Wound dressing changes for another resident with hidradenitis suppurativa were also performed but not entered in the TAR or progress notes, and the DON stated some care was done without proper charting.
Failure to evaluate a cognitively intact resident for self-administration of medications. A resident was observed with OTC products at bedside, but the record lacked a self-administration care plan, physician orders, and an evaluation. The resident said staff told him to hide the items so State would not see them, and he had never been offered an assessment. The DON said staff kept confiscating items he bought and had not considered evaluating him, while the Administrator confirmed he had not been assessed or asked about self-administration since admission.
PRN psychotropic order lacked required review and duration. A resident with generalized anxiety and Hidradenitis Suppurativa had a PRN clonazepam order for anxiety, but the record did not show an evaluation of need after 14 days or a specific duration of use. The DON stated the resident had not used the medication since admission and it should have been discontinued; the facility policy limited PRN psychotropic drugs to 14 days unless the MD documented rationale to extend use.
Inaccurate MDS Coding for Medication Use: Two residents had MDS assessments that did not match the eMAR and physician orders. One resident with dementia and anxiety received scheduled buspirone for anxiety, but the MDS did not code antianxiety use. Another resident with dementia received PRN tramadol for pain, but the MDS did not code opioid use. The MDS Coordinator stated the medications should have been coded, and the RN noted the facility did not have an MDS policy and should follow the RAI.
Failure to follow oxygen orders and date tubing: Two residents receiving O2 were observed with undated tubing, and one resident’s record lacked a physician O2 order. One resident had COPD, dementia, and lung cancer and was on 2.5 L O2 with nebulizer tubing and O2 tubing not labeled with dates; the other resident with COPD was on 2 L O2, stated staff had not changed the tubing since admission, and the DON could not locate an O2 order. Facility policy required O2 to be given only as ordered by the physician and tubing to be discarded after use or when soiled.
Medication administration errors were observed for 3 residents during a med pass, resulting in a 10.34% error rate. A QMA allowed a resident to self-administer an inhaler without an order for self-administration and gave the wrong dose without offering a mouth rinse. Two RNs also failed to prime insulin pen needles, and one RN administered the wrong insulin to a resident with diabetes orders for Basaglar and Novolog.
A resident was not free from a significant med error when an RN administered the wrong insulin during a med pass. The resident had orders for Basaglar 50 units at bedtime and Novolog 10 units TID for DM, but received 10 units of insulin glargine instead of the ordered short-acting insulin. The resident’s BG was 308 at the time of administration, and subsequent MAR readings were 325, 484, 266, and 254.
Improper EBP and Glove Use During Wound Care: During wound care for a cognitively intact resident with DM2, venous insufficiency, and a left BKA, an RN performed a dressing change without a gown despite EBP orders and repeatedly used the same gloves while removing old dressings, touching both legs, irrigating wounds, handling clean supplies, and applying new dressings. The resident’s record included wound care orders and a care plan directing staff to follow EBP and proper hand hygiene/PPE protocols, and the RN later stated she forgot the gown while a regional support nurse said gloves should have been changed at least twice.
Missing Emergency Call Systems in Public Restrooms: The facility failed to ensure working emergency call systems were available in resident-accessible public restrooms. A woman's restroom in the back hallway and the public restrooms on the back and east halls were observed without a key or emergency call bell system. The administrator stated she was not aware of the need for an emergency call light or key for an accessible public bathroom and said she had been told different things; a policy for the call system was requested but not provided.
Surveyors found that staff failed to maintain accurate narcotic drug counts and records on two nursing units. Discrepancies were observed between the count logs and the actual number of controlled substance tablets present, with staff attributing the errors to being hurried or behind in their duties. Facility policy requires real-time documentation and verification of controlled substances, which was not followed.
A resident with multiple wounds and complex medical conditions did not consistently receive wound care as ordered by the physician, as several treatments were not documented as completed in the EMAR. The facility's policy requires all physician orders to be followed, but gaps in documentation for wound treatments, including Betadine and Medihoney applications and use of pillow boots, were identified. The deficiency was confirmed through record review and interviews.
A resident with dementia and other health issues developed a stage 2 pressure injury and facial bruising, but the facility failed to notify the physician and the resident's representative promptly. The ADON was informed of the pressure injury but did not follow up, and the resident's representative was not notified of the bruising when it was first observed. This deficiency was identified during a complaint investigation.
A facility failed to administer medications according to physician's orders and professional standards, resulting in a 16.13% error rate. Errors included improper administration of asenapine, incorrect insulin pen priming for two residents, and an incorrect dose of olanzapine due to a discrepancy between the MAR and medication label. Facility policies on medication administration and insulin injection were not followed.
The facility failed to properly label, date, and store medications in two medication carts. Observations revealed opened insulin pens without dates, expired medications, and lack of refrigeration for certain medications. The DON acknowledged the issue of improper refrigeration due to pharmacy delivery practices.
The facility failed to serve food at palatable temperatures, as evidenced by multiple resident complaints and a test tray evaluation showing food temperatures below the expected level. The Dietary Manager acknowledged the issue and attributed it to the need for new insulated holders and carts.
The facility failed to properly prepare pureed diets for four residents, using an excessive amount of mayonnaise and expired milk. A staff member noted the food's incorrect consistency and taste, deviating from the facility's policies on pureed food preparation and stock management.
The facility failed to maintain sanitary conditions during food preparation, as observed in both the kitchen and dining areas. Staff did not change gloves between handling different items and were not wearing proper hair restraints. The Dietary Manager was observed without a beard net, and other staff had hairnets that did not fully cover their hair. Facility policies on glove use and hair restraints were not followed.
