Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Carnegie Post Acute Care At Princeton Llc during CMS and state inspections, most recent first.
A resident with a history of skin breakdown and multiple medical conditions did not receive a physician-recommended pressure ulcer treatment for three days after the recommendation was made. The facility delayed implementing the new wound care regimen, waiting for an official report before updating the treatment orders, despite policy requiring prompt adherence to physician orders.
The facility failed to maintain an ongoing review of their Antibiotic Stewardship Program, as evidenced by inadequate documentation and tracking of antibiotic use. A resident was prescribed antibiotics without meeting necessary criteria, and the facility's AS binders were not updated. The CNO and DON were unable to provide evidence of proper oversight, and the QAPI meetings lacked documented AS data.
The facility failed to maintain a designated Infection Preventionist (IP) dedicated solely to the infection prevention and control program (IPCP) and physically working onsite. The Chief Nursing Officer (CNO) acted as the IP after the last IP resigned, but only visited the facility three times a week and could not demonstrate accountability for being onsite during lapses. The facility's IP timeline showed multiple lapses without a designated IP, with the longest gap from February to June.
The facility failed to accurately complete the MDS for three residents, leading to deficiencies in the assessment process. A resident with behavior symptoms was inaccurately coded as having none, another resident's smoking status was overlooked, and a third resident requiring assistance with ADLs was incorrectly marked as independent.
A facility failed to ensure timely face-to-face physician visits and progress notes for a resident with multiple diagnoses, including stroke and depression, from April 2024 to January 2025. The resident, with moderate cognitive impairment, did not receive documented visits for several months, violating the facility's policy requiring visits every 30 days initially and every 60 days thereafter.
A facility failed to ensure adequate indication for the use of Seroquel in a resident with behaviors. The resident, admitted with cerebral infarction, major depressive disorder, and type 2 diabetes, was prescribed Seroquel for mood disorder and later for schizophrenia, despite no schizophrenia diagnosis. The facility's policy emphasizes non-medication approaches and appropriate indications for antipsychotic use, which were not adequately followed, leading to the deficiency.
A facility failed to complete the Admission MDS for a resident within the required 14-day timeframe. The MDS Coordinator admitted the assessment was overdue, despite facility policy aligning with CMS regulations. This deficiency was identified through interviews and record reviews.
A facility failed to complete and transmit the MDS for a resident within the required timeframe post-discharge. The MDS was not completed within 14 days as required, and the MDS Coordinator was unsure of the reason for the delay. The deficiency was identified during a review of MDS records over 120 days old.
The facility failed to ensure the Infection Preventionist attended a QAPI meeting and did not review Antibiotic Stewardship data as required. The LNHA confirmed the absence of the IP and the missing AS data during a review, despite facility policies mandating these actions.
The facility failed to provide proper PPE for laundry staff, as observed during a survey. Staff were using short-sleeved hospital gowns instead of long-sleeved disposable PPE gowns, contrary to facility policy. The deficiency was acknowledged by the DON, CNO, and DH, who confirmed the lack of appropriate PPE in the laundry area.
A facility failed to report an alleged abuse incident involving a resident to the New Jersey Department of Health. The resident, with multiple diagnoses and moderate cognitive impairment, reported being restrained, which was investigated and attributed to the use of TED stockings. Despite notifying the LTC Ombudsman, the facility did not inform the state health department, violating their policy and state regulations.
Delay in Initiation of Physician-Recommended Wound Care
Penalty
Summary
The facility failed to initiate a wound care treatment as recommended for three days, contrary to professional standards of practice. A resident with multiple diagnoses, including acute respiratory failure, hypertension, lack of coordination, and anxiety disorder, was admitted with a potential for skin breakdown and had a documented skin injury involving the sacrum, right buttock, and left great toe. The care plan specified wound care per physician orders. On 7/24/25, the wound care team recommended a specific treatment regimen for a pressure ulcer, including cleansing with acetic acid, application of zinc oxide cream, medical-grade honey gel, calcium alginate, and foam dressing, to be performed daily and as needed. Despite these recommendations, the facility did not implement the new wound care orders until 7/27/25, waiting for the official report before making changes to the resident's treatment. The Director of Nursing confirmed that the facility delayed the initiation of the recommended wound care for two days, from 7/24/25 to 7/27/25, and did not consider this a delay in treatment. However, the facility's own policy required following treatment as ordered, which was not adhered to during this period.
Deficient Antibiotic Stewardship Program and Documentation
Penalty
Summary
The facility failed to maintain an ongoing review for their Antibiotic Stewardship (AS) Program, as evidenced by the lack of proper documentation and tracking of antibiotic use. During an interview, the Chief Nursing Officer (CNO), who was acting as the Infection Preventionist (IP), and the Director of Nursing (DON) were unable to provide evidence of antibiotic tracking for a specific resident in January 2025. The surveyor found that the facility's AS binders were not updated, and the data from July 2024 to February 2025 was printed only after the survey began. Additionally, the facility's Quality Assurance and Performance Improvement (QAPI) meetings did not have documented AS data, indicating a lack of proper oversight and accountability in the AS program. A specific case involved a resident who was prescribed antibiotics for an upper respiratory infection without meeting the necessary criteria outlined in McGeer's Criteria. The resident's checklist showed missing documentation for required criteria, such as a chest radiograph interpretation and other respiratory and constitutional criteria. The CNO acknowledged that the nurse should have informed the doctor that the criteria were not met before starting the antibiotic. Furthermore, there was no progress note documenting the decision-making process regarding the antibiotic use. This incident highlights the facility's failure to ensure appropriate antibiotic use and documentation, as well as the lack of adherence to their own AS policy.
