Inspection Reports for Carnegie Post Acute Care At Princeton Llc

5000 Windrow Drive, NJ, 08540

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Deficiencies (last 5 years)

Deficiencies (over 5 years) 3.8 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

27% better than New Jersey average
New Jersey average: 5.2 deficiencies/year

Deficiencies per year

12 9 6 3 0
2021
2022
2023
2024
2025

Census

Latest occupancy rate 144 residents

Based on a April 2025 inspection.

This facility has shown a steady increase in demand based on occupancy rates.

Census over time

90 120 150 180 210 Jan 2021 Dec 2022 Aug 2023 Oct 2024 Apr 2025
Notice Deficiencies: 0 Nov 19, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of NJDHSS, including how their health information may be used and disclosed, and their rights related to this information.
Findings
The notice details the types of information covered, reasons for use and disclosure of health information, individuals' rights to access and control their information, and the legal duties of NJDHSS to protect privacy.
Report Facts
Effective date: 2011
Employees Mentioned
NameTitleContext
Devon L. GrafDirector, Office of Legal and Regulatory ComplianceListed as NJDHSS Privacy Officer contact for questions about the notice
Inspection Report Complaint Investigation Census: 144 Deficiencies: 0 Apr 1, 2025
Visit Reason
The inspection was conducted as a complaint investigation based on Complaint Number NJ184901.
Findings
The facility was found to be in compliance with the requirements of 42 CFR, Part 483, Subpart B, for long term care facilities based on this complaint visit.
Complaint Details
Complaint Number NJ184901 was investigated and found to be unsubstantiated as the facility was in compliance.
Report Facts
Sample Size: 4
Inspection Report Annual Inspection Census: 156 Capacity: 180 Deficiencies: 9 Feb 25, 2025
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities, including a Life Safety Code Survey and assessment of compliance with staffing and infection control requirements.
Findings
The facility was found deficient in multiple areas including comprehensive resident assessments, accuracy of assessments, physician visit frequency, psychotropic medication use, infection prevention and control, staffing ratios, and life safety code compliance. Plans of correction were submitted and accepted with completion dates in April 2025.
Severity Breakdown
Level D: 8 Level E: 1
Deficiencies (9)
DescriptionSeverity
Failure to complete comprehensive resident assessments within required timeframes.Level D
Failure to accurately complete Minimum Data Set (MDS) assessments.Level D
Failure to ensure responsible physician conducted timely face-to-face visits and documented progress notes.Level D
Failure to provide adequate indication for psychotropic medications and failure to follow psychotropic drug regulations.Level D
Failure to maintain adequate staffing ratios as mandated by the state of New Jersey.Level D
Failure to maintain infection prevention and control program including adequate staffing, committee meetings, and antibiotic stewardship.Level E
Failure to maintain integrity of smoke barrier partitions and proper installation of sprinklers and life safety features.Level D
Failure to maintain required means of egress including exit doors and locking arrangements.Level D
Failure to ensure laundry staff had proper personal protective equipment and proper handling of contaminated linens.Level D
Report Facts
CNA staffing counts: 14 CNA staffing counts: 17 CNA staffing counts: 15 CNA staffing counts: 18 Resident census: 156 Total licensed beds: 180 Deficiency completion date: Apr 10, 2025
Inspection Report Complaint Investigation Census: 135 Deficiencies: 2 Oct 31, 2024
Visit Reason
The inspection was conducted in response to complaints NJ00178815 and NJ00178967 alleging abuse, neglect, exploitation, or mistreatment at Carnegie Post Acute Care at Princeton LLC.
Findings
The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, based on failure to report alleged violations of abuse and neglect timely and failure to maintain required staffing ratios for Certified Nurse Aides (CNAs) on multiple day shifts.
Complaint Details
Complaint investigation based on allegations NJ00178815 and NJ00178967. The complaint was substantiated as the facility failed to report alleged abuse and neglect timely and did not meet staffing requirements. The investigation included interviews, document reviews, and policy assessments.
Severity Breakdown
Level D: 1
Deficiencies (2)
DescriptionSeverity
Failure to report alleged violations involving abuse, neglect, exploitation, or mistreatment within required timeframes.Level D
Failure to maintain required minimum staffing ratios for Certified Nurse Aides (CNAs) on 14 of 14 day shifts reviewed.
Report Facts
Census: 135 Staffing Deficiency Days: 14 Certified Nurse Aides required: 17 Certified Nurse Aides present: 13
Inspection Report Complaint Investigation Census: 129 Deficiencies: 1 Jul 31, 2024
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ00152846 and NJ00169811 to determine compliance with federal and state regulations.
Findings
The facility was found not in compliance with New Jersey Administrative Code 8:39 standards for licensure of Long Term Care Facilities due to failure to maintain required minimum staff-to-resident ratios on 17 of 28 day shifts. The facility submitted a plan of correction and was required to ensure staffing ratios met state mandates.
Complaint Details
Complaint numbers NJ00152846 and NJ00169811 were investigated. The facility was found deficient in staffing ratios but was in compliance with 42 CFR Part 483, Subpart B based on this complaint survey.
Deficiencies (1)
Description
