Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Princeton Health Care Center during CMS and state inspections, most recent first.
Surveyors found that multiple residents did not have water pitchers, [NAME] cups, or other drinks at bedside, with some having only leftover juice from lunch, despite facility policies requiring fresh bedside water and a structured hydration program. One resident complained of feeling very hot and repeatedly requested a drink, and an LPN and a NA confirmed that several residents lacked bedside water. The facility’s written procedures assigned night shift staff to replace used water containers daily with clean, filled containers, and dietary staff to wash and supply pitchers, yet these processes did not result in consistent bedside hydration for the affected residents.
Dishwasher temperatures were not maintained within required ranges during dishwashing. A Dietary Aide did not know the temp while washing breakfast dishes, and the ADM confirmed wash and rinse temps were below the facility’s stated standards before directing the aide to drain and refill the machine. The ADM said temps were checked only at the end of dishwashing, and later the Administrator and Maintenance Director reported the gauge did not appear to be working correctly, with moisture observed in the gauge.
Accurate clinical records were not maintained for three residents. A resident had a weight entered in the EMR despite documented refusal to be weighed, and two residents had TAR entries showing ordered braces/orthotics were applied when surveyor observation showed the devices were not in place. The DM and Administrator confirmed the discrepancies between the charted documentation and what was actually observed.
Infection control lapses were observed during meal service and ice pass activities. A NA served lunch trays to residents on 300 hall without performing hand hygiene before the meal, and later stated handwashing was usually done but was not done that day. On 200 hall, an NA was observed using a clear cup to dip ice from a pitcher and leaving the cup in the pitcher while serving ice; the Administrator confirmed this was an infection control issue.
A resident’s care plan included general splint/brace interventions such as monitoring effectiveness, providing PROM before application, checking for redness or skin breakdown, and hand hygiene, but it did not specify the exact anatomical placement of the splint/brace. The Administrator confirmed the care plan was not accurate about where the splint/brace should be placed, leaving staff without clear guidance for implementation.
Two residents had care plans that were not revised when changes occurred. One resident on a nectar-thick diet had a care plan that also listed jello, ice cream, and popsicles, which the DON confirmed were not consistent with nectar-thick liquids. Another resident had a fractured ankle with a walking boot, yet the care plan contained two different mobility interventions, including ambulating independently with a roller walker and ambulating with one-assist plus wheelchair use for long distances.
Failure to apply ordered orthotic devices for two residents. A resident with a hand contracture and a broken leg boot reported that the ordered devices were not always put on. The record showed orders for a podus boot and a carrot orthotic, and the TAR documented both as applied, but observation found neither device in place despite being charted as done.
A resident's record showed prior PCV13 and PPSV23 immunizations, but there was no documentation that PCV20 had been considered despite the facility policy and CDC guidance. An RN confirmed the vaccine had not been considered in accordance with facility and CDC policies.
The facility failed to maintain an effective infection prevention and control program, with 29 missed hand hygiene opportunities out of 193 observations and one missed during a medication pass. The Infection Preventionist acknowledged the lack of immediate education for staff and could not provide documentation of corrective actions.
A facility failed to protect residents from abuse, specifically misappropriation of medication, affecting three residents. Narcotic medications were borrowed by LPNs from one resident to administer to another, against protocol. The LPNs involved cited issues with obtaining medications as reasons for their actions. Residents did not express distress or miss doses due to these incidents.
The facility failed to timely revise comprehensive care plans for two residents receiving 1:1 care interventions. One resident had a 1:1 sitter after a fall, which was not documented in the care plan, while another had ongoing 1:1 care not timely reflected in the care plan. The DON and QAN acknowledged these oversights during the survey.
The facility failed to provide person-centered care by not adequately documenting and managing the use of one-on-one sitters for residents who had experienced falls. A resident had a Health Team Aide providing one-on-one care 24 hours a day since a fall, yet there was no physician's order for this intervention, and it was not included in the resident's care plan. Similarly, another resident was observed with a staff member sitting with her after a fall, but this was not documented in the care plan. The lack of documentation and formal assessment of the need for one-on-one sitters indicates a deficiency in the facility's approach to individualized resident care and safety management.