The facility failed to ensure accurate documentation and proper medication administration for several residents. Insulin was administered by unqualified staff, and medications were given late without proper documentation. The Director of Nursing confirmed that QMAs were not authorized to administer insulin, yet records showed otherwise. Additionally, medications scheduled for 8 P.M. were administered late, with discrepancies in the documentation of the actual administration time.
A resident with severe cognitive impairment was given crushed medications without a physician's order. An LPN administered the crushed medications mixed with pudding, and the DON confirmed the lack of a physician order. The facility's policy required checking orders and a 'Crush List' before crushing medications, which was not adhered to.
The facility did not complete the MDS assessments for two residents within the required 14-day period after admission. A resident's MDS was still in progress and incomplete upon review, despite being admitted earlier. The DON confirmed that the facility expected the Admission MDS to be completed within 14 days, following RAI manual guidelines.
The facility failed to accurately complete MDS assessments for two residents, resulting in care planning deficiencies. A resident with cognitive impairment was observed with a chair alarm not documented in the MDS, and their care plan lacked necessary interventions. Another resident's MDS inaccurately recorded an antiplatelet medication not present in physician orders. These errors highlight the facility's failure to ensure accurate documentation and care planning.
A facility failed to develop a care plan for a resident who spoke Spanish as her first language, resulting in unmet communication needs. The resident, diagnosed with dementia and requiring supervision, did not have a Spanish communication board readily available. Observations showed the resident struggling to communicate with a CNA who did not understand Spanish. Facility staff acknowledged the absence of a necessary care plan, contrary to the facility's policy on communication in the predominant language.
The facility failed to update care plans for two residents, leading to deficiencies in their care. One resident, with conditions including dementia, lacked interventions for fall prevention. Another resident, with sepsis and end-stage renal disease, had an outdated care plan post-hospitalization. The facility did not adhere to its policy of updating care plans based on changes in residents' conditions.
A facility failed to ensure professional standards in diagnostic practices for a resident diagnosed with schizoaffective disorder and bipolar disorder. The resident, who was severely cognitively impaired, was receiving multiple medications without a care plan for behavioral disturbances or monitoring for side effects. A pharmacy review led to changes in diagnoses without a physician evaluation, and the facility lacked a policy on professional standards.
A resident with chronic conditions and stage three pressure ulcers did not receive consistent wound care as ordered by a physician. Treatments were sometimes administered by a QMA, who was not authorized to handle advanced skin conditions. The resident's wounds worsened, and documentation was incomplete, indicating a failure to adhere to professional standards.
A resident with significant weight loss was not provided with the recommended fortified foods despite multiple Nutrition at Risk Reviews suggesting such interventions. The resident, who had several medical conditions and was moderately cognitively impaired, experienced a 15.1% weight loss over six months. Interviews with facility staff indicated awareness of the issue, but necessary dietary changes were not implemented.
A facility failed to follow a pharmacy recommendation for a resident's medication management. The resident, with severe cognitive impairment, was prescribed omeprazole, but the clinical record lacked a care plan for its use. A pharmacy recommendation to hold the medication for two weeks was not properly documented or followed up, as the medication was restarted without noting any gastrointestinal symptoms or rationale for continuation.
A facility failed to implement infection prevention measures by not following physician orders for enhanced barrier precautions during wound care for a resident with a left calf abrasion. An LPN provided care without wearing a gown, despite the requirement for PPE during high-contact activities. This was contrary to the facility's policy, as confirmed by the MDS coordinator and the Director of Nursing.
A facility failed to update a care plan for a resident who returned from the hospital with a new diagnosis of cellulitis and a prescription for clindamycin. Despite the facility's policy requiring updates to care plans upon readmission, the clinical record lacked a care plan addressing these changes, as confirmed by the MDS Coordinator.
The facility failed to follow physician orders for a resident's medication administration, specifically not adhering to blood pressure parameters for Midodrine HCI. The medication was given multiple times outside the prescribed parameters, and required blood pressure readings were not documented.
Improper Medication Labeling, Storage, and Expired Drug Handling
Penalty
Summary
The facility failed to ensure medications were properly dated and labeled, failed to keep medications refrigerated until opening, and failed to destroy expired medications in 3 of 4 medication carts observed, including the west hall and east hall medication carts. During observation, surveyors found multiple unlabeled or improperly labeled items in the East back hall cart, including a Symbicort inhaler dated 9/28/25 with no label, a Humalog vial with no label or open date, and multiple loose tablets with various imprints. In the East front hall cart, surveyors observed an antacid liquid bottle with no label and no open date, a box of sumatriptan 25 mg tablets with no label and no open date that had expired in 6/2025, and additional loose tablets without proper identification. In the [NAME] Hall cart, surveyors observed an opened Lantus vial with no open date, a Basaglar pen that was not opened and was not refrigerated despite the label stating to refrigerate until open, two open Basaglar pens with no open date, and a Degludec pen dated open 12/4/25 and expired 1/4/26. Also observed were inhalers and polyethylene glycol packets without required patient names or pharmacy labels, along with loose tablets in the cart. In the narcotic box, a cup labeled for a resident contained an oxycodone tablet, and during interview RN 5 stated she was not sure where the loose narcotic medication came from and could not find where it was signed out in the narcotic medication administration book. The facility policy stated medications and biologicals are to be stored safely and securely, refrigerated when required, and outdated or deteriorated drugs are to be immediately withdrawn from stock, and prescription labels must include required resident and medication information.
