Princeton Health & Rehabilitation

Inspectors wroteBased on record review and interviews, the facility failed to submit a separate initial incident report and five day follow up investigation report within the required timeframe to the State Agency for 1 (R #16) of 1 (R #16) resident, after R #16 experienced two separate falls with injuries requiring hospitalization. If the facility does not submit the summary of its investigation to the State Agency, the State Agency cannot appropriately review the allegation for further investigation.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to maintain a safe and sanitary environment to prevent the transmission of infectious agents and communicable diseases for 1 (R #1) of 1 (R #1) resident, when the facility failed to prevent a Foley catheter (a thin, sterile tube inserted into the bladder to drain urine) drainage bag (also called a catheter collection bag; a device connected to the catheter tubing and collects urine) from touching the floor. This deficient practice has the potential to expose staff and other residents to infectious diseases.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from neglect for 2 (R #20 and R #24) of 3 (R #20, #22 and #24) residents reviewed, when:The facility's nursing staff did not assess or change R #20's wound dressing for several hours after R #20 requested assistance. The facility's nursing staff did not assist R #24 as required, which caused R #24 to become upset. If the facility fails to assist residents as required or requested, then residents are likely to experience physical injury and psychological harm, including fear or distress related to staff interactions.

Inspectors wroteBased on record review and interview, the facility failed to ensure staff revised the care plan for 1 (R #5) of 1 (R #5) residents reviewed, when:Facility staff failed to update R #5's plan of care to include substance use (the intake of various substances, including alcohol, tobacco products, and drugs, which can be consumed, inhaled, injected, or otherwise absorbed into the body). This deficient practice is likely to result in residents' care and needs not being addressed if care plans are not updated.

Inspectors wroteBased on interview, the facility failed to submit the required five-day follow-up investigation results to the State Agency (SA) for 1 (R #1) of 1 (R #1) resident reviewed for incidents. If the facility is not submitting the summary of the facility's investigation to the State Agency, then the State Agency is unable to appropriately triage (review) the allegation for further investigation.

Inspectors wroteBased on record review and interview, the facility failed to complete a thorough investigation for allegations of abuse and report the investigation findings within five working days for 1 (R #1) of 1 (R #1) resident reviewed for incidents. If the facility is not completing an accurate and thorough investigation and submitting the summary of the facility's investigation to the State Agency, then the State Agency (SA) is unable to appropriately triage (review) the allegation for further investigation.

Inspectors wroteBased on a record review and interviews, the facility failed to ensure medical records were complete for 1 (R #2) of 1 (R #2) resident reviewed when the facility failed to: Accurately document R #1's oxygen (O2) saturations (oxygen saturation levels, refer to the percentage of hemoglobin in the blood that is carrying oxygen). This deficient practice is likely to result in staff not having the information they need to provide competent, comprehensive care and services to residents.

Inspectors wroteBased on interviews and record reviews, the facility failed to demonstrate its measures to minimize the risk of Legionella (bacteria naturally found in water that can cause a severe type of lung infection called legionnaires' disease when people inhale tiny water droplets containing the bacteria) in the building's water system, when the Legionella Water Management Program (LWMP) team failed to develop and implement an adequate LWMP. This failure had the potential to affect all residents in the facility. This deficient practice is likely to lead to outbreaks of legionellosis (legionnaires' disease and Pontiac fever, a milder flu-like illness).

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident was free from physical restraints for 1(R #10) of 1(R #10) resident when staff held a resident down to give him an injection of Haldol (anti-psychotic medication) for his behaviors. This deficient practice could likely cause harm to the resident from being restrained, fear to the resident if he does not understand what is going on, and does not promote a safe, secure environment.

Inspectors wroteBased on record review and interview the facility failed to ensure a resident was free from chemical restraints for 1(R #10) of 1(R #10) resident when staff administered Haldol (antipsychotic medication) injection, 5 milligram (mg), multiple times without a qualifying diagnosis and without attempting other interventions first. This deficient practice could likely create an environment of fear for the resident and does not promote a safe, secure environment.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to protect the residents from the potential for accidents and hazards when the facility:- Permitted residents, with independent smoking privileges, to keep smoking materials, to include lighters and cigarettes, in their possession and to take them to their rooms.- Failed to ensure residents who utilized supplemental oxygen did not take their oxygen tanks into the designated smoking area. These failures had the potential to affect all residents. If residents have smoking materials in their possession, then there is the potential to light cigarettes or start fires in the facility. If this occurred around supplemental oxygen, then the oxygen could ignite and feed the fire. This puts residents at risk of serious injury, serious harm, and possibly death.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure resident was assessed for risk of entrapment (state of being stuck or caught on bed rail) from bed rails for 2 (R #123 and R #296) of 3 (R #101, R #123 and R #296) resident reviewed for accidents. This deficient practice has the potential to cause serious injury by becoming trapped between the mattress and bed rail.

