Princeton Health Care Center

Inspectors wroteBased on record review and staff interview, the facility failed to ensure water and other liquids consistent with residents' needs and preferences were provided at bedside. This failed practice had the potential to affect more than a limited number of residents. Resident Identifiers: #10, #13, #39, #49, #81, #103, and #113. Facility Census: 110.

Inspectors wroteBased on record review, staff interview and observation, the facility failed to ensure dishes were cleaned under sanitary conditions in accordance with professional standards This failed practice had the potential to affect more than a limited number of residents. FACILITY:FACILITY. Facility Census:

Inspectors wroteBased on observations, staff interviews, and record reviews, the facility failed to maintain accurate and complete clinical records related to treatment documentation for two (2) of two (2) resident reviewed for brace use and one (1) resident for weight documentation. This failed practice had the potential to affect more than a minimal number of residents during the long term care survey process. Resident Identifier: #92, #4, and #7. Facility census: 110a) Resident #7 On 02/05/26 at 10:25 AM, during the record review a weight was documented on 01/15/2026 for Resident #7 in the electronic medical record. Progress Notes dated 01/08/2025 and 01/19/2026 documented the resident had refused to be weighed in January 2026. [...]

Inspectors wroteBased on observation and staff interview the facility failed to maintain an infection control program to aid in preventing the spread of disease. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents during the Long-Term Care Survey Process. Facility census: 110. Findings Include: a) Resident hand hygiene An observation of the noon time meal on 02/02/25 being served on 300 hall, revealed that room [ROOM NUMBER] thru #306 were served their lunch tray and no hand hygiene had been performed on the residents before eating their meal. During an interview on 02/02/25 at 1:10 PM, Nursing Assistant (NA) # 35 stated, We usually do wash their hands, but no I did not do it today. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to develop and implement a comprehensive, person-centered care plan that provided sufficient and specific instructions to guide staff in the use of a prescribed splint/brace for Resident #92. This was a random opportunity for discovery and had the potential to affect more than a minimal number of residents residing in the Long Term Care Facility. Resident identifier:#92 Facility Census:

Inspectors wroteBased on record review and staff interview, the facility failed to revise two (2) of 23 resident care plans when changes occurred. This deficient practice had the potential to affect two (2) of 23 residents reviewed in the long-term care survey sample. Resident Identifiers: #64 and #7. Facility Census: 110.

Inspectors wroteBased on observation, record review, staff interview and resident interview the facility failed to provide care and services in accordance with professional standards of practice, by not applying devices ordered by the physician. This failed practice was found true for (2) two of (2) two residents reviewed for position and mobility during the Long-Term Care Survey Process. Resident identifiers: #4, and #92. Facility census: 110. .

Inspectors wroteBased on record review and staff interview, the facility failed to offer pneumococcal vaccines in accordance with professional standards of practice. This deficient practice had the potential to affect one (1) of five (5) residents reviewed for the care area of immunizations. Resident Identifier: #7. Facility Census: 110.

Inspectors wroteThe facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed practice included: the missed opportunity for hand hygiene was true for 29 of 193 documented hand hygiene observations made by the facility and for 1 (one) of 32 observations made during a medication pass for the medication administration portion of the long term survey process. This failed practice had the potential to affect more than an isolated number of residents. Facility census: 114.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure residents were free from abuse which included misappropriation of medication. This was true for three (3) of three (3) residents reviewed during the survey. Resident identifiers: #10, #20, #81. Facility Census: 114. This will be cited as past non compliance because the facility identified what had happened and took immediate steps to correct the failure to ensure it does not reoccur. All components of the of plan of correction were completed prior to this survey beginning.

Inspectors wroteBased on observation, medical record review and staff interview, the facility failed to revise the residents comprehensive care plan. Residents had one-on-one (1:1) interventions put in place without being care planned or being care planned timely. This was a random opportunity for discovery during the long term care survey process. Resident identifiers: #47, #75 and #101. Census: 114.