Meals Served at Inappropriate Temperatures
Penalty
Summary
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature was not met when the facility failed to serve food at palatable temperatures for 1 of 1 trays tested. Multiple residents reported that meals were cold or lukewarm, including residents who ate in their rooms and stated the food was cold by the time it arrived. During the Resident Council meeting, 10 out of 10 residents indicated that the food was not hot when served. On observation, lunch food on the steam table was measured at 179 F for pork roast, 190 F for mixed vegetables, and 200 F for rice, but a test tray from the 200-hall later showed much lower temperatures of 128.8 F for rice, 136.6 F for vegetables, and 118.6 F for pork roast, and the food tasted cool. The Kitchen Manager stated that food should only be three to four degrees cooler when served than on the steam table and reported that a heating element had gone out on the heating plates and he was waiting for a replacement. The facility policy stated that meals are to be served attractively, accurately, efficiently, and at the appropriate temperature.
Incomplete Documentation for Weights, Insulin, and Wound Care
Penalty
Summary
The facility failed to maintain complete and accurate documentation for resident weights, insulin administration, and wound care records. For Resident 9, the clinical record showed a documented weight of 175 lbs on 11/13/25 after prior weights of 231 lbs and 231.5 lbs earlier in the year, reflecting a 24.41% weight loss. The record lacked documentation of a follow-up weight, notification of the physician or registered dietitian, or any interventions started. During interview, the DON stated the weight was probably not accurate because the resident refused weights often, and the Administrator later stated the previous DON entered the weight wrong. Resident 9 was then observed being weighed at 263.5 lbs. For Resident 28, the eMAR showed multiple insulin regular and Lantus doses were administered outside the ordered time parameters, and some blood glucose checks were also documented outside the expected timing. The resident stated nursing staff sometimes checked blood sugar and gave insulin late. The DON stated insulin could be administered within one hour before or after the ordered time and that blood glucose checks should also fall within those parameters, but later acknowledged that staff sometimes had to administer medications and document them later because the internet did not reach all hallways. The DON stated insulin should be documented in real time or, if necessary, back charted to reflect the accurate administration time. For Resident 5, the eMAR showed multiple Lantus and Novolog administrations were given outside the ordered time parameters, including doses that were delayed by hours and some blood glucose checks that were not aligned with the medication times. For Resident 14, the MAR/TAR showed scheduled Lispro and Lantus for an 8:00 P.M. blood glucose of 217 were not administered until after midnight, and the nurses' progress notes lacked documentation explaining why the medications were late or whether the resident experienced a hypoglycemic episode. For Resident 36, wound dressing changes ordered for hidradenitis suppurativa were not marked as administered or refused on multiple shifts across November, December, and January, and the DON stated the dressings were changed but not documented.
Failure to Evaluate Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident who had medications in his room was evaluated for the ability to self-administer them. Resident 11 was observed with a bottle of nasal spray, a tube of Neosporin, a tub of Balmex, and a tub of Burt's Beeswax on the bedside table. His record showed diagnoses including cellulitis of the buttock and COPD, and the most recent MDS indicated he was cognitively intact, needed setup assistance for eating, required supervision for transfers, and had one stage two and one stage three pressure ulcer. The clinical record did not contain a self-administration of medication care plan, physician orders for the nasal spray, Neosporin, Balmex, or Burt's Beeswax, or a self-administration evaluation. During interview, the resident said staff told him to hide the items in a drawer so State would not see them because he was not supposed to have them, and that he had never been offered an evaluation to keep medications at bedside. The DON stated he did not self-administer medications, that staff kept confiscating items he bought, and that she had not thought to evaluate him for self-administration. The Administrator later stated he had not been assessed or asked if he wanted to be assessed since admission, despite a consent for treatment indicating he did not want to self-administer his own medications.
PRN Psychotropic Order Lacked Required Review and Duration
Penalty
Summary
The facility failed to ensure that a PRN order for a psychotropic medication included an evaluation of need after 14 days and a specific duration of use for one resident. Resident 36 was admitted with diagnoses including Hidradenitis Suppurativa and generalized anxiety, and the most recent Quarterly MDS indicated the resident was cognitively intact, required supervision for toileting and transfers, and received antianxiety medication during the seven-day lookback period. The resident’s current physician orders included clonazepam 0.5 mg by mouth every 12 hours as needed for anxiety, with a start date of 5/15/25. The clinical record did not contain an evaluation of need for the medication after 14 days or a specific duration of use. During interview, the DON stated the resident did not have an assessment for PRN antianxiety medication, had not used clonazepam since admission, and should have had it discontinued. The Administrator provided a policy stating PRN psychotropic drugs are limited to 14 days unless the physician documents rationale to extend use beyond 14 days.
Inaccurate MDS Coding for Medication Use
Penalty
Summary
Ensure each resident receives an accurate assessment. Based on record review and interview, the facility failed to accurately code the Minimum Data Set (MDS) assessments for 2 of 5 residents reviewed for unnecessary medications. One resident had diagnoses including dementia and anxiety, and the most recent quarterly MDS indicated severe cognitive impairment, substantial supervision for toileting and bathing, and receipt of antipsychotic, antidepressant, and antiplatelet medications during the seven-day lookback period. The resident had a physician order for buspirone 5 mg twice daily for anxiety, and the eMAR showed the medication was administered on all seven days of the lookback period, but the MDS did not indicate use of an antianxiety medication. The care plan also identified anxiety and use of anxiolytic therapy. A second resident had a diagnosis including dementia, and the most recent quarterly MDS indicated severe cognitive impairment, partial assistance needed for toileting and bathing, and receipt of antipsychotic, antiplatelet, and anticonvulsant medications during the seven-day lookback period. The resident had an order for tramadol 50 mg every four hours as needed for moderate to severe pain, and the eMAR showed tramadol was administered on two dates within the reviewed period, but the MDS did not indicate opioid use during the seven-day lookback period. During interview, the MDS Coordinator stated the buspirone and tramadol should have been coded on the MDS, and the Regional Support Nurse stated the facility did not have a policy for MDS assessments and should follow the RAI.