The facility failed to ensure accurate and current Daily Staffing Posting information, with discrepancies in reported staff numbers and hours worked. The forms were not posted in a prominent place accessible to residents and visitors. The Administrator acknowledged these inaccuracies and the improper posting location.
The facility failed to ensure cooking pans were dry before storage, leading to wet nesting, and improperly stored a hot/cold compress pack in the resident pantry refrigerator. This was confirmed by a Certified Dietary Manager and an LPN during a kitchen tour and pantry inspection.
The facility failed to provide a dignified dining experience by not serving residents seated together at the same time. Two residents were observed sitting together, but one had to wait three minutes to be served while the other ate. A CNA explained that a mix-up with the meal ticket led to this situation, and the administrator confirmed the error.
A facility failed to obtain informed consent for a psychotropic medication prescribed to a resident for inappropriate sexual behaviors related to unspecified psychosis. During a medical record review, it was found that the resident was prescribed aripiprazole 20 mg without documented informed consent. The DON confirmed the absence of informed consent during an interview.
A resident's medical information was compromised when a sign indicating an allergy to Latex was posted behind their bed, visible from the hallway. This violated the facility's confidentiality policy, which prohibits leaving personal or medical information viewable by unauthorized persons. The administrator acknowledged the privacy breach.
A strong unpleasant odor was detected in a resident's room during a survey, persisting over several days. An LPN suggested it might be due to soiled undergarments, but the Administrator later identified the PTAC unit as the source. Despite efforts, the odor remained unresolved.
The facility did not notify the Ombudsman of a resident's discharge to the hospital. Although the social worker stated that notification was made, no verification could be provided.
The facility did not update the PASARR for two residents with new or possible serious mental disorders. For one resident, the PASARR was outdated and not revised after a new diagnosis of delusions. The social worker confirmed the lack of an updated PASARR.
The facility failed to ensure that the PASARR for two residents accurately reflected their pre-admission diagnoses. For one resident, the PASARR did not include the diagnosis of unspecified psychosis, which was part of the admitting diagnosis. This discrepancy was confirmed during a record review and verified in an interview with the Social Services/Admissions Director.
The facility failed to develop comprehensive care plans for two residents. One resident, with traumatic brain disorder and dementia, was discharged without a care plan focus on discharge planning, despite arrangements for medical equipment and home health visits. Another resident, diagnosed with a psychotic disorder with delusions, lacked a care plan for this condition. The DON acknowledged the oversight and requested corrections.
The facility failed to obtain physician orders for 1:1 interventions for two residents at high risk for falls. One resident had a 1:1 sitter after a fall, but this was not documented in the care plan, and no physician order was obtained. Another resident received 1:1 care 24 hours a day due to frequent falls, but there was no physician order, and the intervention was not included in the care plan for falls. The DON acknowledged the lack of documentation and policy regarding 1:1 interventions.
A resident with PTSD did not receive adequate trauma-informed care, as the facility failed to identify and manage potential triggers since the last assessment in 2021. Despite a care plan, there was no follow-up on the resident's increased medication for tearfulness, and the DON confirmed the lack of recent assessments.
A facility failed to perform a scheduled hemoglobin A1c test for a resident on Ziprasidone, a medication that can elevate blood sugar levels. The test, ordered every six months, was last conducted several months ago, as confirmed by the DON during a survey.
The facility failed to maintain accurate medical records for two residents. One resident's MDS indicated PTSD, but it was not listed in their medical diagnoses, despite having a trauma care plan. Another resident's POST form lacked the physician's contact number, which was acknowledged by the social worker. These deficiencies were identified during the LTC survey process.
Failure to Provide Bedside Hydration Consistent With Resident Needs and Facility Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents consistently had access to drinks at bedside in accordance with their needs, preferences, and the facility’s hydration policies. During surveyor observations, multiple residents were found without water pitchers, [NAME] cups, or any water at their bedside. One resident explicitly stated feeling very hot and repeatedly requested a drink, and an LPN confirmed that this resident had no drinks at bedside. Another resident and that resident’s roommate were also observed without any drinks at bedside, which the LPN again confirmed. A nursing assistant later verified that several additional residents had no water or water pitchers at bedside, with some having only leftover juice in Kennedy cups from lunch. The facility’s written Hydration Program policy stated that each resident should receive sufficient fluid intake to maintain proper hydration and health, and the Bedside Water Containers policy required that residents have fresh drinking water at bedside daily, with two complete water container sets per resident. The procedure assigned night shift staff to collect used water containers and replace them daily with clean containers filled with fresh water and ice, which were to be cleaned and sanitized by the food and nutrition services department and then stored inverted until needed. The Dietary Manager reported that water pitchers are replaced and washed in the morning, with dietary staff delivering clean pitchers early and other staff distributing ice and water. The Administrator reported that the facility conducts a hydration pass twice a day. Despite these policies and processes, survey findings showed that several residents did not have water or appropriate bedside fluids available at the time of observation.
