Carnegie Post Acute Care at Princeton LLC

Inspectors wroteComplaint # 2624594, 2593784, 2584559 Based on interviews, medical record review, and review of pertinent facility documents on 10/17/25, it was determined that the facility failed to initiate a wound care treatment as recommended for three days in accordance with professional standards of practice. This deficient practice was identified for 1 of 5 residents reviewed for wounds (Resident #5). The evidence was as follows: A review of the admission Record (AR) revealed that Resident #5 was admitted to facility with diagnoses that included but were not limited to, acute respiratory failure, hypertension, lack of coordination, and anxiety disorder. A review Resident #5's comprehensive Minimum Data Set (MDS) dated [DATE] revealed that the resident had a Brief Interview Mental Status (BIMS) score of 11 out of 15, indicating that the resident's cognition was moderately impaired. [...]

Inspectors wroteBased on interviews and review of facility documents, it was determined that the facility failed to maintain an ongoing review for their Antibiotic Stewardship (AS) Program. This deficient practice was evidenced by the following: On 2/20/25 at 1:54 PM, the surveyor interviewed the Chief Nursing Officer (CNO), who stated she was the acting Infection Preventionist (IP) since the last one had recently resigned. She stated she attended the quarterly Quality Assurance & Performance Improvement (QAPI) meeting and reports on infection control. The surveyor requested to review the AS. The CNO requested the Director of Nursing (DON) to join the meeting. At 2:19 PM, the DON joined the interview with 2 Antibiotic Stewardship binders, 2024 and 2025. [...]

Inspectors wroteBased on interviews and review of pertinent facility documents, it was determined that the facility failed to have a designated Infection Preventionist (IP) dedicated solely to the infection prevention and control program (IPCP) and physically worked onsite in the facility. This deficient practice was evidenced by the following: Reference: According to the NJ Executive Directive 21-012 (revised 12/22/22) included The facility's designated individual(s) with training in infection prevention and control shall assess the facility's IPCP by establishing or revising the infection control plan, annual infection prevention and control program risk assessment, and conducting internal quality improvement audits. [...]

Inspectors wroteBased on interview, record review, and review of the Resident Assessment Instrument (RAI) User's Manual, it was determined that the facility failed to complete the admission Minimum Data Set (MDS), a periodic and federally mandated, standardized assessment tool, within the required time frame. This deficient practice was identified for 1 of 2 residents (Residents #339) reviewed for timing of assessments and was evidenced by the following: This deficient practice was evidenced by the following: On 2/21/25 a review of the electronic health record (EHR) reflected that Resident #339 was admitted to the facility on [DATE]. The Comprehensive admission MDS was noted to be in progress. On 2/21/25 at 12:45 PM, the surveyor interviewed the MDS Coordinator, who stated the MDS assessment on a new admission was due within 14 days of admission. [...]

Inspectors wroteBased on interview, review of medical records and review of the Resident Assessment Instrument (RAI) User's Manual, it was determined that the facility failed to complete and electronically transmit the Minimum Data Set (MDS), an assessment tool, within 14 days of the resident's discharge. This deficient practice was identified for 1 of 1 resident, (Resident # 83) reviewed in the Resident Assessment Task for MDS record over 120 days old. On 2/18/25, the surveyor reviewed the MDS history in the electronic medical record (EMR), which revealed that Resident #83 was discharged on 12/2/2024. The surveyor was unable to locate a discharge MDS in Resident #83's EMR. On 2/18/25, the surveyor interviewed the MDS Coordinator, who stated the discharge MDS on Resident #83 should've been completed within 14 days of the discharge date . She also stated, I'm not sure what happened. [...]

Inspectors wroteComplaint #: NJ 00179151 Based on observation, interview, review of medical records, other facility documentation, and review of the Resident Assessment Instrument (RAI) User's Manual, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS), an assessment tool, for 3 of 31 residents reviewed (Resident #5, Resident #43, and Resident #53) for MDS accuracy. This deficient practice was evidenced by the following: 1. On 2/19/25 at 11:33 AM, the surveyor observed Resident #5, in a wheelchair, in the day room on the 2nd floor. The resident was noted with their head down and eyes closed. On 2/19/25 at 02:43 PM, the surveyor observed Resident #5, out of bed, in a wheelchair in the bedroom, yelling out for help. On 02/19/25 at 02:46 PM, the surveyor observed Resident #5, in a wheelchair in the 3rd floor dining room yelling help continually. [...]