Inspectors wroteBased on record review and interview, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs by ensuring adequate indication of use based off of the residents' conditions for 3 (R #2, R #123, and R #282) of 4 (R #2, R #44, R #123, and R #282) residents reviewed for unnecessary medications. This deficient practice could likely lead to adverse drug effects and poor patient outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received routine dental services (an annual inspection of the oral cavity for signs of disease, diagnosis of dental disease, dental radiographs as needed, dental cleaning, fillings (new and repairs), minor partial or full denture adjustments, smoothing of broken teeth, and limited prosthodontic procedures, e.g., taking impressions for dentures and fitting dentures) were provided dental visits annually for 2 (R #1 and R #14) of 2 (R# 1 and R #14) residents reviewed for routine dental services. This deficient practice is likely to negatively impact residents through pain, mood, and state of well-being if dental conditions have not been addressed in a timely manner. R #1 A. Record review of R #1's Electronic Health Record (EHR), R #1 was admitted on [DATE] with the following diagnoses: 1. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain proper infection prevention measures by: 1. Not disinfecting direct patient care equipment after use. 2. Not adhering to Enhanced Barrier Precautions (EBP; an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities), 3. Not adhering to contact precautions (used for individuals with infections that can spread through direct or indirect contact with the patient or their environment). These deficient practices have the potential to affect all 291 residents residing in the facility according to the census provided by the Administrator (ADM) on 07/21/25 by experiencing an increase of infections leading to further health concerns.

Inspectors wroteBased on observation and interview, the facility failed to maintain an effective pest control program for 3 (R #2, R #52, and R #172) of 3 (R #2, R #52, and R #172) residents reviewed by allowing insects and their waste in their living space. If the facility does not maintain an effective pest control program, then residents are at a greater risk of contracting certain diseases and may feel disgusted or embarrassed about their living space.

Inspectors wroteBased on record review and interview, the facility failed to ensure Certified Nurse Aides (CNAs) received the required in-service training of 12 hours per year for 3 (CNA #3, CNA #4, and CNA #5) of 5 (CNA #1, CNA #2, CNA #3, CNA #4, and CNA #5) CNAs reviewed for required in-service training. This deficient practice is likely to result in the CNAs not receiving the necessary training to meet the care needs of the residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents and/or their representatives were informed in advance of what medications they received and understood the reasons, risks, and benefits of the medications for 1 (R #282) of 3 (R #2, R #123, and R #282) residents reviewed for unnecessary medications. If the residents or their representatives are not informed of the risks and benefits of the medication or treatment alternatives, they are not able to make informed decisions regarding residents' care.

Inspectors wroteBased on record review and interview, the facility failed to update/revise the advance directive for 1 (R #6) of 1 (R #6) resident reviewed for advanced directives. This deficient practice could likely result in residents' declination of treatment such as refusals of artificial nutrition (a medical treatment for a person to receive nutrition when they are no longer able to) or intravenous (IV; into the vein) hydration as well as life saving measures such as attempting cardiopulmonary resuscitation (CPR; full code, an emergency procedure that combines chest compression with artificial ventilation) against resident's wishes.

Inspectors wroteBased on observations and interviews, the facility failed to provide a comfortable and homelike environment by ensuring safe temperature levels (between 71 degrees to 81 degrees) for residents ensuring and a clean, comfortable, and safe environment. These deficient practices could affect all 291 residents as identified by the Daily Census provided by the Administrator (ADM) on 07/21/25. If the facility does not ensure safe temperature levels, clean and safe environment then the residents could be at risk causing additional or increased adverse health conditions and uncomfortable living conditions for the residents.

Inspectors wroteBased on record review and interview the facility failed to complete the quarterly review Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) assessment within 92 days for 1 (R #179) of 2 (R #179 and R #294) residents reviewed for resident MDS assessments. This deficient practice could likely result in residents not receiving the care and assistance needed.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Minimum Data Set (MDS; a federally mandated comprehensive assessment of a resident's functional, medical, psychosocial and cognitive assessment completed by facility staff) was accurate for 1 (R #282) of 3 (R #2, R #101, and R #282) residents reviewed for MDS assessments. This deficient practice could result in a failure to provide adequate care and treatment of the resident's needs.

