Lions Gate
Inspection history, citations, penalties and survey trends for this long-term care facility in Voorhees, New Jersey.
- Location
- 1100 Laurel Oak Road, Voorhees, New Jersey 08043
- CMS Provider Number
- 315499
- Inspections on file
- 13
- Latest survey
- February 13, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Lions Gate during CMS and state inspections, most recent first.
The facility failed to maintain proper kitchen sanitation and food storage practices, leading to potential foodborne illness. Observations revealed unlabeled and expired food items in refrigerators, improper sealing of ice cream tubs, and wet nesting of pans. Dietary staff were responsible for these areas but did not adhere to facility policies, resulting in the disposal of several food items.
A facility failed to develop and implement a comprehensive care plan for a resident prescribed anti-anxiety and anti-psychotic medications. The resident, with diagnoses including major depressive disorder and systemic lupus erythematosus, was observed without a care plan addressing the use of Abilify and Xanax. Despite the resident's intact cognition, the care plan was only initiated after surveyor inquiry. Interviews with nursing staff revealed an expectation for immediate care planning for residents with behavioral issues, which was not met in this instance.
The facility failed to secure a wound treatment cart, properly document narcotic counts, and manage expired medical supplies. An LPN admitted to leaving a cart unlocked and forgetting to sign narcotic logs, while expired items were found in storage and crash carts, indicating non-compliance with facility policies.
The facility failed to provide palatable food to residents, as evidenced by complaints about cold, tough, and inedible meals. During a resident council meeting, several residents expressed dissatisfaction with the food quality, noting that previous complaints had not led to improvements. Surveyors confirmed these issues by tasting meal trays and finding them bland and unappetizing.
The facility failed to maintain proper infection control practices during meal service, with staff not performing hand hygiene between tasks. Additionally, improper equipment was used for dispensing ice, and respiratory equipment was not stored correctly. A resident with a midline IV catheter was not placed on Enhanced Barrier Precautions due to a misunderstanding by the Infection Preventionist.
Two residents were not served meals in a dignified manner, with one resident left unattended and not fed promptly, and another not receiving their requested meal items. Staff fed residents while standing, contrary to facility policy, and communication issues led to incomplete meal service.
A facility failed to timely report a suspected narcotic diversion involving an LPN and three residents. Narcotics were signed out but not documented as administered, with two residents denying receipt. The DON delayed reporting to the NJDOH and Ombudsman, uncertain of the requirement, and confirmed diversion after LPN's non-compliance with an interview.
A facility failed to re-weigh a resident with significant weight loss, as required by policy. The resident, with vascular dementia and dysphagia, experienced weight fluctuations, but staff did not perform re-weighs or notify the RD and doctor. The facility's policy required re-weighing for weight changes of 5% or more, which was not followed, leading to the deficiency.
Deficiencies in Kitchen Sanitation and Food Storage
Penalty
Summary
The facility failed to maintain kitchen sanitation in a safe and consistent manner, leading to potential foodborne illness. During an inspection, the surveyor observed several deficiencies in the kitchen and dining areas. In the meat refrigerator, a pan of tilapia was found without a label or use-by date, and it was discarded by the Director of Culinary (DC). Similarly, in the dairy refrigerator, items such as Asiago cheese, marinara sauce, creamed herring, and capers were either not labeled or had expired use-by dates, leading to their disposal. Additionally, the surveyor noted improper dish drying practices, with several pans found wet nested, indicating they were not air-dried as required. Further observations in the dining room refrigerators revealed improperly sealed and unlabeled ice cream tubs and containers of nectar thick water with expired dates. Dietary Service Aides (DSAs) were responsible for maintaining these refrigerators, but they failed to ensure items were labeled and discarded appropriately. Interviews with the DC and the Licensed Nursing Home Administrator (LNHA) confirmed that the dietary staff were expected to label and date food items correctly and discard expired items. The facility's policies on food storage and dish drying were not adhered to, contributing to the identified deficiencies.
Failure to Implement Comprehensive Care Plan for Resident on Psychotropic Medications
Penalty
Summary
The facility failed to develop and implement an individualized comprehensive care plan for a resident who was prescribed anti-anxiety and anti-psychotic medications. This deficiency was identified during a survey when the surveyor observed the resident, who was awake, alert, and sitting in a wheelchair, and reviewed their medical records. The resident had a diagnosis of systemic lupus erythematosus, major depressive disorder, protein-calorie malnutrition, and primary insomnia. Despite these conditions and the resident's intact cognition, as indicated by a BIMS score of 15 out of 15, the care plan did not include interventions for the use of Abilify and Xanax, which were prescribed for the resident's major depressive disorder. The surveyor's inquiry prompted the facility to initiate a care plan for the use of these medications. Interviews with the nursing staff, including a Registered Nurse and a Licensed Practical Nurse, revealed that there was an expectation for a care plan to be initiated for residents with suicidal ideation or behavior issues. The Director of Nursing acknowledged the oversight and stated that the care plan should have been initiated promptly. The facility's Behavioral Management policy emphasized the need for interdisciplinary evaluation and assessments to assist residents in reaching their highest level of mental and psychosocial functioning, which was not adhered to in this case.
Medication and Supply Management Deficiencies
Penalty
Summary
The facility failed to ensure the security and proper management of medications and medical supplies, as evidenced by several observations and interviews. A wound treatment cart was found unlocked, which was acknowledged by an LPN who admitted to forgetting to lock it after use. Additionally, a Lidocaine Patch was found in the medication cart without proper documentation of which resident it was intended for, indicating a lapse in medication management. The facility also demonstrated a lack of accountability in the shift-to-shift narcotic count logs. Several instances were noted where the required signatures were missing, suggesting that the narcotic counts were not properly conducted or documented. This was confirmed by interviews with nursing staff, who admitted to forgetting to sign the logs, and the DON, who acknowledged the importance of accurate documentation to prevent discrepancies. Furthermore, expired medical supplies were found in the medication storage room and emergency crash carts, including culture swabs, suction connection tubing, and examination gloves. The facility's policies on medication administration, narcotic counts, and crash cart inspections were not adhered to, as evidenced by the presence of expired items and the lack of proper documentation and accountability in medication management.
