Lions Gate

Inspectors wroteBased on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices in a manner to prevent food borne illness. This deficient practice was observed and evidenced by the following:On 6/4/26 at 9:36 AM, the surveyor conducted an interview with the Chief Executive Chef (CEC) prior to the initial tour of the kitchen. The CEC stated that the kitchen was Kosher which included separate kitchens, refrigerators, freezers, and dish machines for meat and dairy. On 6/4/26 at 9:48 AM, the surveyor in the presence of the CEC and the Food Service Director (FSD) toured the kitchen and observed the following:1. On the chef's preparatory table, there was a can opener with a black sticky residue. The CEC stated the can opener should be cleaned daily.2. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to complete and transmit a Minimum Data Set (MDS) discharge tracking record in accordance with federal guidelines. This deficient practice was identified for 1 of 1 resident reviewed for resident assessment (Resident #77). This deficient practice was evidenced by:ReferenceA MDS is a comprehensive tool that is a federally mandated process for clinical assessment of all residents that must be completed and transmitted to the Quality Measure System. The facility must electronically transmit the MDS within 14 days of the assessment being completed. On 6/4/26 at 1:10 PM, the surveyor reviewed Resident #77's electronic medical record. The record included that the resident was discharged home on 2/15/26, but that there was no discharge tracking record completed for the resident's discharge date . [...]

Inspectors wroteBased on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to develop a comprehensive care plan for 1 of 2 residents (Resident #11) reviewed for limited range of motion. This deficient practice was evidenced by the following:On 6/04/26 at 10:15 AM, the surveyor observed Resident #11 lying in bed. The resident's left hand was contracted without a splint device in place. On 6/05/26 at 12:46 PM, the surveyor observed Resident #11 lying in bed. The resident's left hand was contracted without a splint device in place. The surveyor reviewed the electronic medical record (EMR) for Resident #11. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to maintain kitchen sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 2/7/25 at 9:50 AM, the surveyor conducted an interview with the Director of Culinary (DC) prior to the initial tour of the kitchen. The DC stated that items stored in the refrigerators and freezers should be labeled and dated with the received date, the opened dated, and the use-by date. The DC further stated that dishware should be inverted and air dried after washing. On 2/7/25 at 10:18 AM, the surveyor, accompanied by the DC, observed the following in the kitchen: In the Meat Refrigerator: 1. A shallow two-inch hotel pan of tilapia which was sealed with plastic wrap. [...]

Inspectors wroteBased on observation, interviews and review of pertinent facility records, the facility failed to develop and implement an individualized comprehensive care plan for a resident that was requiring an anti-anxirty and anti-psychotic medication. This deficient practice was identified for 1 of 5 residents (Resident #29) reviewed for medication regimen. On 2/10/25 at 10:00 AM, during the initial tour, the surveyor observed Resident #29 awake, and alert, fully dressed, sitting in a wheelchar in their room. The survyeor reviewed the medical record for Resident #29. [...]

Inspectors wroteComplaint #NJ179408 Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure a.) that the wound treatment cart was locked when not in use b.) accountability for the completion of the narcotic shift-to-shift count logs in accordance with the facility policy b.) an accurate account of the administration and documentation of controlled medications c.) properly dispose of medications at the time of resident refusal and d.) that expired medical supplies were not available for use in resident care in the medication storage room and in the emergency crash cart. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure food served to residents was palatable. This deficient practice was identified for 5 out of 5 residents (Resident # 29, #31, #37, #74 and #75) who attended the Resident Council meeting conducted by the survey team on 2/10/25 and confirmed during the lunchtime meal service on 2/11/25 for 1 of 4 nursing units (Skilled 1) tested for food palatability. This deficient practice was evidenced by the following: On 2/7/25 at 10:00 AM, during the initial tour of the Skilled 1 nursing unit, Resident #29 stated that the food was the worst and the meat was tough. At 10:13 AM, Resident #37 stated that the food was cold, and the meat was tough and inedible. At 10:34 AM, Resident # 31 stated that the food was inedible, cold, and the meat was tough. [...]