Failure to Follow Oxygen Orders and Date Tubing
Penalty
Summary
The facility failed to ensure oxygen services were provided according to physician orders for 2 residents reviewed for respiratory care. Resident 14, who had diagnoses including COPD, diabetes mellitus type 2, and dementia, was observed sitting in a recliner with a nasal cannula delivering oxygen at 2.5 liters. The oxygen and nebulizer tubing had no dated label, and the water bottle attached to the oxygen concentrator was dated 1/5/26. The resident’s record showed orders to change and date the nebulizer tubing weekly on Sunday night shift and to change and date the oxygen and hand held nebulizer tubing weekly on Sunday night shift. The care plan indicated the resident required supplemental oxygen related to COPD and lung cancer. An RN stated that oxygen and nebulizer tubing is usually changed on Sundays by the night shift nurses. Resident 11, who had COPD and was cognitively intact, was observed receiving 2 liters of oxygen via nasal cannula, and the oxygen tubing was not dated. The resident stated that staff had not changed the oxygen tubing since admission. The record showed the resident was not receiving oxygen on the admission MDS and admission assessment, but later notes documented oxygen use for shortness of breath and breathing 2 liters via nasal cannula. The clinical record lacked a physician order for oxygen, and the DON stated she was unable to find an oxygen order for the resident. The facility policy stated oxygen therapy is administered only as ordered by a physician or as an emergency measure until an order can be obtained, and that disposable masks, cannulas, and tubing are discarded after use or when soiled.
Medication Administration Errors Exceeded 5 Percent
Penalty
Summary
Medication administration errors occurred during observation and record review for 3 of 7 residents, resulting in a 10.34% error rate. During a medication pass, QMA 9 allowed a resident to self-administer Budesonide-Formoterol Fumarate inhalation, and the resident took one puff even though the clinical record did not contain a physician order for self-administration. The resident was ordered Budesonide-Formoterol Fumarate Inhalation Aerosol 160-4.5 mcg/actuation, two puffs twice a day, and the resident was not given the correct dose. QMA 9 also did not offer the resident to rinse her mouth after using the inhaler. During the same medication pass, RN 5 administered 10 units of insulin glargine to another resident whose orders included Basaglar insulin glargine 50 units subcutaneously at bedtime and Novolog insulin aspart 10 units subcutaneously three times a day for diabetes. RN 5 did not prime the insulin pen needle before administration and gave the wrong insulin. In a separate observation, RN 7 administered 7 units of insulin lispro to a resident with an order for Novolog PenFill insulin aspart 7 units before meals, with a note that Fiasp or Admelog could be substituted per pharmacy. RN 7 did not prime the pen needle before administering the insulin. The DON stated the insulin pen needle should be primed after attachment, and the facility policy required verifying the correct insulin product and patient, reading the MAR and order entirely, and priming the pen until a drop of insulin appears at the needle tip.
Wrong insulin administered during medication pass
Penalty
Summary
A resident was not free from a significant medication error during insulin administration. During a medication pass observation, the resident’s blood sugar was 308, and RN 5 administered 10 units of insulin glargine to the resident. Review of the clinical record showed physician orders for Basaglar (insulin glargine) 50 units subcutaneously at bedtime for diabetes mellitus and Novolog (insulin aspart) 10 units subcutaneously three times a day for diabetes, indicating that the resident received the wrong insulin at the time of administration. The medication error was identified during the observation and the facility was notified. The record also showed that the physician was notified and that the resident was to be monitored with blood sugar checks every four hours for two times. The MAR documented blood sugars after the wrong insulin administration of 325, 484, 266, and 254 over the following day and a half. The facility policy titled Medication Administration Errors stated that upon identification of a medication error, the facility would complete an error report, notify the physician and family, conduct an investigation, and institute interventions to prevent recurrence.
Improper EBP and Glove Use During Wound Care
Penalty
Summary
The facility failed to implement proper Enhanced Barrier Precautions and glove use during wound care for Resident 39. During an observation of dressing change on 1/15/26 at 1:40 P.M., RN 5 donned gloves but did not apply a gown even though the resident was on EBP. While removing the old dressing from the resident’s right leg, the nurse placed some dressing material on the floor using the same gloves, placed a clean towel under the right leg without changing gloves, touched the resident’s left leg and removed old dressing with the same gloves, and later removed gloves, washed hands, and applied new gloves. The nurse then irrigated the underside of the right leg, patted the wound with gauze, used the same gloved hand to apply alginate dressing, irrigated the outer wound with the same gloves, and continued the dressing change without changing gloves when obtaining new gauze or holding the leg. The nurse dropped gauze wrap on the floor, said she would cut above the dressing that was on the floor, applied elastic wrap with the same gloves, removed gloves, and did not sanitize before placing new gloves. She then placed dressing on the left foot and removed gloves without sanitizing. Resident 39’s record showed diagnoses including diabetes mellitus type 2, venous insufficiency, and acquired absence of the left leg below knee. The current MDS indicated the resident was cognitively intact and required varying levels of assistance with eating, transferring, hygiene, and dressing. Physician orders included droplet isolation every shift and wound care orders for the left below-knee amputation and another wound. The care plan for wounds or skin openings requiring a dressing directed staff to follow Enhanced Precaution Guidelines during direct care activities, including wound care, and to reinforce proper handwashing and PPE protocols. During interview, RN 5 stated she forgot to apply a gown before starting wound care, and Regional Support Nurse 2 stated gloves should have been changed at least two times during the dressing changes.