Inspectors wroteBased on record review and interview, the facility failed to create an accurate baseline care plan (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) within 48 hours of admission for 2 (R #44 and R #123) of 5 (R #2, R #44, R #55, R #123 and R #321) residents reviewed for baseline care plans. This deficient practice could likely result in residents not receiving the appropriate care and may place residents at risk of an adverse event (undesirable experience, preventable or non-preventable, that caused harm to a resident because of medical care or lack of medical care) or worsening of current condition after admission.

Inspectors wroteBased on record review and interview, the facility failed to develop a comprehensive care plan for 4 (R #2, R #44, R #56, and R #123) of 5 (R #2, R #44, R #55, R #56 and R #123) residents reviewed when staff failed to: 1. Develop a care plan for R #2's anticonvulsant medication and seizure disorder. 2. Develop a care plan for R #44's diagnosis of dementia. 3. Develop a care plan for R #56's use of a trapeze bar (a device suspended above a bed to assist with transferring or repositioning). 4. Develop a care plan for R #123's diagnosis of schizophrenia. This deficient practice is likely to result in staff not being aware of the residents' care needs and preferences, and residents not receiving the needed care.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure staff revised the care plan for 3 (R #101, R #123 and R #200) of 3 (R #101, R #123 and R #200) residents reviewed when staff failed to -update R #101's, and R #123'scare plan to include use of bed rails. -update R #200's care plan to include interventions for pain management These deficient practices are likely to result in residents' care and needs not being addressed if care plans are not updated.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to follow Physician Orders for 1 (R #10) of 1 (R #10) residents reviewed for comprehensive care plans (plan with measurable goals and timeframes to meet a resident's medical, nursing, mental health and psychosocial needs). This deficient practice could likely lead to harm of the resident.

Inspectors wroteBased on observation, record review and interview, the facility failed to utilize infection control practices for handling respiratory equipment for 1 (R #10) of 1(R #10) residents reviewed for respiratory services. This deficient practice is likely to place the resident at risk with cross contamination and the development of respiratory infections.

Inspectors wroteBased on record review and interview, the facility failed to a resident received appropriate treatment and services for dementia for 1 (R #44) of 1 (R #44) resident reviewed. This deficient practice could likely lead to residents not attaining or maintaining their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on record review, observation and interview, the facility failed to ensure trash receptacles were covered to minimize odors and prevent pest or mice. If staff fail to keep trash cans closed both inside and outside the facility, then the environment may become unsanitary and increase the risk of pest infestation and disease transmission to residents.

Inspectors wroteBased on record review and interview, the facility failed to document a pain medication was given to 1 (R #1) of 1 (R #1) resident reviewed for pain. This deficient practice could likely cause confusion with staff on whether a pain medication was administered and could cause harm to the resident if the pain medication was administered again.

Inspectors wroteBased on record review and interview, the facility failed to complete and document a thorough investigation, implement measures to prevent further incidents, and implement corrective actions regarding allegations of neglect (failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness), abuse (knowingly causing physical or mental harm or failing to provide goods and services necessary to avoid physical or mental harm), and injury of unknown origin for 3 (R #4, #5, and #6) of 3 (R #4, #5, and #6) residents reviewed for abuse and neglect allegations when staff failed to complete and submit thorough follow-up reports for R #4, #5, and #6. If facilities do not submit follow up reports then the SA cannot assure the residents are safe and free of abuse. R #4 A. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure staff did not leave medications on the bedside table for 1 (R #13) of 1 (R #13) resident. This deficient practice could likely result in residents misplacing or not taking medications which could cause the resident to be pain.

Inspectors wroteBased on observation and interview, the facility failed to ensure medication carts were locked when unattended. This deficient practice is likely to negatively impact the health of residents on the 600 unit if they were to ingest (swallow) medications not intended for them.

Inspectors wroteBased on observation and interview, the facility failed to ensure residents had a safe and functional environment when the facility failed to ensure flooring was flat, smooth, and level for 1 (R #1) of 1 (R #1) residents reviewed. This deficient practice could likely result in residents living in an unsafe environment and could increase their risk for injuries and decrease their quality of life.

Inspectors wroteBased on interview and record review, the facility failed to keep residents free from abuse and neglect for 1 (R #1) of (R #1) residents sampled for abuse when staff failed to: 1. Provide line of sight supervision for R #1 after she requested a one on one or to be sent to the hospital. This deficient practice could likely result in physical harm to residents, and/or psychosocial distress (unpleasant emotions associated with a highly stressful situation), or worsening of current mental health conditions for the residents who were subject to this behavior.