Inspectors wroteThe facility failed to create and sustain an environment that humanizes and individualizes each resident's quality of life as they were not provided a person-centered care to honor and support the residents individual preference, choices, values and beliefs. This was a random opportunity for discovery during the long term survey process. This had the ability to affect a limited number of resident's. Resident identifiers: #75, #47, #101. Facility census: 114.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure the Daily Staffing Posting information was accurate and current. The Daily Staffing Posting Form was not posted in a prominent place readily accessible to residents and visitors; the Daily Staffing Posting Form did not accurately reflect the direct care staff; and the Daily Staffing Posting Form did not identify the actual number of staff and or the actual hours worked. This was identified during the long-term care survey process of reviewing the sufficient and competent nursing staff. This has the potential to affect potential to affect more than a limited number of residents and visitors. Identifiers: Accurate and current data of direct care, Accurate and current date of actual numbers of staff and or the actual hours worked; [...]

Inspectors wroteBased on observation and staff interview the facility failed to ensure cooking/serving pans were completely dry before storing them on the shelf wet nesting. Wet nesting occurs when wet dishes or pots and pans are stacked, preventing them from drying, and creating conditions that are ripe for microorganisms to grow. Hot/Cold compress pack was stored in the resident pantry refrigerator where cold snacks are stored. This failed practice was found during the initial kitchen tour during the Long-Term Care Survey and had the potential to affect more than a minimal number of residents residing in the facility. Facility Census: 114 Findings Include: a) wet nesting During the initial Kitchen tour on 05/06/24 at 11:00AM with Certified Dietary Manager (CDM) #132 Pans were stacked under the counter, when one was pulled it was observed to be wet on the right side. [...]

Inspectors wroteBased on observation and staff interview the facility failed to provide a dignified dining experience by not serving residents sitting together at the same time. This was a random opportunity for discovery and had the potential to affect a minimal number of residents in the facility. Facility Census: 114 Resident Identifiers: #14, #52, #106 Findings Include: On 05/08/24 at 12:20 PM in the South Dining room Resident #52 and #106 were observed setting together and Table one (1) and Resident #14 observed setting to herself at Table two (2). Further observation on 05/08/24 at 12:25 PM revealed Resident #52 was served first at table one (1) then Resident #14 was served at table two (2) at 12:26 PM. Resident #106 waited Three minutes at table one(1) while Resident #52 ate. Resident #106 was served at 12:29 PM. [...]

Inspectors wroteBased on medical record review and staff interview the facility failed to ensure an informed consent was obtained for a psychotropic medication. This was true for one (1) of five (5) residents reviewed for unnecessary medication during the long term care survey. Resident identifier: #43 Census: 114.

Inspectors wroteBased on observation, record review and staff interview the facility failed to ensure residents' information was protected. This failed practice was found true for (1) one of (1) one resident looked at for privacy during the Long-Term Care Survey Process. Resident Identifiers #19. Facility Census 114.

Inspectors wroteBased on observation and staff interviews the facility failed to provide a clean, comfortable, and homelike environment. A strong unpleasant odor was observed when entering a resident's room. This was a random opportunity for discovery during the long-term care survey process. Room Identifier: room [ROOM NUMBER]. Census: 114.

Inspectors wroteBased on Record review and staff interview the facility failed to notify the Ombudsman of resident #45's discharge to the hospital. This was true for one (1) of one(1) residents reviewed for the carrier of hospitalization. Resident identifier; #45. Facility census: 114.

Inspectors wroteThe facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid. The PASARR was not resubmitted for residents with newly evident or possible serious mental disorder. This was true for two (2) of six (06) residents PASARR reviewed during the long term care process. This had the ability to affect a limited number of residents. Resident Identifier: Resident #67, Resident #80; Census: 114. Findings Included: a) Resident #67 During a medical record review on 05/07/24 at 11:02 AM for Resident #67, the PASARR was dated 05/04/22. Further record review of the residents diagnosis identified an updated diagnosis of delusions due to known physiological condition dated 5/06/22. No further PASARR's were identified to have been completed for this diagnosis dated 05/06/22. [...]