Missing Emergency Call Systems in Public Restrooms
Penalty
Summary
The facility failed to ensure that working emergency call systems were available in resident-accessible bathrooms and bathing areas. During observation, the woman's public restroom in the back hallway was found to have no key or emergency call system, and later the public restrooms on the back hall and east hall were again observed to have no key or emergency call bell systems. In interview, the administrator stated she was not aware of the need to have an emergency call light or key for a public bathroom if it could be accessed and said she had been told different things. When a policy for the call system was requested, it was not provided.
Inaccurate Narcotic Drug Counts and Recordkeeping
Penalty
Summary
The facility failed to maintain accurate drug records and account for all controlled substances on two nursing units. During observations, discrepancies were found between the narcotic count logs and the actual number of medications present in the drug packs. On the East unit, the narcotic count log for hydrocodone-acetaminophen 5-325 mg tablets indicated 23 available, but only 22 were present, and another log indicated 30 available with only 29 present. The RN responsible stated she may have forgotten to sign out the medications after administration, as she typically signs the narcotic log as she gives them. On another unit, similar discrepancies were observed. The count log for clonazepam 0.5 mg tablets showed 17 available, but only 16 were present, and the log for Ativan 1 mg tablets showed 8 available, but only 7 were present. The QMA responsible indicated she was passing medications on two halls and was behind, but normally signs the medication out as she gives it. The facility's policy requires each dose to be recorded at the time of administration and the drug supply to be confirmed before and after assembling the required dose, including documentation of date, time, dosage, signature, and quantity remaining.
Failure to Follow Physician Orders for Wound Care
Penalty
Summary
The facility failed to ensure that physician orders for wound care were consistently followed for one resident with multiple wounds. Review of the clinical record, care plans, and the Electronic Medication Administration Record (EMAR) revealed that several wound treatments were not documented as completed on multiple dates, despite active physician orders. The facility's policy requires all physician orders to be implemented and followed as received, but documentation gaps were identified for various wound care treatments, including the application of Betadine, Medihoney, and the use of pillow boots and gauze for wounds on the resident's toes and foot. The resident involved had a complex medical history, including cerebral infarction, hemiplegia, diabetes, dysphagia, aphasia, peripheral vascular disease, and recent toe amputations. The care plans detailed multiple wounds and interventions, such as skin assessments, wound treatments, and the use of pressure-reducing devices. The resident also exhibited behavioral symptoms, including restlessness and resistance to care, which sometimes resulted in the removal of dressings and boots. Despite these challenges, the EMAR showed that wound care treatments were not signed as completed on several occasions, indicating a lack of adherence to physician orders. Specific dates were identified where wound care orders were not documented as completed, including treatments for abscesses, arterial ulcers, and post-amputation care. The deficiency was confirmed through observation, interview, and record review, and the facility's policy on following physician orders was provided by the Director of Nursing. This failure to document and ensure completion of ordered wound care services constituted a deficiency under the cited regulation.
Failure to Notify Physician and Representative of Resident's Condition Change
Penalty
Summary
The facility failed to notify the physician and resident representative of a change in condition for a resident with a pressure injury and facial bruising. The resident, who had diagnoses including personality disorder, diabetes mellitus, and dementia, was found to have a stage 2 pressure injury on the left buttock. Although the nurse reported the open area to the Assistant Director of Nursing (ADON) on 12/23/24, the ADON did not follow up on it, and a treatment order was not obtained until 1/10/25. Additionally, the resident's representative was not notified of the pressure wound or the bruising around the eyes, which was first observed on 1/1/25. The Director of Nursing (DON) confirmed that there was no record of the resident's representative being notified of the bruising when it was discovered. The facility's policy requires prompt notification of changes in a resident's condition to the resident, their attending physician, and the resident's responsible party. However, this policy was not followed, as evidenced by the lack of timely communication regarding the resident's pressure injury and facial bruising. This deficiency was identified during a complaint investigation.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure medications were administered according to physician's orders and professional standards, resulting in a medication error rate of 16.13%, which is significantly higher than the acceptable threshold of 5%. During a medication pass, four residents were observed, and five medication errors were identified out of 31 opportunities. For Resident 10, the medication asenapine was not administered sublingually as prescribed. Resident 39 received insulin without the pen needle being properly primed, which is against the standard procedure. Similarly, Resident 42's insulin pen was not primed correctly before administration. Additionally, Resident 30 was given an incorrect dose of olanzapine due to a discrepancy between the medication administration record and the medication label, which was not verified against the physician's orders. The facility's policy on medication administration, which includes reviewing the medication administration record and checking for discrepancies, was not followed. The insulin injection instruction leaflet provided by the facility also emphasized the importance of performing a safety test before each injection, which was not adhered to in the observed cases.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling, dating, and storage of medications, as observed in two medication carts. On the 200 hall east medication cart, several insulin pens, including Humalog and Lantus, were found opened without an 'opened on' or expiration date. Additionally, a Lantus insulin pen had an expiration date of 9/23/24, and a Humalog insulin pen lacked an identification tag or resident name with an expiration date of 10/14/24. Other issues included an opened bottle of Pro-Stat lacking a label or opened date, and two insulin lispro pens with the name rubbed off the identification tag. Furthermore, two insulin lispro pens and two novolog insulin pens were not refrigerated as required until opening. Similarly, the 100 hall west medication cart contained expired and improperly labeled medications. Humalog and insulin lispro pens had expired on 9/11/24, and several insulin pens, including Basaglar and Novolog, were opened without an 'opened on' or expiration date. The cart also contained an opened bottle of Pro-Stat without a label or opened date. The Director of Nursing acknowledged the issue of injections not being refrigerated properly due to the pharmacy delivering them without ice packs. The facility's policy on medication storage, dated 6/2012, was provided, which outlined the proper storage and disposal procedures for medications.