Dishwasher Temperatures Not Maintained During Dishwashing
Penalty
Summary
The facility failed to ensure dishes were cleaned under sanitary conditions in accordance with professional standards. During record review, staff interview, and observation, the dishwasher was observed during three cycles on 02/04/2026 at approximately 10:00 AM, and the wash temperatures ranged from 160-162 degrees Fahrenheit while the rinse temperatures ranged from 140-142 degrees Fahrenheit. The facility’s dishwashing log stated that corrective action was required if the wash temperature did not reach 152 degrees Fahrenheit or if the rinse did not meet 182 degrees Fahrenheit. A Dietary Aide reported not knowing the temperature while washing breakfast dishes. The Assistant Dietary Manager confirmed the temperatures and directed the aide to drain and refill the dishwasher. The Assistant Dietary Manager stated that dishwasher temperatures are taken at the end of all dishwashing. At 10:05 AM, the temperatures were rechecked and found to be within the acceptable range, with the wash temperature at 162 degrees Fahrenheit and the rinse temperature at 195 degrees Fahrenheit. The Administrator later confirmed the dishwasher temperatures, and at 11:05 PM the Administrator and Maintenance Director reported the gauge did not appear to be working correctly and that they had emailed Ecolab to come fix the problem. Moisture was observed in the gauge.
Inaccurate Documentation of Weights and Ordered Braces
Penalty
Summary
The facility failed to maintain accurate and complete clinical records related to treatment documentation and weight documentation for three residents. For Resident #7, a weight was documented in the electronic medical record even though progress notes documented that the resident had refused to be weighed in January 2026. The Dietary Manager confirmed the refusal documentation and the recorded weight, stated she did not know how the weight was entered, and noted that the resident was marked as refused on her note and weight sheet. For Resident #4, the resident had orders for a right podus boot to be worn for up to 6 hours on day shift and a carrot orthotic to the left hand for contracture every day shift. The TAR showed both devices as applied, but observation revealed that neither device was in place. The Administrator confirmed that the podus boot and carrot were not on the resident as ordered and as documented. For Resident #92, the resident had an order for a brace to the right upper extremity for 6 hours during day shift, and the TAR documented it as applied; however, surveyor observation showed the resident was not wearing the brace, and it remained off until surveyor intervention, while the TAR continued to reflect that it had been applied.
Infection Control Lapses During Meal Service and Ice Pass
Penalty
Summary
Provide and implement an infection prevention and control program. During observation and staff interview, the facility failed to maintain an infection control program to help prevent the spread of disease. During the noon meal on 02/02/25 on 300 hall, residents in rooms [ROOM NUMBER] through 306 were served lunch trays without hand hygiene being performed before eating. During interview at 1:10 PM, NA #35 stated, "We usually do wash their hands, but no I did not do it today. Now the one I just served I was gonna wash hers at the sink." Further observation showed the resident whose hands NA #35 planned to wash was sitting in bed with her tray in front of her. On 02/02/26 during the lunch tray pass on 200 hall, NA #39 was observed passing ice by using a clear cup to dip ice from the pitcher and leaving the cup in the ice pitcher while serving. When asked if this was how ice was normally passed, NA #39 stated that it was. During interview at 12:30 PM, the Administrator confirmed that leaving the cup in the ice pitcher was an infection control issue.
Incomplete Care Plan Instructions for Splint/Brace Use
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan with sufficient and specific instructions for Resident #92 regarding the use of a prescribed splint/brace. Record review of the care plan report revised 01/23/2026 showed interventions related to splint/brace use, including monitoring effectiveness, providing PROM prior to application, observing for redness or skin breakdown, washing hands prior to application of a hand splint, and reporting concerns to nursing or restorative staff. However, the care plan did not identify the specific anatomical placement or location of the splint/brace, leaving staff without clear guidance for where it was to be applied. On 02/04/26 at approximately 1:00 PM, the Administrator confirmed the care plan was not accurate regarding where to place the splint/brace.