Failure to ensure staffing ratios were met to maintain the required minimum staff-to-resident ratios as mandated by the state of New Jersey for 17 of 28 day shifts.
Report Facts
Census: 129 Deficient day shifts: 17 Sample size: 7 Correction completion date: Sep 10, 2024 Staffing shortfalls: 5 Staffing shortfalls: 12
Inspection Report Routine Census: 133 Deficiencies: 0 Aug 20, 2023
Visit Reason
A COVID-19 Focused Infection Control survey was conducted on behalf of the New Jersey Department of Health.
Findings
The facility was found to be in substantial compliance with 42 CFR 483 subpart B.
Report Facts
Sample Size: 6
Inspection Report Complaint Investigation Census: 126 Deficiencies: 2 Aug 3, 2023
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ00146686 and NJ00150785 regarding facility compliance with resident care documentation and staffing requirements.
Findings
The facility was found not in substantial compliance with requirements due to failure to consistently document Activities of Daily Living (ADL) care for multiple residents and failure to maintain required minimum staff-to-resident ratios for certified nursing assistants (CNAs) on numerous day shifts.
Complaint Details
Complaint numbers NJ00146686 and NJ00150785 triggered the survey. The facility was found not in substantial compliance based on these complaints.
Severity Breakdown
SS=E: 1
Deficiencies (2)
DescriptionSeverity
Facility staff failed to consistently document Activities of Daily Living (ADL) status and care provided to residents, and failed to follow the facility's ADL policy for 4 of 4 residents reviewed.SS=E
Facility failed to ensure staffing ratios met the required minimum staff-to-resident ratios mandated by the state of New Jersey for 28 of 28 day shifts reviewed.
Report Facts
Census: 126 Sample Size: 5 Deficient CNA staffing day shifts: 28 Required CNA staffing: 16 Actual CNA staffing: 8
Employees Mentioned
NameTitleContext
CNA #1Certified Nursing AssistantInterviewed regarding ADL documentation expectations and practices.
LPN #1Licensed Practical NurseInterviewed regarding ADL documentation requirements and staff responsibilities.
LPN/UMLicensed Practical Nurse/Unit ManagerInterviewed about ADL care and documentation oversight.
Licensed Nursing Home AdministratorAdministratorInterviewed about expectations for ADL documentation and identified night shift documentation as a weakness.
Director of NursingDirector of NursingInterviewed about staffing challenges and recruitment efforts.
Inspection Report Complaint Investigation Census: 129 Deficiencies: 2 Dec 7, 2022
Visit Reason
The inspection was conducted based on complaint NJ00159874 to investigate the facility's compliance with staffing requirements and other regulatory standards.
Findings
The facility was found not in substantial compliance with federal and state staffing requirements, specifically failing to maintain minimum direct care staff-to-resident ratios and required Registered Nurse staffing for multiple days during the review period.
Complaint Details
Complaint #: NJ00159874. The facility was found deficient in staffing ratios and RN coverage based on review of staffing reports and interviews during the complaint survey.
Deficiencies (2)
Description
Failure to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey for 14 of 14 days reviewed.
Failure to provide the required Registered Nurse staffing as required by New Jersey State Regulations on multiple dates.
Report Facts
Census: 129 Deficient CNA staffing days: 14 CNA staffing counts: 9 Required CNA staffing counts: 16
Inspection Report Complaint Investigation Census: 124 Deficiencies: 0 Nov 30, 2022
Visit Reason
The inspection was conducted as a complaint investigation based on complaint number NJ142990.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR Part 483, Subpart B, for long term care facilities based on this complaint visit.
Complaint Details
Complaint number NJ142990 was investigated and the facility was found to be in substantial compliance.
Report Facts
Sample size: 3
Inspection Report Abbreviated Survey Census: 99 Deficiencies: 3 Jan 12, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations related to COVID-19.
Findings
The facility was found not to be in compliance with infection control regulations, specifically failing to ensure proper hand hygiene, appropriate use of personal protective equipment (PPE), and correct donning of PPE prior to entering rooms of residents on Transmission Based Precautions. Multiple staff members, including nursing and housekeeping staff as well as physicians, were observed not following required infection control practices.
Severity Breakdown
SS=E: 3
Deficiencies (3)
DescriptionSeverity
Failure to appropriately perform hand hygiene to prevent the spread of infection.SS=E
Failure to wear appropriate Personal Protective Equipment (PPE) to prevent the spread of infection.SS=E
Failure to appropriately don PPE prior to entering resident's rooms on Transmission Based Precautions.SS=E
Report Facts
Sample size: 4
Employees Mentioned
NameTitleContext
Housekeeper #1Observed wearing cloth face mask improperly and educated on proper mask use and hand hygiene.
Housekeeper #2Observed wearing cloth face mask improperly and educated on proper mask use.
Housekeeper #3Observed wearing surgical mask improperly and educated on proper mask use.
Licensed Practical Nurse/Unit ManagerLicensed Practical Nurse/Unit ManagerObserved wearing KN95 mask improperly and educated on proper mask use.
PhysicianObserved wearing cloth face mask over KN95 mask, not wearing eye protection, and improperly donning gown; educated on PPE requirements.
Registered Nurse Interim Director of NursingInfection PreventionistProvided statements on proper infection control practices and PPE use.

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