Inspectors wroteBased on record review and staff interview the facility failed to ensure a resident's Preadmission Screening and Resident Review (PASARR) reflected the diagnoses sheet for pre admission diagnoses. This was true for two (2) of five (5) residents reviewed for the PASARR care area. Resident identifiers: #80, #1, Facility Census:

Inspectors wroteBased on record review and staff interview, the facility failed to develop a complete and accurate comprehensive care plan for two (2) of 34 residents reviewed in the long-term care survey sample. Resident identifiers: #115, #67. Facility census: 114.

Inspectors wroteThe facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. The facility failed to obtain the physicians order for one on one (1:1) interventions. This was a random opportunity of discovery during the long term care survey process. This had the ability to affect a limited number of residents. Resident Identifiers; Resident #47, Resident #75, and Resident #101. Facility Census: 114. Findings Included: a: Resident #47 On 05/06/24 at 11:13 PM Resident #47 was observed to be sitting in her room with an apparent black eye. A staff member was observed at this time to be sitting in the room with the resident. On 05/07/24 at approximately 12:15 PM Resident #47 was observed to have a staff member sitting with her in her room. [...]

Inspectors wroteBased on record review and staff interview the facility failed to provide services for Post Traumatic Stress Syndrome (PTSD). This failed practice was found true for (1) one of (3) three residents looked at for mood and behavior during the Long-Term Care Survey Process. Resident identifier #76. Facility Census: 114.

Inspectors wroteBased on record review and staff interview, the facility failed to obtain laboratory services as ordered by the physician. This deficient practice had the potential to affect one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #80. Facility census: 114.

Inspectors wroteBased on Record review and staff interview the facility failed to ensure that the medical record contained the diagnosis of Post Traumatic Stress Syndrome (PTSD) as indicated on the Minimum Data Set (MDS) and that the Physician Order for Selective Treatment (POST) form was complete and accurate. This failed practice was found true for (2) two of 34 residents reviewed for medical record accuracy during the Long-Term Care Survey Process. Resident identifiers #76, #86. Facility Census 114.

Inspectors wroteBased on observation, policy review, resident council meeting and staff interview the facility failed to make grievances forms accessible to all resident and/or residents family/representatives residing in the facility. This had the potential to affect an unlimited amount of residents living in the facility. Facility census: 115. Findings Included: a) Grievance Forms A review of the facility policy titled Resident and Family Grievances and Communicated Concern with an implementation date 11/28/16 and a revision date 07/17/21, read as follows. Procedure: .8. A grievance may be filed anonymously During the Long Term Care Survey Process from 07/23/23 to 07/25/23 many observations throughout the facility revealed no evidence of grievance forms made accessible to the residents and/or resident representatives. [...]

Inspectors wroteBased on record review, observation and staff interview the facility failed to ensure four (4) of 26 Residents reviewed received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. A surgical consult was not scheduled for Resident #55 as directed by the nurse practioner, Resident #68's medication was not provided timely, an enteric coated medication was crushed before being administered, and blood pressures were not obtained as ordered by the physician for Resident #102. Resident identifiers: #55, #68, and #102. Facility census: 115.

Inspectors wroteBased on observations and staff interviews the facility failed to assure handrail were firmly secured and affixed to the corridor walls. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents residing on North Unit 100 Hall. Facility Census: 115 Findings Included: a) Handrails During a tour on 07/24/23 at 1:11 PM this surveyor discovered on 100 Hall the following handrails were not firmly secured and affixed to the corridor walls. -The handrail between room [ROOM NUMBER] and the chapel door -Two (2) handrail between the 113 and the chapel door -The handrail between room [ROOM NUMBER] and 110 -The handrail between room [ROOM NUMBER] and 109 -The handrail between room [ROOM NUMBER] and 107 During an interview 07/24/23 at 1:20 PM, the Administrator acknowledged the rails were not secure and needed repaired. .

