Inspection Reports for
Lions Gate

Complaint #NJ179408 involved allegations of narcotic drug diversion by an agency nurse (LPN #4) who was suspected of removing narcotics without administration to residents and forging signatures. The facility delayed reporting the event to the New Jersey Department of Health and the Office of the Ombudsman by six days. The investigation confirmed missing narcotics and forged signatures. The nurse was placed on a do not return list and reported to her agency.

The facility failed to timely report suspected narcotic drug diversion to the New Jersey Department of Health and the Office of the Ombudsman. Deficiencies included improper narcotic inventory management, forged signatures on narcotic records, unsecured wound treatment cart, incomplete narcotic shift-to-shift counts, inaccurate medication administration documentation, improper disposal of medications, and expired medical supplies in medication storage and emergency crash carts.

The facility was found deficient in multiple areas including failure to ensure residents were served meals with dignity and respect, failure to timely report narcotic drug diversion, incomplete care planning for residents on antipsychotic medications, failure to monitor significant weight loss, medication management deficiencies including narcotic accountability, poor food palatability and kitchen sanitation, and lapses in infection prevention and control practices including hand hygiene and respiratory equipment storage.

Complaint investigation for allegations NJ165086, NJ175960, and NJ179408. The complaint was substantiated with findings including failure to serve meals with dignity, failure to report alleged violations timely, and medication administration errors.

The facility was found to have multiple deficiencies including failure to ensure residents were served meals in a manner that promotes respect and dignity, failure to report alleged violations timely, failure to develop and implement comprehensive care plans, failure to maintain food palatability, failure to maintain infection control practices, and failure to conduct required inspections and maintenance of fire safety and emergency equipment.

Complaint #: NJ00176485. The facility was not in substantial compliance with 42 CFR Part 483, Subpart B, based on this complaint visit.

The facility was found not in substantial compliance with staffing requirements, failing to meet minimum staff-to-resident ratios on 1 of 14 evening shifts and 1 of 14 day shifts during specified periods. No residents were found to be affected by the deficient practice.

The facility failed to ensure accurate Minimum Data Set assessments reflecting dental status, failed to complete required Level II PASRR screening for a resident with a new mental illness diagnosis, failed to implement daily foot inspections and provide appropriate foot care for a diabetic resident, and failed to follow the planned menu and serve correct portion sizes to residents.

The facility was found not in substantial compliance with several regulatory requirements including accuracy of assessments, coordination of PASARR and assessments, comprehensive care plans, foot care, menus and nutritional adequacy, staffing ratios, and life safety code compliance. Deficiencies were cited across multiple areas with corrective actions planned and completion dates set for March 21, 2023.

Complaint investigation based on complaints NJ147082 and NJ146321. The complaint was substantiated as the facility failed to prevent accidents and ensure adequate supervision for Resident #1, leading to injury and hospitalization.

The facility failed to ensure the resident environment was free of accident hazards and that residents received adequate supervision and assistance devices to prevent accidents. Specifically, Resident #1 was found on the floor after a failed intervention, resulting in hospitalization. The facility's policies and staff actions were inadequate to prevent the incident and ensure resident safety.

The facility failed to disinfect a blood pressure cuff between each resident use, as observed with four residents on one unit. The Licensed Practical Nurse did not clean the blood pressure cuff before or after use despite contact precaution signage and facility policy requiring disinfection.

The facility was found deficient in infection prevention and control practices, specifically failing to disinfect reusable blood pressure cuffs between resident uses, which could lead to the spread of infection.