Manor Court of Princeton

Inspectors wroteBased on interview and record review the facility failed to investigate an alleged allegation of physical abuse. This applies to 1 of 3 residents (R1) reviewed for physical abuse in the sample of 4.

Inspectors wroteBased on interview and record review the facility failed to notify local police and a resident's physician of an allegation of sexual abuse for one of eight residents (R1) reviewed for abuse.

Inspectors wroteBased on Observation, Interview and Record Review, the facility failed to document a diagnosis and identify target behaviors to warrant the use of an antipsychotic medication and provide appropriate justification for a failed gradual dose reduction of Risperdal (antipsychotic) for one of one resident (R2) reviewed for antipsychotic medications in the sample of 34.

Inspectors wroteBased on interview and record review, the facility failed to revise a care plan to accurately reflect a resident's wound condition for one of 21 residents (R13) reviewed for care plan accuracy in the sample of 34.

Inspectors wroteBased on observation, interview, and record review, the facility failed to address and implement care plan interventions for a resident's ongoing, significant weight loss for one of three residents (R42) reviewed for weight loss in the sample of 34. Findings Include: The Facility's Weight Monitoring Policy dated/revised 09/06/24, documents, To consistently assess for significant weight loss or gain. Licensed staff will notify physician of the following, 7.5% or more gain or loss in a 90-day period, 10% or more gain or loss in a 180-day period, events will be opened for a significant weight loss. Notification to the physician must be documented, and whether or not new orders were received for either significant weight losses or gains. Families/POA (power of attorney) must be notified of significant weight loss or gain. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain cleanliness of tube feeding equipment for one of one resident (R102) reviewed for tube feeding in a sample of 34.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure aseptic technique was followed during intravenous medication administration and failed to perform a physician-ordered flush prior to the administration of an intravenous medication for one of one residents (R80) receiving intravenous medications, in a sample of 34.

Inspectors wroteBased on Interview and Record Review, the facility failed to ensure a resident with a diagnosis of Dementia had a Care Plan to include goals and interventions to manage Dementia, for one of one resident (R2) reviewed for Dementia Care in the sample of 34.

Inspectors wroteBased on interview and record review, the facility failed to document a rationale for the continued use of antibiotic therapy for one of three residents (R69) reviewed for unnecessary medications in a sample of 34.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a clean and sanitized floor in the facility kitchen. This failure has the potential to affect all 99 residents who receive food from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to ensure Advanced Directives were documented correctly in the resident's clinical record for one (R17) of two residents reviewed for Advanced Directives in a sample of 40.

Inspectors wroteBased on observation, interview and record review, the facility failed to include indwelling urinary catheter with cares on a Baseline Care Plan for one (R257) of 21 residents reviewed for Care Plans in a sample of 40.

Inspectors wroteBased on observation, record review and interview, the facility failed to revise a Comprehensive Care Plan for one resident (R7) of 21 residents reviewed for Care Plan revision in a sample of 40.

Inspectors wroteBased on observation, interview, and record review the facility failed to change gloves and sanitize between glove changes during Indwelling Urinary Catheter cares for one (R257) of three residents reviewed for Catheters in a sample of 40.

Inspectors wroteBased on interview and record review, the facility failed to obtain weekly weights as ordered by the physician for one of two residents (R92) reviewed for nutrition in the sample of 40.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's oxygen humidifier bottle was not empty while in use for one (R254) of one resident reviewed for Oxygen in a sample of 40.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide an appropriate indication for use for an antipsychotic medication, failed to identify target behaviors, and failed to identify non-pharmacological interventions for one (R2) of five residents reviewed for unnecessary medications in the sample of 40.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Enhanced Barrier Precaution/EBP signage was posted and PPE (Personal Protective Equipment) was available for two (R257 and R25) of nine residents reviewed for Infection Control in a sample of 40.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy to ensure that an effective discharge plan was developed and implemented. The facility also failed to ensure that referrals were made to the appropriate community resources at the time of discharge for one of four residents (R1) reviewed for discharge planning in the sample of four.

Inspectors wroteBased on interview, record review and observation, the facility failed to ensure that equipment in the kitchen was clean and free of debris. This has the potential to affect all 84 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to revise a resident's care plan for one resident (R15) out of 19 residents reviewed for care plans in a sample of 47.

Inspectors wroteBased on observation, interview and record review, the facility failed to keep a resident's fingernails trimmed to reduce the risk of impaired skin integrity for one resident (R15) out of one resident reviewed for skin conditions in a sample of 47.

Inspectors wroteBased on interview, observation and record review, the facility failed to ensure a resident with limited range of motion was provided appropriate treatment and services to maintain and/or prevent a further decrease for one of four residents (R74) reviewed for limited range of motion in the sample of 47.

Inspectors wroteBased on interview, observation and record review, the facility failed to ensure an indwelling urinary catheter was secured for one of two residents (R50) and failed to keep an indwelling suprapubic catheter drainage bag and tubing off the floor for one of two residents (R48) reviewed for indwelling urinary catheters in the sample of 47. Findings Include: 1. The facility's Catheter Care policy (revised 05/06) documents the following: Secure the catheter to the thigh and/or lower abdomen in men to facilitate flow of urine and prevent excessive tension on the catheter. On 04/24/23 at 11:20 AM, R50 was sitting in a chair next to her bed. An Indwelling urinary drainage bag inside of a dignity bag was hanging on the lower aspect of R50's bed. R50 stated she has an indwelling urinary catheter, and has had it, a long time. Clear urine was noted in R50's drainage tubing. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a dementia specific plan of care for one of two residents (R197) reviewed for dementia care in the sample of 47.