Inspectors wroteComplaint #: NJ 00179151 Based on interviews and review of pertinent facility documentation, it was determined that 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 from April 2024 through January 2025 for 1 of 34 residents, (Resident #5) reviewed for physician visits. This deficient practice was evidenced by the following: On 2/19/25 at 11:33 AM, the surveyor observed Resident #5 in a wheelchair in the day room on the 2nd floor. The resident was noted with their head down and eyes closed. A review of Resident #5's admission record reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; cerebral infarction (stroke), major depressive disorder (depression), and type 2 diabetes (high blood sugar). [...]

Inspectors wroteComplaint #: NJ 00179151 Based on observations, interviews, review of the medical record and review of other facility documentation, it was determined that the facility failed to ensure adequate indication for a resident with behaviors prior to the administration of an antipsychotic medication (Seroquel). This deficient practice was identified for 1 of 6 residents (Resident #5) reviewed for unnecessary medications and was evidenced by the following: On 2/14/25 at 12:13 PM, the surveyor observed Resident #5 in a wheelchair with raised footrests in the 3rd floor dining room ready for lunch. On 2/19/25 at 9:55 AM, the surveyor observed Resident #5 in a wheelchair in the day room on the 2nd floor. The resident was sitting with their head down and eyes closed. On 2/19/25 at 10:28 AM, the surveyor observed Resident #5 in a wheelchair in the day room on the 2nd floor. [...]

Inspectors wroteBased on interview and review of pertinent facility documentation, the facility failed to a.) ensure the required committee members, the Infection Preventionist (IP), was present for one of seven Quality Assurance and Performance Improvement (QAPI) meetings and b.) review of Antibiotic Stewardship (AS). This deficient practice was evidenced by the following: A review of the facility provided QAPI Meeting 3rd Quarter dated 10/17/24, did not reveal the Infection Preventionist (IP) signed in. A review of the facility provided QAPI Meeting 4rd Quarter dated 1/16/24, revealed the Infection Preventionist (IP) signed in. On 02/25/25 at 1:21 PM, the surveyor met with the Licensed Nursing Home Administrator (LNHA) to review the facility's QAPI. The LNHA reviewed the QAPI sign in sheets dated 10/17/24 and verified he did not see where the IP had signed in. [...]

Inspectors wroteBased on observation, interview, and a review of facility documentation, it was determined that the facility failed to ensure laundry staff had the proper personal protection equipment (PPE) necessary to handle linens to prevent the spread of infection. This deficient practice was evidenced by the following: On 02/20/25 at 2:34 PM, the surveyor toured the laundry room with the Director of Nursing (DON), the Chief Nursing Officer (CNO) and the Director of Housekeeping (DH). The surveyor observed 3 dryers in use and clean linens, which included patient johnny coats (hospital gowns), folded on a table. The tour continued into to the washing machine side. The surveyor observed empty linen carts. The surveyor did not observe any PPE. The surveyor asked the DH the process for sorting dirty laundry. He stated staff sorted the laundry by wearing gloves and a patient gown. [...]

Inspectors wroteComplaint #: NJ00178967 Based on interviews and review of pertinent facility documents on 10/31/24, it was determined that the facility failed to report an alleged violation of abuse and its subsequent findings to the New Jersey Department of Health state agency and follow their facility policy on Abuse, Neglect and Mistreatment of Residents for a resident (Resident #1). The deficient practice was evidenced by the following: According to Resident #1's admission Record (AR), Resident was admitted to the facility with diagnoses of that included but not limited to the following: Cerebral Infarction, Metabolic Encephalopathy, Hypertension, Respiratory Failure, and Glaucoma. [...]

