Deficiency Records for Princeton Manor Healthcare Center, LLC
Updated as of March 01, 2024
A list of the most recent deficiencies for Princeton Manor Healthcare Center, LLC. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-09-26 | 2023-10-12 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-08-01 | 2023-08-25 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-08-01 | 2023-08-25 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-11-14 | 2022-11-23 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-05-20 | 2022-07-28 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-05-20 | 2022-07-28 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-05-20 | 2022-07-28 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-05-20 | 2022-07-28 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-05-20 | 2022-07-28 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2022-05-20 | 2022-07-28 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-05-20 | 2022-07-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-20 | 2022-07-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-05-20 | 2022-07-28 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-05-20 | 2022-07-28 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-05-20 | 2022-07-28 | N |
| Keep all essential equipment working safely. | Health | 2022-05-20 | 2022-07-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-05-20 | 2022-07-28 | Y |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2022-05-24 | 2022-06-07 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-05-24 | 2022-06-07 | N |
| Develop a communication plan. | Fire Safety | 2022-05-24 | 2022-06-07 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-05-24 | 2022-06-07 | N |
| Use approved construction type or materials. | Fire Safety | 2022-05-24 | 2022-06-07 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-05-24 | 2022-06-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-05-24 | 2022-06-07 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-05-24 | 2022-06-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-05-24 | 2022-06-07 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-05-24 | 2022-06-07 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-05-24 | 2022-06-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-05-24 | 2022-06-07 | N |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2022-03-07 | 2022-05-26 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-10-13 | 2021-11-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-13 | 2021-11-10 | Y |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2021-10-13 | 2021-11-10 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-10-13 | 2021-11-10 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2021-10-13 | 2021-11-10 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-09-07 | 2021-10-14 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-08-06 | 2021-09-27 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-05-06 | 2021-06-23 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-05-06 | 2021-06-23 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-03-29 | 2021-05-24 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-03-29 | 2021-05-24 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2019-12-11 | 2019-12-31 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-12-11 | 2019-12-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-12-11 | 2019-12-31 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-12-11 | 2019-12-31 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-12-11 | 2019-12-31 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-12-11 | 2019-12-31 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-10-24 | 2019-12-04 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-10-24 | 2019-12-04 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-10-24 | 2019-12-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-24 | 2019-12-04 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2019-10-24 | 2019-12-04 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-10-24 | 2019-12-04 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-10-24 | 2019-12-04 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-10-24 | 2019-12-04 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-10-24 | 2019-12-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-24 | 2019-12-04 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-10-24 | 2019-12-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-24 | 2019-12-04 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-01-03 | 2019-01-17 | N |
| Develop a communication plan. | Fire Safety | 2019-01-03 | 2019-01-17 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-01-03 | 2019-01-17 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-01-03 | 2019-01-17 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-01-03 | 2019-01-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-10-11 | 2018-11-10 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2018-10-11 | 2018-11-10 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2018-10-11 | 2018-11-10 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2018-10-11 | 2018-11-10 | N |
| Ensure that residents are free from significant medication errors. | Health | 2018-10-11 | 2018-11-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-10-11 | 2018-11-10 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2018-10-11 | 2018-11-10 | N |