Care Plans Not Revised After Changes in Diet and Mobility Needs
Penalty
Summary
The facility failed to revise two of 23 resident care plans when changes occurred. For Resident #7, the diet order specified a mechanical soft diet with ground meats and nectar/mildly thick consistency, but the care plan stated mechanical soft ground meat nectar thick per order and also directed staff to offer additional fluids such as jello, ice cream, and popsicles. On 02/05/2026, the DON confirmed the care plan listed nectar thickened liquids while also including items that are not considered thickened liquids, and confirmed that popsicles are thinner than nectar consistency liquids. The report also cited that, according to the National Dysphagia Diet and the IDDSI, ice cream and gelatin are not allowed with thickened liquid classifications. For Resident #64, the record showed an ankle fracture with a walking boot placed on 01/12/26. The comprehensive care plan included a mobility focus for ADL self-care performance deficit related to disease process, with an intervention initiated on 01/15/26 for ambulating one assist with a roller walker and wheelchair for long distances. The same care plan also included a fall-risk focus related to history of falls, medication use, and impaired mobility, with an intervention initiated on 05/23/23 for ambulating independently with a roller walker. On 02/05/26, the Administrator confirmed the comprehensive care plan contained two different mobility interventions.
Failure to Apply Ordered Orthotic Devices
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice by not applying physician-ordered devices for two residents reviewed for position and mobility. Resident #4 was observed with a contracture to the left hand and stated that a carrot orthotic was supposed to be applied but was not always put on, and that the right leg boot was broken and needed replacement. The record showed orders for a right podus boot to be worn for up to 6 hours on day shift and a carrot orthotic to the left hand every day shift, and the TAR indicated both devices were documented as applied. However, during observation, neither the carrot orthotic nor the podus boot was in place even though both had been checked off on the TAR. The report also states that this issue affected 2 of 2 residents reviewed for position and mobility.
Failure to Consider PCV20 for Eligible Resident
Penalty
Summary
The facility failed to offer pneumococcal vaccines in accordance with professional standards of practice. The facility policy titled, Pneumococcal Vaccine, stated that residents were to be offered immunizations in accordance with current CDC guidelines and recommendations, including consideration of a single dose of PCV20 for adults who had previously received both PCV13 and PPSV23 when the PPSV23 was given at age [AGE] or older and the interval since the last PCV13 or PPSV23 dose was five years or more. Review of Resident #7's electronic medical record showed the resident received PCV13 on 12/26/16 and PPSV23 on 01/27/18, and the resident was currently [AGE] years old and had been in the facility since 2022. The medical record contained no documentation that PCV20 had been considered for the resident. On 02/05/2026 at 9:38 AM, RN #14 confirmed that PCV20 had not been considered in accordance with the facility and CDC policies and stated he would contact the resident's health care provider.
Infection Control Deficiency Due to Missed Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, which is essential for providing a safe, sanitary, and comfortable environment and preventing the transmission of communicable diseases. Specifically, there were 29 missed opportunities for hand hygiene out of 193 documented observations, as well as one missed opportunity during a medication pass observed during the long-term survey process. These missed opportunities occurred over several dates in February, March, and April of 2024. During an interview, the Infection Preventionist acknowledged the lack of immediate education for staff who missed hand hygiene opportunities and was unable to provide documentation of any corrective education provided.
Misappropriation of Medication in LTC Facility
Penalty
Summary
The facility failed to ensure residents were free from abuse, specifically misappropriation of medication, affecting three residents. The issue was identified during an in-house audit conducted by the facility. It was found that narcotic medications were borrowed from one resident to administer to another, which is against the facility's protocol. This occurred multiple times for the residents involved, with one resident having their medication borrowed five times, another once, and the third resident twice. The incidents involved Licensed Practical Nurses (LPNs) who borrowed medications due to various reasons, such as the inability to obtain the medication from the pharmacy or issues with the medication dispensing system. The LPNs involved provided verbal and written statements acknowledging their actions and the reasons behind them. They believed they were acting in the best interest of the residents in pain, although this was not in line with the facility's procedures. Interviews with the residents involved revealed that they did not express any distress or mental anguish due to the incidents. The residents were described as pleasant, comfortable, and without voiced needs or concerns during the social worker's visits. The facility's management confirmed the incidents and acknowledged that the residents did not miss any doses of their medication due to the borrowing of narcotics.