Inspectors wroteBased on observation, interview and record review it was determined that the facility failed to a.) develop a comprehensive, person-centered care plan to address dementia care for Resident #16, b.) develop a comprehensive, person-centered care plan to address a sacral pressure ulcer for Resident #83, c.) develop a comprehensive, person-centered care plan to address the use of an antibiotic for Resident #109 and d.) develop a comprehensive, person-centered care plan to address pain management for Resident #122. This deficient practice was identified for 4 of 29 residents reviewed for comprehensive care plans and was evidenced by the following: 1. On 1/20/23 at 12:25 PM, the surveyor observed Resident #16 in the dining room in a recliner. The resident was alert but did not respond to the surveyor's inquiries. A review of the resident's medical record reflected the following: [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to a.) follow physician orders for Dilantin and Keppra (anti-epileptic medications used to control seizures) levels every three months since 8/9/2021 for Resident #13. This deficient practice was identified for 1 of 28 residents (Resident # 13) reviewed for physician orders; b.) act upon the Urology Consultation's recommnedation according to professional standards of clinical practice for Resident #90. This deficient practice was evidenced for 1 of 2 residents (Resident #90) reviewed for catheters. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to a.) consistently monitor fluid restriction instructions in accordance with the physician's order and professional standards of care and b.) carry out a dietitian recommendation for 1 of 2 residents (Resident #71) reviewed for dialysis care. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards a.)accurately document the administration of a controlled medication for Resident #11; and b.) ensure that a resident was administered all their medications for Resident #11. This deficient practice was identified for one (1) of three (3) residents, Resident #11 and one (1) of two (2) nurses during medication observation pass; and failed to c.) maintain the availability of two topical analgesic medications (Diclofenac 1% gel and Biofreeze 4% gel ) for (1) one of (6) six residents interviewed during resident council, Resident #103. The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the medication observation performed on 1/26/23, the surveyor observed three (3) nurses administer medications to three (3) residents. There were 29 opportunities, and three (3) errors were observed, which calculated to a medication administration error rate of 10.34 %. This deficient practice was identified for two (2) of three (3) residents, (Resident #11 and #73), that were administered medications by two (2) of three (3) nurses. The deficient practice was evidenced by the following: On 1/26/22 at 9:05 AM, during the medication administration observation, the surveyor observed the Licensed Practical Nurse (LPN #1) in the room of Resident #11. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to properly label, store and dispose of medications in 4 of 5 medication carts inspected. This deficient practice was evidenced by the following: On 1/27/23 at 11:25 AM, the surveyor inspected the 3rd floor medication cart #1 in the presence of a Licensed Practical Nurse (LPN#1). The surveyor observed an opened and undated bottle of Morphine 20 mg/ml solution (medication for pain). The surveyor interviewed LPN #1 who stated that once a bottle of Morphine solution was opened that it should be dated because once opened it only had a 90-day expiration date. On 1/27/23 at 11:30 AM, the surveyor inspected the 3rd floor medication cart #2 in the presence of LPN #2. The surveyor observed an opened bottle of blood Glucose test strips (a product to test the blood sugar levels) that was not dated. [...]

Inspectors wroteBased on observation, interview and review of pertinent facility documents, it was determined that the facility failed to ensure the safe and appetizing temperatures of food and drink served to the residents. This deficient practice was identified by 6 of 6 residents, who during the 1/23/23 Resident Council group meeting stated that hot foods were received cold, and confirmed during the lunch time meal service on 1/27/23 on 1 of 3 nursing units (third floor) tested for food temperatures by two surveyors, and was evidenced by the following: On 1/23/23 at 10:26 AM, the surveyor conducted a group meeting with six residents who were alert and oriented and selected by the facility to attend the group meeting. All six residents stated that hot foods were received cold at meals. [...]

Inspectors wroteBased on interview and review of pertinent facility documents, it was determined that the facility failed to consistently serve residents a nourishing snack when there was more than a 14-hour span of time between the dinner and breakfast mealtimes. This deficient practice was identified for 6 of 6 residents (Resident's #2, #27, #30, #46, #63 and #103) during resident council meeting and was evidenced by the following: On 1/23/23 at 10:26 AM, the surveyor conducted a group meeting with six residents who were alert and oriented and selected by the facility to attend the group meeting. Four of six residents stated that they did not receive a bedtime snack even when they asked. One resident stated that I didn't know they had snacks, so I didn't know to ask for it. [...]

Inspectors wroteBased on interview and review of pertinent facility documents, it was determined that the facility failed to provide documentation to account for the Infection Control Preventionist attendance for 2 of 3 Quarterly Quality Assessment and Assurance (QAA) and Quality Assurance and Performance Improvement (QAPI) meetings. This deficient practice was evidenced by the following: On 1/24/23 at 9:42 AM, the surveyor interviewed the Interim Infection Control Preventionist (ICP) in the presence of the survey team. The Interim ICP stated that she was responsible for the facility's infection prevention control program. She also stated that she had been coming in and out of the facility. However, she stated that she had been working full time in the facility, 50 hours per week for the past 3 weeks. [...]