Failure to Maintain Onsite Infection Preventionist
Penalty
Summary
The facility failed to have a designated Infection Preventionist (IP) dedicated solely to the infection prevention and control program (IPCP) and physically working onsite. This deficiency was identified through interviews and review of facility documents, revealing that the facility did not comply with the NJ Executive Directive 21-012 and CMS QSO-22-19-NH Memo requirements. These directives mandate that the IP must be at least part-time, physically present onsite, and not an off-site consultant. The facility's IP timeline showed multiple lapses without a designated IP, with the longest gap from February 24, 2024, to June 2, 2024. During the survey, the Chief Nursing Officer (CNO) admitted to acting as the IP after the last IP resigned, but she only visited the facility three times a week and could not demonstrate accountability for being onsite during the lapses. The CNO acknowledged that the IP's role should be full-time and admitted the facility was not in compliance. The facility's job description for the IP position requires the individual to be qualified by education, training, experience, or certification in infection control and to work at least part-time at the facility.
Inaccurate MDS Completion for Three Residents
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) for three residents, leading to deficiencies in the assessment process. Resident #5, who was admitted with diagnoses including cerebral infarction, major depressive disorder, and type 2 diabetes, exhibited behavior symptoms such as screaming continuously during the look-back period. However, the MDS was inaccurately coded to indicate no behavior symptoms, despite documentation in the Medication Administration Record (MAR) showing otherwise. Resident #43, admitted with conditions such as orthopedic aftercare and major depressive disorder, was observed to be a smoker. The resident's comprehensive care plan included a focus on independent smoking, yet the MDS inaccurately indicated no current tobacco use. This discrepancy was due to the smoking assessment being overlooked during the MDS completion. Resident #53, with diagnoses including surgical aftercare and epilepsy, required assistance with activities of daily living (ADLs) and toileting hygiene. Despite this, the MDS inaccurately coded the resident as independent in these areas. The interdisciplinary care plan and task sheets indicated the need for assistance, but the MDS Coordinator relied on staff interviews that suggested independence, leading to the inaccurate coding.
Failure to Conduct Timely Physician Visits
Penalty
Summary
The facility failed to ensure that the responsible physician supervising the care of residents conducted face-to-face visits and wrote progress notes at least once every thirty days for a resident from April 2024 through January 2025. This deficiency was identified during a survey when it was observed that the resident, who was in a wheelchair with their head down and eyes closed, had not received the required physician visits. The resident's medical history included diagnoses such as cerebral infarction, major depressive disorder, and type 2 diabetes, and they had a moderate cognitive impairment as indicated by a BIMS score of 7 out of 15. Upon review of the electronic medical record and handwritten notes, it was found that the attending physician had not documented visits for several months, specifically May 2024, June 2024, October 2024, and January 2025. The facility's policy required that the attending physician visit residents at least once every thirty days for the first ninety days following admission and then at least every sixty days thereafter. However, the facility did not adhere to this policy, as evidenced by the lack of documented visits and progress notes for the specified months.
Inadequate Indication for Antipsychotic Medication Use
Penalty
Summary
The facility failed to ensure adequate indication for the administration of an antipsychotic medication, Seroquel, to a resident with behaviors. The resident, who was admitted with diagnoses including cerebral infarction, major depressive disorder, and type 2 diabetes, was observed multiple times in a wheelchair, often with their head down and eyes closed, and at times yelling for help. The resident was prescribed Seroquel for mood disorder and later for schizophrenia, despite the absence of a schizophrenia diagnosis in the medical records. The facility's policy on psychotropic drug use emphasizes non-medication approaches and requires appropriate indications for antipsychotic use. However, the resident's behavior monitoring records showed continuous screaming, and the comprehensive care plan included the use of psych medication for mood disorder and behavior problems. The certified consultant pharmacist noted the need to clarify the diagnosis for Seroquel use, as mood disorder is not an approved indication for the medication. The surveyor's review of the manufacturer's specifications for Seroquel highlighted warnings about increased mortality in elderly patients with dementia-related psychosis and the need for appropriate indications such as schizophrenia or bipolar disorder. Despite these guidelines, the facility did not provide adequate justification for the use of Seroquel in this resident, leading to the identified deficiency.