Inspectors wroteBased on observation and interview, the facility failed to provide a safe, clean, and comfortable environment for and R #13 and all residents who utilized the courtyard and the 600 unit hallway. This deficient practice is likely to cause all residents in this facility to be exposed to environmental hazards and not to feel comfortable, which could affect their psychosocial well-being.

Inspectors wroteBased on record review and interview, the facility failed to notify the Power of Attorney (POA; a health care power of attorney grants, in writing, a particular agent the power to make healthcare decisions on another's behalf) when R#2 wandered into another resident's room and sustained an injury from an unknown resident, for 1 (R #2) of 1 (R #2) resident reviewed. If the facility is not notifying the resident's POA when the resident has a change of condition, then the POA is unable to make decisions related to treatment and advocate for the resident's care.

Inspectors wroteBased on record review and interview, the facility failed to prevent an accident for 1 (R#2) of 2 (R#2 and R #3) when the facility failed to implement interventions to prevent R #2 from walking into other residents' rooms without permission and potentially putting himself at risk for harm. This deficient practice could likely result in physical harm to residents, physical harm and/or psychosocial distress (unpleasant emotions associated with a highly stressful situation), or worsening of current mental health conditions for the residents who were subject to this behavior.

Inspectors wroteBased on record review, observation, and interviews the facility failed to: 1. Ensure eye drops were disposed of within 30 days of opening. 2. Ensure all expired supplies were not kept with unexpired supplies. 3. Ensure medications are kept in original package. 4. Ensure all expired medications were not kept with unexpired supplies. These deficient practices are likely to result in all 261 residents', identified on the census list provided by the Executive Director (ED) on 04/21/24, medications that were pre-poured (put into unmarked cups, without patient identifiers), to receive expired medications or supplies that have lost either their potency or effectiveness, or to receive medication or vaccines that have lost either their potency or effectiveness.

Inspectors wroteBased on observation, record review, and interview the facility failed to maintain proper infection prevention measures when staff failed to: 1. Ensure safe transport of soiled laundry from resident room to laundry chute. 2. Ensure staff members wore appropriate personal protective equipment (PPE; gloves, face mask, eye protection, and a gown) while sorting contaminated laundry in the laundry room. Failure to adhere to an infection control program could likely cause the spread of infections and illness to all 261 residents listed on the census provided by the Administrator on 04/21/24.

Inspectors wroteBased on observation and interview the facility failed to provide a homelike environment for 2 (R #190 and R #37) out of 3 (R #190, R #37, and R #23) residents (residents were identified by the resident matrix provided by the Administrator on 04/21/24), when they failed to: 1) Repair damaged or missing drawer face from one resident's room. 2) Prevent or remove cockroaches inside a resident's continuous positive air pressure (CPAP; helps keep your airway open when asleep) humidifier tank. 3) Repair water leaks and damaged ceiling in the therapy room. If residents do not have a homelike environment, they may become depressed and anxious about things in disrepair.

Inspectors wroteBased on observation, record review, and interview, the facility failed to meet professional standards of quality for 2 (R #26 and R # 87) of 2 (R #26 and R #87) residents reviewed by when staff failed to administer medications per recommend guidelines. If the facility is not administering medications in accordance with physician orders and accepted professional practices, then residents are likely to not get the therapeutic results needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain records of controlled substances (drugs subject to strict government control because they may cause addiction) on the 400 north, 500 south, and 600 front medication carts. This deficient practice could likely cause controlled substances to be diverted (the transfer of any legal prescribed controlled substance from the individual for whom it was prescribed to another person for any illegal use).

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure the comprehensive care plan was accurate for 1 (R #202) of 1 (R #202) residents reviewed for care plan accuracy. This deficient practice could likely result in staff not understanding and implementing the most appropriate interventions and treatments for the resident.

Inspectors wroteBased on record review and interview, the facility failed to document weekly wound assessments for 1 (R #7) of 1 (R #7) residents reviewed for wound care. This deficient practice could likely result in a resident's wound progression not being evaluated on a weekly basis. A. Record review of R #7's face sheet revealed R #7 was admitted to the facility on [DATE] with the pertinent diagnoses of: metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), cerebral infarction (an ischemic stroke- caused by disrupted blood flow to the brain due to problems with the blood vessels that supply it), and type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). B. Record review of physician orders revealed the following: 1. [...]