Inspectors wroteBased on observation, interview, and review of other pertinent documentation, it was determined that the facility failed to ensure a.) staff adhered to standards of infection control practices for the appropriate disposal of a soiled incontinence brief and b.) practiced appropriate hand hygiene in accordance with the Centers for Disease Control (CDC). This deficient practice was identified for (1) one staff member on one (1) of three (3) units. This deficient practice was evidenced by the following: According to the U.S. CDC guidelines, Hand Hygiene Recommendations, Guidance for Healthcare Providers for Hand Hygiene and COVID-19, page last reviewed 01/18/2021 included, Hands should be washed with soap and water for at least 20 seconds when visibly soiled, before eating, and after using the restroom. Immediately after glove removal. [...]

Inspectors wroteBased on record review and interview, it was determined that the facility failed to provide written notification of the emergency transfer to the resident, resident representative, and the Office of the Long-Term Care Ombudsman (LTCO) for two (2) of two (2) residents (Resident # 88 and Resident # 113), reviewed for hospitalizations. This deficient practice was evidenced by the following: 1. The surveyor reviewed the medical records of Resident # 88. Review of the admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but not limited to functional quadriplegia, epilepsy, unspecified, and gastrostomy status. Review of the New Jersey Universal Transfer Form (NJUTF) dated 8/31/22, indicated the resident was transferred to the hospital for fever. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to provide residents and/or their representatives with the facility's notice of bed hold policy. This deficient practice was identified for two (2) of two (2) resident (Resident # 88 and Resident # 113), reviewed for hospitalization. This deficient practice was evidenced by the following: 1. The surveyor reviewed the medical records of Resident # 88. Review of the admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but not limited to functional quadriplegia, epilepsy, unspecified, and gastrostomy status. Review of the New Jersey Universal Transfer Form (NJUTF) dated 8/31/22, indicated the resident was transferred to the hospital for fever. [...]

Inspectors wroteBased on observation, interview and medical record review, and review of other facility documentation, it was determined that the facility failed to: a.) transcribe orders to the electronic physician's orders and medication administration record (eMAR), for 2 of 3 residents reviewed for oxygen, (Resident #25 and #30); b.) check for placement of an enteral feeding tube prior to a bolus feed; and c.) label and date a resident specific multi-use gallon of water for an enteral tube flush for 1 of 2 residents (Resident #50) reviewed for tube feeding. This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. [...]

Inspectors wroteBased on observation, interview, medical record review, and review other facility documentation, it was determined that the facility failed to a.) ensure a care plan was developed timely for a resident who was receiving oxygen and b.) to ensure a fall intervention was implemented after a resident had a fall. This was identified for 2 of 21 residents reviewed for care plans (Resident #30 and #89). This deficient practice was evidenced by the following: 1. According to the admission Record, Resident #30 was admitted in 07/2020 with diagnosis which included but were not limited to; Chronic Obstructive Pulmonary Disease and Congestive Heart Failure. Review of Resident #30's admission Minimum Data Set (MDS), an assessment tool dated 07/16/20, revealed that the resident had a Brief Interview for Mental Status (BIMS) of 15 which indicated that the resident's cognition was intact. [...]

Inspectors wroteBased on observation, interview, and review of facility documents, it was determined the facility failed to remove an expired medication and maintain a clean, orderly medication cart for 2 of the 3 carts inspected. This deficient practice was evidenced by the following: On [DATE] at 12:27 PM, in the presence of the Unit Manager (UM), the surveyor inspected the second floor medication cart (Cart #2) and observed the following: in the first bin of the third drawer, there was one pink tablet and one green tablet which were unwrapped and unmarked. In the second bin of the third drawer, there were two orange tablets, one pink tablet, one yellow tablet, two white tablets, and one-half white table which were unwrapped and unmarked. When interviewed at that time, the UM stated the med cart drawers were cleaned before and after every shift and as needed for spills. [...]

Inspectors wroteBased on observation, interview, and review of documentation provided by the facility, it was determined that the facility failed to maintain proper kitchen sanitation practices and properly store dry foods in a safe and sanitary environment to prevent the development of food borne illness. This deficient practice was evidenced by the following: On 10/20/20 at 9:35 AM, during the initial tour of the kitchen, the surveyor who was accompanied by the Food Service Director (FSD), observed the following in the kitchen: In the dry storage room: 1. A 20-pound opened bag of [NAME] was not labeled with a received or opened date. 2. A 10-pound opened bag of Tri-Color Rotini was not labeled with a received or opened date. In the walk-in freezer: 1. An opened bag of potato skins was not labeled with a received or opened date. 2. [...]