Failure to Complete Admission MDS Timely
Penalty
Summary
The facility failed to complete the Admission Minimum Data Set (MDS) for a resident within the required time frame, as mandated by federal regulations. The deficiency was identified during a review of the electronic health record, which showed that the Comprehensive Admission MDS for a resident admitted to the facility was still in progress beyond the 14-day requirement. The MDS Coordinator acknowledged that the assessment was overdue, stating it should have been completed two days prior. The facility's policy, which aligns with the Centers for Medicare and Medicaid Services (CMS) regulations, requires the completion of the Comprehensive Admission assessment no later than 13 calendar days after admission. Despite this policy, the MDS for the resident was not completed on time, indicating a lapse in adherence to the established procedures. This oversight was confirmed through interviews and record reviews conducted by the surveyor.
Failure to Timely Complete and Transmit MDS Post-Discharge
Penalty
Summary
The facility failed to complete and electronically transmit the Minimum Data Set (MDS) for a resident within the required timeframe following discharge. Specifically, the discharge MDS for a resident was not completed within 14 days of the discharge date, as required by the Centers for Medicare and Medicaid Services (CMS) regulations. The surveyor's review of the electronic medical record (EMR) revealed that the discharge MDS was missing, and the MDS Coordinator confirmed that it should have been completed within the specified period but was unsure of the reason for the delay. The deficiency was identified during a review of the Resident Assessment Task for MDS records over 120 days old. The discharge MDS was eventually completed and transmitted well past the required deadlines, with completion due by mid-December and transmission due by the end of December. The facility's policy, which aligns with CMS regulations, mandates the timely completion and submission of MDS data, but this was not adhered to in this instance, resulting in a deficiency finding.
Infection Preventionist Absence and Lack of Antibiotic Stewardship Review
Penalty
Summary
The facility failed to ensure the presence of the Infection Preventionist (IP) at one of the seven Quality Assurance and Performance Improvement (QAPI) meetings, specifically the 3rd Quarter meeting dated 10/17/24. The absence of the IP was confirmed by the Licensed Nursing Home Administrator (LNHA) during a review of the QAPI sign-in sheets. Additionally, the facility did not review the Antibiotic Stewardship (AS) data during the QAPI meetings as required. The LNHA was unable to locate the AS data in the QAPI binder, although other departmental information was present. The facility's policy on Antibiotic Stewardship mandates that the IP is responsible for infection surveillance and data collection, which should be reported to the QA committee. However, during the review, the LNHA acknowledged that the AS information was not available in the QAPI binder, despite being printed and reviewed at meetings. The surveyor noted that the AS tracking data from July 2024 to the present was printed by the President of Nursing on 2/17/25, but it was not included in the QAPI review. This oversight indicates a failure to adhere to the facility's policies on infection control and quality assurance processes.
Failure to Provide Proper PPE for Laundry Staff
Penalty
Summary
The facility failed to ensure that laundry staff had the proper personal protective equipment (PPE) necessary to handle linens, which is crucial for preventing the spread of infection. During a tour of the laundry room, the surveyor observed that there were no PPE gowns available on either the dryer or washer side. The Director of Housekeeping (DH) explained that staff sorted laundry by wearing gloves and a patient gown, which was then put into the laundry after use. However, the Chief Nursing Officer (CNO) clarified that this was not acceptable protection and that staff should be wearing long-sleeved disposable PPE gowns. The deficiency was further highlighted by the facility's own policies, which were not being followed. The policy on Linen Handling for Nursing Personnel and the undated policy on Personnel Linen Handling for Residents on Isolation both emphasized the need for proper PPE, including gowns and gloves, to handle contaminated linen. Despite these policies, the necessary PPE was not available, and the staff was not adhering to the required procedures, as confirmed by the Director of Nursing (DON), CNO, and DH during the surveyor's visit.
Failure to Report Alleged Abuse to State Health Department
Penalty
Summary
The facility failed to report an alleged violation of abuse involving a resident to the New Jersey Department of Health, as required by their policy. The incident involved a resident who was admitted with multiple diagnoses, including cerebral infarction and metabolic encephalopathy, and had a moderately impaired cognitive status. The resident's daughter reported via email that the resident claimed to have been restrained or tied up, which the facility's Director of Nursing acknowledged and initiated an investigation. However, despite the investigation concluding that no restraints were used and attributing the resident's discomfort to the use of TED stockings, the facility did not report the allegation to the state health department. The facility's policy mandates that all incidents of actual or suspected abuse be reported to the Administrator and the Department of Health within one business day. Although the facility notified the Office of the Long-Term Care Ombudsman, there was no documented evidence of notification to the New Jersey Department of Health. This oversight constitutes a failure to adhere to the facility's own policy and state regulations, as outlined in NJAC 8:39-4.1(a) and NJAC 8:39-9.4(f); Appx.B.
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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.
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Nursing homes near Princeton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Merwick Care & Rehab Center, Llc | 1.4 mi | ★★★★★ | 4 | 0 |
| Complete Care At Park Place Llc | 2.1 mi | ★★★★★ | 16 | 0 |
| Stonebridge At Montgomery Health Care Center | 4 mi | ★★★★★ | 0 | 0 |
| The Elms Rehab And Healthcare Center Of Cranbury | 6.3 mi | ★★★★★ | 15 | 1 |
| Clover Meadows Healthcare And Rehabilitation Cente | 7.5 mi | ★★★★★ | 1 | 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.