Failure to Serve Food at Palatable Temperatures
Penalty
Summary
The facility failed to ensure that food was served at palatable temperatures, as evidenced by multiple resident complaints and a test tray evaluation. On several occasions, residents reported that their food was cold and tasted bad. Specifically, Resident 52, Resident 31, Resident 15, and Resident 42 all indicated dissatisfaction with the temperature and taste of their meals. A test tray obtained on October 21, 2024, revealed that the food temperatures were significantly below the expected serving temperature, with BBQ chicken at 102.9°F, roasted potatoes at 109.7°F, and yellow squash at 107.9°F. The Dietary Manager acknowledged the issue, stating that food should be served at approximately 148°F and expressed awareness of the problem, attributing it to the need for new insulated holders and carts. The facility's current Food Temperatures policy, provided by the Dietary Manager, indicated that best efforts would be made to present hot foods hot and cold foods cold at the point of service. However, the policy was undated, and the manager's acknowledgment of the issue suggests a lack of effective implementation of this policy, leading to the deficiency in maintaining appropriate food temperatures for residents.
Improper Preparation of Pureed Diets
Penalty
Summary
The facility failed to ensure that food was correctly prepared for four residents who were on pureed diets. During an observation, a staff member, referred to as [NAME] 5, was seen preparing pureed beef and cheddar sandwiches. The preparation involved blending ingredients such as pre-cooked roast beef, hamburger buns, cheese, and an excessive amount of mayonnaise, totaling 13 ounces. The staff member noted that the food did not look right and would likely taste like mayonnaise. She mentioned that she usually added broth for consistency but did not do so because the new recipe did not call for it. Additionally, expired milk was used in the preparation, which was not noticed by the Dietary Manager. The Dietary Manager acknowledged that the menu and recipes were new to the facility and admitted that 13 ounces of mayonnaise was excessive. He stated that he would have advised using milk to achieve the appropriate consistency. The facility's policies on pureed food preparation and the First In First Out (FIFO) method for stock management were not followed, as evidenced by the use of expired milk and the improper preparation of pureed food. The policies indicated that milk, broth, soup, gravy, juice, and margarine should be used to thin pureed food and that expired items should be discarded, which was not adhered to in this instance.
Sanitation Deficiencies in Food Preparation
Penalty
Summary
The facility failed to ensure food was prepared under sanitary conditions during multiple observations in both the kitchen and dining areas. During a lunchtime dining observation, staff from the Activities Department were seen assembling and serving hot dogs without changing gloves between handling different food items and condiment bottles. Additionally, these staff members were not wearing hairnets while preparing food. In the kitchen, the Dietary Manager was observed without a beard net, and other staff members wore hairnets that did not fully cover their hair. Further observations revealed that a staff member, identified as [NAME] 5, did not change gloves after touching various non-food surfaces before handling food items, such as a bread bun. The Dietary Manager acknowledged that gloves should be changed after touching non-food items and that hairnets should cover all hair, including facial hair. The facility's policies on glove use and hair restraints were provided, indicating that gloves should be changed to prevent cross-contamination and that hair restraints should be worn at all times in the kitchen.
Documentation and Medication Administration Deficiencies
Penalty
Summary
The facility failed to ensure complete and accurate documentation for several residents, particularly concerning insulin administration and medication timing. For Resident 53, the clinical record lacked documentation from the nurse who administered insulin on specific dates, despite the Medication Administration Record (MAR) indicating that insulin was given by the nurse on duty. Similarly, Resident 16's record showed insulin administration by a Qualified Medication Aide (QMA) who was not qualified to administer insulin, as per the facility's scope of practice guidelines. This issue was also observed with Resident 15, where the MAR indicated insulin administration by QMA 10, who was not authorized to do so. Additionally, the facility failed to administer medications on time for several residents. Residents 15, 17, 42, 259, and 22 did not receive their medications scheduled for 8 P.M. on 10/15/24 at the correct time. The night shift nurse administered the medications late, and there was a lack of proper documentation to reflect the actual time of administration. The controlled drug receipt/record/disposition forms indicated that the medications were given at 8:00 P.M., but the time card of RN 22 showed they clocked in at 9:45 P.M., suggesting discrepancies in the documentation. The Director of Nursing (DON) confirmed that QMAs were not permitted to administer insulin and that a nurse would give the insulin for the QMA, who would then mark it as done. The facility's guidelines for nursing documentation emphasized the importance of accurate and timely record-keeping, stating that if an action was not documented, it was considered not done. The report highlights significant issues with documentation practices and adherence to professional standards within the facility.