Inspectors wroteBased on observation, interview, and review of facility documents, it was determined that the facility failed to maintain proper infection control practices to ensure a.) staff performed appropriate hand hygiene during meal service for 1 of 4 dining rooms observed (First floor Skilled Nursing Unit ), b.) an ice scooper was used to obtain ice from the ice machine during dining observation of 1 of 4 dining rooms observed (First floor skilled nursing unit), c.) ensure respiratory equipment was stored in an appropriate way to prevent the spread of infection for 1 of 4 residents reviewed for use of respiratory equipment (Resident # 18) and d.) enhanced barrier precautions (EBP) was initiated for 1 of 4 residents (Resident #31) reviewed for infection control. This deficient practice was evidenced by the following: [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure that residents were served their meals in a manner that promotes respect and dignity for 2 residents (Resident #32 and #42) observed during a lunch meal service on 1 of 4 units (Skilled 2). This deficient practice was evidenced by the following: 1.) On 2/10/25 at 12:00 PM, the surveyor observed the lunch meal service in the Skilled 2 nursing unit dining room. Resident #32 was seated in a geriatric (geri) chair (a reclining chair) at a table with two other residents. At 12:38 PM, the surveyor observed Licensed Practical Nurse (LPN) #1 standing over Resident #32 while feeding the resident tomato soup and sips of his/her beverage. At 12:47 PM, LPN #1 stopped feeding Resident #32 as the resident had finished his/her soup. [...]

Inspectors wroteComplaint #NJ179408 Based on interview, record review, and review of facility documents, it was determined that the facility failed to report an allegation of narcotic drug diversion to the New Jersey Department of Health and the Office of the Ombudsman for the Institutionalized Elderly in a timely manner in accordance with state and federal requirements. This deficient practice was identified for 1 of 1 Nurse (Licensed Practical Nurse (LPN) #4 and 3 of 3 residents (Resident #197, #198, and #199) reviewed for pain medication administration on 1 of 4 nursing units (Rehabilitation Unit #1) and was evidenced by the following: Refer to F755 On 2/11/25 at 8:48 AM, the surveyor reviewed the medical record of Resident #197. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to obtain a re-weight according to the facility's policy for a resident with a history of significant weight loss. This deficient practice was identified for 1 of 1 resident (Resident #51) reviewed for nutrition and evidenced by the following: On 2/10/25 at 1:01 PM, the surveyor observed Resident #51 in the first-floor skilled nursing unit dining room being served breakfast. The resident received pancakes cut into bite sized portions. The resident complained that the pancakes were cold and did not eat the pancakes. On 2/11/25 at 8:20 AM, the surveyor observed Resident #51 in the first-floor skilled nursing unit dining room being served breakfast. The resident received pancakes cut into bite sized portions. The resident ate about 50% of their meal. [...]

Inspectors wroteBased on observations, interviews, facility document review, and facility policy review, it was determined that the facility failed to follow the planned menu and serve foods to residents in the amount indicated on the diet spreadsheet for 2 of 2 meals observed. This had the potential to affect 71 residents who received meals from the kitchen, as identified by the facility.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected a resident's dental status for 1 (Resident #161) of 1 sampled resident reviewed for dental services. A review of Resident #161's admission Record revealed the resident had diagnoses that included type 2 diabetes mellitus with unspecified complications and need for assistance with personal care. An admission Minimum Data Set (MDS), dated [DATE], revealed Resident #161 had a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. The MDS indicated the resident did not have any tooth fragments or broken natural teeth. A review of Resident #161's Nursing Admission/Readmit Screening/History, dated 01/25/2023, indicated the resident did not have any broken teeth. [...]

Inspectors wroteBased on interviews, facility policy review, and record review, it was determined the facility failed to ensure a Level II Pre-admission Screening and Resident Review (PASRR) was conducted for 1 (Resident #61) of 3 sampled residents reviewed for PASRR. Specifically, the facility failed to refer Resident #61 for a Level II PASRR when the resident was newly diagnosed with a mental illness.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, it was determined the facility failed to ensure a care planned intervention for daily inspections of a resident's feet was implemented for 1 (Resident #161) of 3 residents reviewed for diabetes management. A review of an admission Record indicated the facility admitted Resident #161with diagnoses that included type 2 diabetes mellitus with unspecified complications and need for assistance with personal care. An admission Minimum Data Set (MDS), dated [DATE], revealed Resident #161 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderate cognitive impairment. The MDS indicated Resident #161 required supervision with personal hygiene and did not have any ulcers, wounds, or skin problems. [...]

Inspectors wroteBased on observations, record review, interviews, and facility document and policy review, it was determined the facility failed to provide foot care and services to prevent potential diabetes complications for 1 (Resident #161) of 3 sampled residents reviewed for diabetes management. A review of Resident #161's admission Record revealed the resident had diagnoses that included type 2 diabetes mellitus with unspecified complications and need for assistance with personal care. An admission Minimum Data Set (MDS) dated [DATE] revealed Resident #161 had a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. The MDS indicated the resident had no ulcers, wounds, or skin problems. [...]