Failure to Revise Comprehensive Care Plans Timely
Penalty
Summary
The facility failed to revise the comprehensive care plans for residents in a timely manner, leading to deficiencies in care planning. Resident #47 was observed with a black eye and had a 1:1 sitter intervention in place following a fall, which was not documented in the care plan. The resident had a history of falls and was identified as high risk due to confusion, deconditioning, and poor safety awareness. Despite the intervention being implemented, it was not included in the care plan, and the Director of Nursing acknowledged this oversight during an interview. Similarly, Resident #75 had a Health Team Aide providing 1:1 care, which was not timely reflected in the care plan. The intervention was documented in the medical record dating back several months, but the care plan was only updated recently. The Quality Assurance Nurse confirmed that the care plan had not been revised in a timely manner to reflect the ongoing 1:1 care. These findings indicate a failure to update and revise care plans to include necessary interventions for residents, as observed during the survey process.
Deficiency in Person-Centered Care and Documentation for Fall Interventions
Penalty
Summary
The facility failed to provide person-centered care by not adequately documenting and managing the use of one-on-one sitters for residents who had experienced falls. Resident #75 had a Health Team Aide (HTA) providing one-on-one care 24 hours a day since a fall on 09/18/23, yet there was no physician's order for this intervention, and it was not included in the resident's care plan for falls. The Director of Nursing (DON) acknowledged that the Interdisciplinary Team (IDT) determines the appropriateness of one-on-one sitters without a physician's order and without documenting the review process. Additionally, the facility's Social Worker did not routinely assess the psychosocial well-being of residents receiving one-on-one sitters, and there was no documentation of such an assessment for Resident #75. Similarly, Resident #47 was observed with a staff member sitting with her after a fall on 05/03/24, which resulted in a black eye and other minor injuries. Despite the use of a one-on-one sitter as an intervention, this was not documented in the resident's care plan. The DON confirmed that the IDT had not yet met to discuss the fall or the continued use of the one-on-one sitter for Resident #47. The lack of documentation and formal assessment of the need for one-on-one sitters indicates a deficiency in the facility's approach to individualized resident care and safety management.
Inaccurate and Inaccessible Daily Staffing Information
Penalty
Summary
The facility failed to ensure that the Daily Staffing Posting information was accurate and current, as identified during a long-term care survey. The Daily Staffing Posting Form was not posted in a prominent place readily accessible to residents and visitors. Additionally, the form did not accurately reflect the direct care staff, nor did it identify the actual number of staff and the actual hours worked. This deficiency was observed during the survey process of reviewing the sufficiency and competency of nursing staff, potentially affecting more than a limited number of residents and visitors. During the review of the Daily Staffing Posting Forms with the Administrator, it was found that the total number of Registered Nurses (RNs) for direct care staff was inaccurately reported. The Administrator admitted that RNs with administrative duties were included in the RN direct care staff count because they occasionally assisted floor staff. However, according to the Centers for Medicare & Medicaid Services guidelines, staffing should be reported based on the employee's primary role. The Administrator acknowledged that the RN staffing totals and hours worked were not accurate. Further discrepancies were identified in the Staffing Posting Forms for several dates, where the reported numbers of staff and hours worked did not match the actual numbers from the Detail Hours Overview report. For example, on one date, the form reported nine Certified Nursing Assistants (CNAs) working 103.5 hours, while the actual numbers were ten CNAs working 112 hours. Similar inaccuracies were found for Licensed Practical Nurses (LPNs) and RNs across multiple dates. The Administrator agreed that the forms did not reflect the total number of staff or the actual hours worked. Additionally, it was noted that the Daily Staffing Posting Form was not posted in a location easily accessible to residents and visitors, which the Administrator also acknowledged.