Failure to Obtain Physician Order for Crushed Medications
Penalty
Summary
The facility failed to ensure physician consultation was provided before altering the treatment of a resident by modifying medications prior to administration. Resident 47, who was severely cognitively impaired and dependent on staff for various activities, was given medications in a crushed form without a physician's order or notification. The resident's clinical record, including physician orders and care plans, did not contain any documentation authorizing the crushing of medications. During an observation, an LPN was seen crushing four tablets and opening one capsule, mixing them with chocolate pudding, and administering the mixture to Resident 47. The Director of Nursing confirmed the absence of a physician order or evaluation for crushing the medications. The facility's policy on medication administration required checking physician orders and a 'Crush List' reference before crushing medications, which was not followed in this instance.
Failure to Complete MDS Assessments Timely
Penalty
Summary
The facility failed to complete the Minimum Data Set (MDS) assessments for two residents within the required 14-day period following their admission. Resident 261's clinical record review on October 17, 2024, revealed that their Admission MDS was still in progress and incomplete, despite the resident being admitted earlier. Similarly, Resident 259's clinical record review on October 21, 2024, showed that their Admission MDS was also in progress and not completed. The Director of Nursing confirmed that the facility's expectation was to complete the Admission MDS within 14 days of admission, in accordance with the Resident Assessment Instrument (RAI) manual guidelines for comprehensive assessments.
Inaccurate MDS Assessments Lead to Care Planning Deficiencies
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in care planning and documentation. Resident 50, who was moderately cognitively impaired and required supervision for daily activities, was observed with a chair alarm on multiple occasions, yet the MDS assessment did not reflect the use of this device. Additionally, the resident's care plan lacked interventions for the chair alarm and Dycem device, as well as fortified foods, despite a physician's order for a general diet with fortified foods. The MDS Coordinator acknowledged the omission of the chair alarm in the assessment, and the Director of Nursing confirmed the facility's policy to use the Resident Assessment Instrument as a guide for MDS assessments. Resident 30's MDS assessment inaccurately documented the receipt of an antiplatelet medication, which was not present in the physician orders for September and October 2024. The resident, who was cognitively intact and required partial assistance for daily activities, was receiving multiple medications, including antipsychotic and antianxiety drugs. The MDS Coordinator admitted that the antiplatelet medication was marked in error on the assessment. These inaccuracies in the MDS assessments highlight the facility's failure to ensure accurate documentation and care planning for its residents.
Failure to Develop Communication Care Plan for Non-English Speaking Resident
Penalty
Summary
The facility failed to develop a care plan for a resident who primarily spoke Spanish, which was necessary to address her communication needs. During an observation, it was noted that there was no Spanish communication board available in the resident's room. The resident's clinical record, which included diagnoses of weakness, osteoarthritis, and dementia, did not contain an order for communication devices or a care plan addressing her communication needs. The resident was moderately cognitively impaired and required supervision for daily activities, yet her communication needs were not adequately planned for. Further observations revealed that the communication board was not readily accessible, as it was found under a stack of papers. Additionally, the resident was seen attempting to communicate in Spanish with a CNA, who did not understand her and did not attempt to facilitate communication. Interviews with facility staff, including the ADON, confirmed that there should have been a care plan in place for the resident's communication needs. The facility's policy on communication in the predominant language was not adhered to, as the resident was not fully informed in a language she understood.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to update the care plans for two residents, leading to deficiencies in their care. Resident 50, who has diagnoses including weakness, osteoarthritis, and dementia, was found to have a care plan that lacked necessary interventions such as a chair alarm and a Dycem device, despite being at risk for falls. The Assistant Director of Nursing acknowledged that care plans should be updated with each fall, indicating a lapse in the facility's protocol to ensure resident safety. Similarly, Resident 36, who has complex medical conditions including sepsis and end-stage renal disease, returned from a hospital admission for sepsis with a urinary tract infection, yet their care plan was not updated to reflect these changes. The Director of Nursing confirmed that the care plan should have been revised following the hospitalization. The facility's policy states that comprehensive care plans should be reviewed and updated quarterly or more frequently based on changes in the resident's condition, which was not adhered to in these cases.
Failure to Ensure Professional Standards in Diagnostic Practices
Penalty
Summary
The facility failed to ensure that the practitioner's diagnostic practices met professional standards of care for a resident diagnosed with schizoaffective disorder and bipolar disorder after admission. The resident, who was admitted with diagnoses including dementia, major depressive disorder, and anxiety, was found to be severely cognitively impaired and dependent on staff for various activities. The resident was receiving multiple medications, including antipsychotic, antianxiety, and antidepressant medications, but the clinical record lacked a care plan related to behavioral disturbances requiring antipsychotic medication use or monitoring for side effects. A pharmacy medication review indicated that the resident was receiving risperidone and Depakote for dementia with behaviors, but the physician changed the diagnosis associated with these medications to schizoaffective disorder and bipolar disorder, respectively. However, there was no physician evaluation found related to these diagnoses. Additionally, the facility was unable to provide a policy related to services meeting professional standards when requested by the surveyors.
Failure to Administer Proper Pressure Ulcer Care
Penalty
Summary
The facility failed to provide care consistent with professional standards to prevent the progression of pressure ulcers for a resident with chronic obstructive pulmonary disease and diabetes mellitus. The resident, who was cognitively intact and required assistance for daily activities, had physician orders for the treatment of stage three pressure ulcers on the sacral region and left heel. These orders included specific wound care procedures and the use of devices to alleviate pressure. However, the facility did not consistently administer these treatments as ordered, and there were multiple instances where treatment administration was not documented. Additionally, a Qualified Medication Aide (QMA), who was not authorized to administer treatments for advanced skin conditions, was documented as having administered treatments. The resident's left heel wound tested positive for methicillin-resistant Staphylococcus aureus, and the sacral wound worsened after the failure of an air pressure mattress. The facility's Assistant Director of Nursing confirmed that QMAs should not administer such treatments, and the Director of Nursing provided documentation indicating that QMAs are not permitted to administer treatments for stage two, three, and four pressure ulcers. Despite a request, the facility did not provide a policy related to the treatment and staging of wounds, highlighting a lack of adherence to professional standards and proper documentation practices.