Inspectors wroteBased on interview and record review the facility failed to help maintain acceptable parameters of nutritional status, such as usual body weight, for 1 (R #409) of 3 (R # 26, R # 87, and R # 40) residents sampled for nutrition, when they failed to put a plan into place for R #409 who had weight loss. This deficient practice could likely result in the residents losing weight, causing physical and mental health issues.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an orderly, homelike environment for 1 (R [Resident] #1) of 3 (R #1, R #2, & R#3) residents reviewed for resident rights by leaving unused medical equipment in the resident's room for 24 days after last use. This deficient practice could lead to residents feeling disrespected, uncomfortable, and depressed.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure that services were provided to meet professional standards for 3 ( R #123, R #132, and R #135 ) of 3 (R #123, R #132 and R #135) residents reviewed by: 1. Not administering and discharging medications as indicated on pharmacist's recommendations and physician's agreement and orders. 2. Not accurately documenting and reporting skin assessments conducted with refusals and per resident's self-report, and 3. Not implementing and documenting care measure interventions to prevent contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). 4. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure residents were free from accident and safety hazards and supervised for 4 (R #14, R #123, R #157, R #77) residents of 4 (R #14, R #123, R # 157, R #77) ) residents reviewed for accident hazards by: 1. Having a loose grab bar (a graspable bar attached to the wall as an assistance to maintain balance) in resident bathroom. 2. Having insufficient length of call light cord in resident bathroom. 3. Not removing fall mats from the floor when residents are not in bed 4. Not supervising residents on 300 locked care unit when they failed to have staff present to supervise residents seated in dining room prior to a meal. This deficient practice could likely affect the safety and health of the residents.

Inspectors wroteBased on observation, interview ,and record review, the facility failed to ensure that 3 (R #14, R #70 and R #106) residents of 3 (R#14, R #70, and R #106,) residents reviewed were free from any significant medication errors by: 1. Having been administered (given) the incorrect dosage of a medication for 5 consecutive (in order) days for R #14. 2 Not receiving (getting) medication as prescribed (written by medical doctor) prior to receiving a shower for R #106. 3. Not following the physician's orders by crushing medication that did not have an order to be crushed for R #70. These deficient practice are likely to negatively (in a bad way) impact (result in) a residents' status (how one feels) by increasing anxiety (feeling of worry) and fear (unpleasantness), and can cause dangerous side effects (death; life-threatening; hospitalization; disability or permanent damage). [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure that medications and supplies stored in the medication storage rooms on both the 300 and 500 units and inside of the medication storage refrigerators on the 500 units were not expired. This deficient practice has the potential to negatively impact the health of all the residents on both the 300 and 500 units. Receiving expired medications could likely result in residents receiving medications that have lost their potency and effectiveness leaving them vulnerable to acquiring infections.

Inspectors wroteBased on interview and record review the facility failed to keep accurate, up to date resident records for 6 (R #6, R #90, R #129, R #132, R #157 and R #167) of 8 (R #6, R #35, R #90, R #126, R #129, R #132, R #157 and R #167) residents reviewed by not having the following: 1. A Pre-admission Screening and Resident Review (The PASRR Level II is a comprehensive evaluation required as a result of a positive Level I Screening. A Level II is necessary to confirm the indicated diagnosis noted in the Level I Screening and to determine whether placement or continued stay in a Nursing Facility is appropriate) for resident #6 looked at for PASRR level II screening. 2. Inaccurate care plan and nursing documentation around a Foley catheter (Rubber tube that is inserted into the bladder to drain the urine) for resident #167. 3. Inaccurate diagnosis of Schizophrenia for resident #157. 4. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure that Certified Nursing Assistants (CNA's) had their required 12 hours of yearly in-service training completed for 3 (CNA # 10, 11, and 12) of 5 (CNA #10, 11, 12, 13 and 14) CNA's looked at for staffing competencies. This deficient practice could potentially cause CNA's to not be up to date with the knowledge that they need to care for the residents they work with; which could cause the residents harm.

Inspectors wroteBased on record review and interview, the facility failed to follow physician orders for 1 ( R #107) of 1 (R #107) residents reviewed for therapeutic medication levels of an antipsychotic medication. This deficient practice could likely result in a resident not receiving the accurate dosage of a medication that would ensure clinical effectiveness while avoiding side effects.

Inspectors wroteBased on record review and interview the facility failed to ensure a resident with an order for a Foley catheter (A soft tubing that drains urine from the bladder to a collection bag) that was removed, had the Foley catheter re-inserted due to urinary retention (inability to fully empty the bladder) for one resident (R #77) of one (R #77) reviewed for catheter care. This deficient practice could likely result in resident having an infection and urinary retention.