Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 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.
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.
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.
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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) |
|---|---|---|---|---|
| Riveroaks Health Campus | 1.3 mi | — | 0 | 0 |
| Transcendent Healthcare Of Owensville | 9.2 mi | — | 2 | 0 |
| Oakview Nursing & Rehab | 11.5 mi | — | 0 | 0 |
| Good Samaritan Home & Rehabilitative Center | 12.8 mi | — | 1 | 0 |
| North River Health Campus | 16.2 mi | — | 0 | 0 |
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