Improper Storage of Kitchen Equipment and Medical Supplies
Penalty
Summary
The facility failed to ensure that cooking and serving pans were completely dry before storing them, resulting in wet nesting. During an initial kitchen tour, it was observed that pans were stacked under the counter, and one was found to be wet on the right side. This was confirmed by the Certified Dietary Manager, who acknowledged that staff should have ensured the pans were dry before stacking and storing them. Additionally, a hot/cold compress pack was improperly stored in the resident pantry refrigerator, where cold snacks are kept. This was discovered during an inspection of the facility's North Pantry. A Licensed Practical Nurse confirmed that the hot/cold pack should not have been in the pantry freezer, indicating that there is a designated fridge behind the nurses' station for such items.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to provide a dignified dining experience for residents by not serving them simultaneously when seated together. On May 8, 2024, at 12:20 PM, in the South Dining room, two residents were observed sitting together at one table, while another resident sat alone at a different table. At 12:25 PM, one resident at the first table was served first, followed by the resident at the second table at 12:26 PM. The second resident at the first table had to wait three minutes while the first resident ate, and was only served at 12:29 PM. A staff interview with a CNA revealed that there was a mix-up with the meal ticket, leading to the decision to serve the resident at the second table to prevent their food from getting cold. The facility administrator confirmed that the second resident at the first table should have been served with or after the first resident, and not left waiting while the other resident at the same table ate.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent for the use of a psychotropic medication for a resident. During a medical record review, it was discovered that a resident was prescribed aripiprazole 20 mg tablet for inappropriate sexual behaviors related to unspecified psychosis. However, there was no informed consent documented for the use of this psychotropic medication. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the absence of informed consent for the medication prescribed to the resident.
Privacy Breach of Resident's Medical Information
Penalty
Summary
The facility failed to protect the privacy and confidentiality of a resident's medical information. During an observation, a sign was found posted behind a resident's bed indicating an allergy to Latex, which was visible from the hallway when the door and curtain were open. A record review confirmed the resident's allergy to Latex. The facility's policy on confidentiality states that personal or medical information should not be left unattended or viewable by unauthorized persons. The administrator confirmed that the sign infringed on the resident's privacy.
Unpleasant Odor in Resident's Room
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for its residents, as evidenced by a strong unpleasant odor observed in a resident's room during a long-term care survey. The odor was first noted during a tour of the 200 hall and persisted over several days. A Licensed Practical Nurse (LPN) suggested that the odor might be due to a resident placing soiled undergarments in drawers. However, the Director of Nursing (DON) and the Administrator later identified the smell as emanating from the packaged thermal air conditioner (PTAC) unit. Despite efforts to address the issue, the odor remained unresolved at the time of the report.
Failure to Notify Ombudsman of Resident's Hospital Discharge
Penalty
Summary
The facility failed to notify the Ombudsman of a resident's discharge to the hospital. This deficiency was identified during a record review and staff interview. The resident was discharged to the hospital on December 6, 2024, at 12:48 pm. During an interview on May 6, 2024, the social worker claimed that the Ombudsman was notified of the discharge but could not provide verification of this notification.
Failure to Update PASARR for Residents with New Diagnoses
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASARR) program under Medicaid for residents with newly evident or possible serious mental disorders. This deficiency was identified for two out of six residents reviewed during the long-term care process. Specifically, for one resident, the PASARR was dated over a year prior to the updated diagnosis of delusions due to a known physiological condition, and no subsequent PASARR was completed following this diagnosis. During an interview, the social worker acknowledged the absence of an updated PASARR for the resident's new diagnosis.
PASARR Screening Deficiency for Two Residents
Penalty
Summary
The facility failed to ensure that the Preadmission Screening and Resident Review (PASARR) for two residents accurately reflected their pre-admission diagnoses. Specifically, for Resident #80, the PASARR did not include the diagnosis of unspecified psychosis not due to a substance or known physiological condition, which was part of the admitting diagnosis on 06/16/22. This discrepancy was confirmed during a record review on 05/07/24 and verified in an interview with the Social Services/Admissions Director on 05/08/24.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop a complete and accurate comprehensive care plan for two residents. For the first resident, who had been living at the facility since 2022 and was discharged to a family member's home, the care plan did not include a focus on discharge planning. Despite the resident having diagnoses of traumatic brain disorder and dementia, and receiving discharge planning assistance from a state agency, the care plan was not updated to reflect the discharge process. The RN Case Manager confirmed that no focus on discharge planning was developed, even though arrangements for durable medical equipment, home health agency visits, and an appointment with the primary care provider were made prior to discharge. For the second resident, diagnosed with a psychotic disorder with delusions due to a known physiological condition, the facility did not develop a care plan for this diagnosis. The diagnosis was identified during a medical record review, and it was noted that the care plan had not been developed since the diagnosis was made. The Director of Nursing acknowledged the oversight and requested that the social worker make the necessary corrections.