Failure to Implement Dietary Recommendations for Resident with Weight Loss
Penalty
Summary
The facility failed to ensure diet recommendations were followed for a resident with significant weight loss. The resident, who had diagnoses including gastro-esophageal reflux disease, schizoaffective disorder, and dementia, was noted to be moderately cognitively impaired and required partial assistance for toileting and dressing. Despite physician orders for a general diet with regular texture and thin liquid consistency, the resident experienced a 15.1% weight loss over six months. Nutrition at Risk Reviews repeatedly recommended fortified foods with meals to prevent further weight loss, but the clinical record lacked an order for such dietary changes. Interviews with the Director of Nursing and the Diet Manager revealed that the resident should have been on supplements due to the significant weight loss. The Diet Manager had discussed the resident's weight loss with the dietitian and suggested fortified shakes and other supplements, but no changes had been implemented. The facility's policy indicated that residents with significant weight changes should be monitored and addressed by all disciplines, yet the necessary dietary interventions were not put in place for the resident.
Failure to Follow Pharmacy Recommendation for Medication Management
Penalty
Summary
The facility failed to ensure that a pharmacy recommendation was followed for a resident identified as having unnecessary medications. The resident, who was admitted with diagnoses including dementia and cognitive communication deficit, was severely cognitively impaired and required assistance for daily activities. The resident was prescribed omeprazole, a proton pump inhibitor (PPI), but the clinical record lacked a care plan related to its use. A pharmacy recommendation suggested reducing or holding the omeprazole for two weeks and discontinuing it if no gastrointestinal symptoms occurred. However, the electronic medication administration record showed that the medication was held for 14 days and then restarted without documentation of any gastrointestinal symptoms or rationale for continuing the medication. The facility's policy on pharmacy recommendations stated that medication regimens should be reviewed monthly to ensure effectiveness and safety, with any concerns addressed and resolved per physician orders. Despite this policy, the clinical record for the resident did not document any follow-up on the pharmacy's recommendation or the resident's condition during the medication hold period. This lack of documentation and follow-up indicates a failure to adhere to the facility's policy and ensure the resident's medication regimen was appropriately managed.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to implement infection prevention measures by not adhering to physician orders for enhanced barrier precautions during wound care for a resident. The resident, who was severely cognitively impaired and required assistance with daily activities, had a left calf abrasion that needed specific wound care procedures. The physician's orders included enhanced barrier precautions, which required the use of personal protective equipment (PPE) such as gowns and gloves during high-contact care activities. During an observation, an LPN provided wound care to the resident without wearing a gown, despite the presence of a sign indicating the need for enhanced barrier precautions. The LPN followed some procedures, such as washing hands and wearing gloves, but failed to comply with the full PPE requirements as outlined in the facility's policy. This oversight was confirmed during an interview with the MDS coordinator and was contrary to the facility's policy on enhanced barrier precautions, which was provided by the Director of Nursing.
Failure to Update Care Plan for New Diagnosis and Medication
Penalty
Summary
The facility failed to develop a care plan for a resident who returned from the hospital with a new diagnosis and medication order. Resident M, who had a history of moderate cognitive impairment and required assistance for transfers and toileting, was discharged from the hospital with a diagnosis of cellulitis of the right lower limb and a prescription for clindamycin. Despite these changes, the clinical record did not include an updated care plan to address the new diagnosis and medication. The facility's policy required that new diagnoses or medications be added to the care plan upon admission or readmission. However, this was not done for Resident M, as confirmed by the MDS Coordinator. The facility's Baseline Care Plan Assessment/Comprehensive Care Plans policy outlined that care plans should be revised and updated based on discussions in Morning/CQI meetings, but this process was not followed in this instance, leading to the deficiency.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to ensure physician orders were followed for one of the three residents reviewed for medications. Specifically, a resident with diagnoses including intellectual disabilities, generalized epilepsy, and hypotension did not have their blood pressure parameters followed when administering Midodrine HCI, an antihypotensive agent. The resident's clinical record indicated that the medication was given multiple times outside of the prescribed blood pressure parameters, and there was no care plan developed related to hypotension. Additionally, the EMAR showed instances where the medication was signed as given without documenting the required blood pressure readings. Interviews with the nursing staff revealed that the standard procedure for medications with blood pressure parameters was not consistently followed. The RN indicated that medications should be placed in a separate cup, and blood pressure should be taken before administration, holding the medication if the blood pressure is out of the specified range. However, this procedure was not adhered to, as evidenced by the EMAR and the lack of documentation. The facility's policy on following physician orders was provided by the DON but was undated and not effectively implemented in this case.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 187 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Princeton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Riveroaks Health Campus | 1.3 mi | ★★★★★ | 8 | 0 |
| Transcendent Healthcare Of Owensville | 9.2 mi | ★★★★★ | 2 | 0 |
| Oakview Nursing & Rehab | 11.5 mi | ★★★★★ | 7 | 0 |
| Good Samaritan Home & Rehabilitative Center | 12.8 mi | ★★★★★ | 1 | 0 |
| North River Health Campus | 16.2 mi | ★★★★★ | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.