Inspection Reports for Cardinal Village

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The inspection was conducted as a complaint investigation related to alleged failure to develop, implement, and enforce a policy titled abuse prevention plan and failure to review or update the General Service Plan (GSP) for residents.

The facility was found not in substantial compliance with New Jersey Administrative Code standards, with deficiencies including failure to implement and enforce an abuse prevention plan, failure to review and update residents' General Service Plans following an incident, and failure to document assessments in medical records. The investigation revealed inadequate notification and documentation of a resident-to-resident incident.

Complaint # NJ 00188282 was investigated. The complaint involved an incident where Resident #2 and Resident #3 walked past each other in the hallway, with alleged abuse or neglect reported. The facility failed to notify appropriate parties and law enforcement, and failed to update care plans and document assessments. The complaint was substantiated based on interviews and record reviews.

The inspection was conducted as a complaint investigation based on multiple complaint numbers related to medication management, resident assessments, and care plan deficiencies at Cardinal Village.

The facility was found not in substantial compliance with New Jersey Administrative Code standards, with deficiencies including failure to develop and enforce a comprehensive medication management policy, failure to complete comprehensive resident assessments, and failure to update resident care plans with necessary interventions. Medication errors and documentation issues were noted, particularly involving Resident #2 and Resident #3.

The complaint investigation was substantiated with findings that the Executive Director failed to develop and enforce medication management policies, and the facility failed to complete required resident assessments and update care plans. Medication administration errors were documented, including a medication not administered to Resident #2 for 16 doses due to pharmacy transcription errors.

A COVID-19 Focused Infection Control Survey was conducted by the State Agency on 05/23/2024 to assess compliance with New Jersey Administrative Code 8:36 infection control regulations and CDC recommended practices.

The facility was found to be in compliance with infection control regulations and CDC recommended practices to prepare for COVID-19.

The inspection was conducted as a complaint investigation based on complaints NJ00170794, NJ00164920, and NJ00164583 regarding compliance with New Jersey Administrative Code 8:36 standards for licensure of assisted living residences.

The facility was found not in substantial compliance with standards, specifically failing to ensure proper implementation and enforcement of policies related to wandering residents, staff training on the wander guard system, and maintaining a safe environment for a high-risk resident. Deficiencies included lack of documented wandering risk assessment prior to admission, absence of staff training documentation on the wander guard system, and inadequate safety measures to prevent elopement.

Complaint investigation based on complaints NJ00170794, NJ00164920, NJ00164583. The complaints were substantiated by findings of deficient practices related to wandering resident assessments, staff training, and safety measures.

The inspection was conducted as a complaint investigation based on complaint number NJ00149856.

The facility was found to be in substantial compliance with New Jersey Administrative Code, Chapter 8:36, Standards for Licensure of Assisted Living Residences, Comprehensive Personal Care Homes, and Assisted Living Programs.

Complaint investigation based on complaint number NJ00149856; the facility was in substantial compliance.

A COVID-19 Focused Infection Control Survey was conducted by the State Agency to assess compliance with infection control regulations and CDC recommended practices during the COVID-19 pandemic.

The facility was found not in compliance with infection prevention and control requirements, including failure of staff to perform proper hand hygiene, improper mask use by unvaccinated staff and contractors, failure to disinfect reusable medical equipment between residents, and failure to adhere to manufacturer recommended contact times for disinfectants during cleaning.

The inspection was a standard survey of 98 residential units to assess compliance with New Jersey Administrative Code 8:36, Standards for Licensure of Assisted Living Residences, Comprehensive Personal Care Homes and Assisted Living Programs.

The facility was found not in substantial compliance with all applicable standards, specifically failing to develop and implement a policy for physical examinations upon hire for employees. Five employee files reviewed lacked physical examination records upon hire.

A Covid-19 Focused Infection Control Survey was conducted by the State Agency to assess compliance with New Jersey Administrative Code 8:36 infection control regulations and CDC recommended practices for COVID-19 preparation.

The facility was found to be in compliance with the infection control regulations and CDC recommended practices to prepare for COVID-19.