Failure to Obtain Physician Orders for 1:1 Interventions
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, the facility did not obtain physician orders for one-on-one (1:1) interventions for residents who were at high risk for falls. Resident #47 was observed with a black eye and had a 1:1 sitter after a fall, but this intervention was not documented in the care plan, and no physician order was obtained. The Director of Nursing (DON) acknowledged that the Interdisciplinary Team (IDT) had not yet reviewed the fall or obtained a physician order for the 1:1 sitter. Similarly, Resident #75 had a Health Team Aide (HTA) providing 1:1 care 24 hours a day due to frequent falls, but there was no physician order for this intervention. The resident's care plan for falls did not include the 1:1 sitter intervention, although it was noted in the behavioral care plan. The DON stated that the IDT determines the appropriateness of 1:1 sitters but does not document the review process, and the facility lacks a policy regarding the duration of 1:1 interventions.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with Post Traumatic Stress Syndrome (PTSD). The resident, who has a history of trauma from a car accident, multiple strokes, brain aneurysms, and personal losses, was not assessed for PTSD triggers since October 2021. Despite having a care plan that included interventions such as ensuring safety, engaging in comforting activities, and identifying possible triggers, there was no evidence of follow-up or identification of specific triggers for the resident's PTSD. During the survey, it was noted that the resident experienced frustration and tearfulness, which led to an increase in medication without any documented follow-up to assess the effectiveness of this change. The Director of Nursing confirmed the lack of a recent Trauma Informed Care Assessment and acknowledged the oversight. The absence of a comprehensive approach to managing the resident's PTSD, including the identification and management of triggers, contributed to the deficiency identified during the survey.
Failure to Perform Scheduled Laboratory Tests
Penalty
Summary
The facility failed to obtain laboratory services as ordered by the physician for a resident, which constituted a deficiency. The resident had a physician's order for a hemoglobin A1c (HgbA1-c) test to be performed every six months. This test is crucial for monitoring average blood sugar levels over the past three months, especially since the resident was on Ziprasidone (Geodon) for psychosis, a medication known to potentially elevate blood sugar levels. Upon review, it was found that the last HgbA1-c test was conducted on 09/07/23, indicating that the test was not performed as per the six-month schedule. The Director of Nursing confirmed the oversight during the survey, acknowledging that the test had not been conducted as ordered.
Deficiencies in Medical Record Accuracy and POST Form Completion
Penalty
Summary
The facility failed to ensure the accuracy of medical records for two residents during the Long-Term Care Survey Process. For one resident, the Minimum Data Set (MDS) indicated a diagnosis of Post Traumatic Stress Syndrome (PTSD), but this diagnosis was not listed in the resident's medical records, although there was a care plan for trauma. The Director of Nursing confirmed the discrepancy during an interview but did not provide further information by the end of the survey. For another resident, the Physician Orders for Scope of Treatment (POST) form was incomplete, lacking the contact number of the physician who signed the order. This omission was acknowledged by the social worker during an interview. The absence of the contact number could hinder communication with the physician regarding any errors in the form, as per the 2021 POST form guidance.
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Illustrative
What surveyors actually found near you
We read the 30 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
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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) |
|---|---|---|---|---|
| Glenwood Healthcare Center | 2.2 mi | ★★★★★ | 0 | 0 |
| Bluestone Health And Rehabilitation | 8.5 mi | ★★★★★ | 15 | 1 |
| Mercer Healthcare Center | 9.8 mi | ★★★★★ | 0 | 0 |
| Westwood Center | 10.3 mi | ★★★★★ | 0 | 0 |
| Bland County Nursing & Rehab Center | 12.2 mi | ★★★★★ | 5 | 0 |
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