Inspectors wroteBased on record review and staff interview, the facility failed to report an injury of unknown origin to the proper authorities for Resident #72. This was true for one (1) of two (2) residents reviewed for unsafe wandering. Resident identifier: #72. Facility census: 115.

Inspectors wroteBased on medical record review and staff interview, the facility failed to accurately code the Minimum Data Set for resident's diagnosis. This was true for two (2) of five (5) reviewed for unnecessary medications. Resident identifiers: #49 and #79. Facility census: 115.

Inspectors wroteBased on medical record review and staff interview, the facility failed to complete a Minimum Data Set (MDS) when the resident was admitted to the hospital. Resident identifier: #53. Facility census: 115.

Inspectors wroteBased on record review and staff interview, the facility failed to complete a baseline care plan for one (1) of two (2) newly admitted residents reviewed during the long term care survey. Resident identifier #366. Census 115. Findings Included: a) Resident #115 The surveyor requested copies of the resident's most recent minimum data set (MDS,) list of diagnoses, care plans, and Pre admission Screening (PAS) on 07/24/23. A record review of these records indicated the resident was admitted to the facility on [DATE] with the diagnosis of schizophrenia and bipolar disorder. The care plan received did not address either diagnosis. The PAS, dated 7/5/23, listed both diagnoses. The MDS is still in progress, therefore is not completed. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to develop a comprehensive care plan to include the diagnosis of pneumonia. Resident identifier: #49. Facility census: 115.

Inspectors wroteBased on record review, resident interview, and staff interview, the facility failed to update the care plans of two (2) of five (5) residents reviewed for the care area of nutrition after both residents had a weight loss and a diet change. Resident identifiers: #55 and #83. Facility census: 115.

Inspectors wroteBased on facility policy, observations, and staff interview the facility failed to ensure proper storage of Continuous Positive Airway Pressure (C-pap) while not in use. This was a random opportunity for discovery and has the potential to affect a limited number of residents who currently reside in the facility. Resident Identifiers: # 67, and #3. Facility census 115.

Inspectors wroteBased on observation and staff interview, the facility failed to complete temperature logs for their reach-in refrigerator, reach-in freezer, walk-in refrigerator, walk-in freezer, and dishwasher. This has the potential to affect more than a limited number of residents at the facility. Facility Census 115. Findings Included: On 07/23/23 at 2:24 PM, the initial kitchen walk through occurred. [NAME] #34 was in charge of the kitchen that day due to it being a Sunday. Observation found the dishwasher temperature log did not have any documentation for the date of 07/22/23, on the afternoon section of the form. The reach-in refrigerator temperature log did not have documentation for 07/21/22, on the PM Time section of the form, or 07/22/23, for the PM Time section of the form. [...]

Inspectors wroteBased on observation, staff interview and record review the facility failed to maintain proper infection control standards during medication pass for Resident #8. This failed practice was a random opportunity for discovery and had the potential to affect only a limited number of residents. Resident identifier: #8. Facility census: 115.

Inspectors wroteBased on observation and staff interview the facility failed to make a call system accessible to the resident at each toilet and bath or shower facility, and should be accessible to a resident laying on the floor. This was a random opportunity for discovery. Resident Identifiers: Resident #90. Facility Census: 115. Findings Included: a) Bathroom Call Light During the initial tour of the facility on 07/23/23 at 3:23 PM the bathroom call system cord wrapped around the call system, not reaching the floor. During an interview on 07/23/23 at 3:26 PM Licensed Practical Nurse (LPN) #172 stated the cord is very tangled, she was unable to get it untangled and unable to get the cord to reach the floor. During another tour of the facility on 07/24/23 at 9:00 AM, the call light cord was wrapped around and was not accessible to the Resident if lying on the floor. [...]