Deficiency in Food Palatability
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, as evidenced by multiple complaints from residents and observations by surveyors. During an initial tour of the Skilled 1 nursing unit, several residents reported that the food was cold, inedible, and the meat was tough. These complaints were reiterated during a resident council meeting, where five alert and oriented residents expressed dissatisfaction with the food quality, stating that the meat was tough and the food was not good. Despite previous complaints made at monthly resident council meetings, no improvements were noted. On a subsequent day, the survey team tasted meal trays provided by the facility's Director of Culinary and found several issues with the food's palatability. The regular consistency meal had bland and mushy cauliflower, bland peas and carrots with hard peas, and bland, floury mashed potatoes. The pureed consistency meal was described as pasty with a flavor that did not match the regular texture version. These findings were communicated to the Licensed Nursing Home Administrator and the Director of Nursing, who acknowledged the feedback but noted that taste preferences vary among individuals.
Infection Control Deficiencies in Meal Service and Equipment Handling
Penalty
Summary
The facility failed to maintain proper infection control practices during meal service in the first-floor skilled nursing unit dining room. The Dietary Service Aide (DSA#5) was observed repeatedly not performing hand hygiene between serving residents, handling dirty dishes, and touching various surfaces. This was confirmed through interviews with the DSA, the Infection Preventionist, and the Director of Nursing, all of whom acknowledged the importance of hand hygiene to prevent infection or contamination. The facility's hand hygiene policy clearly outlined the need for handwashing before and after certain tasks, which was not adhered to by the staff. Additionally, the facility did not use proper equipment for dispensing ice. DSA #4 and DSA #5 were observed using plastic drinking cups with bare hands to scoop ice from the ice machine, instead of using an ice scooper as required by the facility's policy. This practice was acknowledged as incorrect by both the DSAs and the Director of Nursing, who emphasized the importance of using an ice scooper to prevent the spread of infection. The facility also failed to store respiratory equipment properly. Resident #18's nebulizer mask was observed lying directly on the bedside table instead of being stored in a plastic bag, as required by the facility's nebulizer therapy policy. The Licensed Practical Nurse confirmed the improper storage and acknowledged the importance of storing the nebulizer mask in a plastic bag to prevent contamination. Furthermore, Resident #31, who had a midline IV catheter, was not placed on Enhanced Barrier Precautions (EBP) as required, due to a misunderstanding by the Infection Preventionist regarding the type of IV catheter used.
Failure to Maintain Dignity During Meal Service
Penalty
Summary
The facility failed to ensure that residents were served their meals in a manner that promotes respect and dignity, as observed during a lunch meal service. Resident #32, who had severe cognitive impairment and was dependent on staff for eating, was not fed in a timely or respectful manner. The resident was left unattended for extended periods, and staff members fed the resident while standing over them, rather than sitting at eye level. This resulted in the resident not finishing their entree and being removed from the dining room without being offered the remainder of their meal. Resident #42 also experienced a lack of dignity during meal service. Despite expressing hunger, the resident was not served their requested meal items in a timely manner and was not offered dessert. The resident was observed watching others eat while waiting for their meal, which was not served according to their preferences. Staff communication issues contributed to the resident not receiving the full meal they requested, and the resident was removed from the dining room without being offered dessert. The facility's policies on Assistance with Meals and Dignity were not followed, as residents were not fed in a manner that met their individual needs or promoted their well-being. Staff interviews revealed a lack of adherence to the facility's guidelines, with staff acknowledging that they should have been seated next to residents while feeding them and that meals should be served promptly to maintain warmth and appeal.
Delayed Reporting of Narcotic Diversion
Penalty
Summary
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. This deficiency was identified in the case of one LPN and three residents on the Rehabilitation Unit #1. The issue arose when narcotics were signed out from the narcotic inventory record but were not documented as administered on the medication administration record (MAR). Two residents denied receiving the medication, and one resident was unable to confirm if they were medicated due to cognitive impairment. The investigation revealed that an agency nurse, LPN #4, was suspected of diverting narcotics. The DON noted that LPN #4 exhibited odd behavior, such as hyperactivity and spending an unusual amount of time with the narcotic inventory book. The narcotic count was accurate during the shift change, but discrepancies were found in the signatures on the narcotic inventory record, which did not match those of the assigned nurses. The DON confirmed that the signatures were forged, and the residents did not receive the medications as documented. The facility's policies required mandatory reporting of incidents affecting residents' health and safety. However, the DON delayed reporting the suspected drug diversion to the NJDOH and the Ombudsman, as she was uncertain about the requirement and wanted to confirm the diversion before reporting. The report was eventually made six days after the event, following the failure of LPN #4 to comply with a face-to-face interview. The facility's policies on reportable events and drug diversion were not followed promptly, leading to the deficiency.
Failure to Re-weigh Resident with Significant Weight Loss
Penalty
Summary
The facility failed to obtain a re-weight for a resident with a history of significant weight loss, as per the facility's policy. The resident, who had vascular dementia, GERD, and dysphagia, experienced a weight loss of more than 5% in the last month, which was not part of a physician-prescribed weight loss regimen. Despite the resident's weight fluctuations and a physician's order for weekly weights, the facility did not perform a re-weight after a significant weight loss was documented on multiple occasions. The resident's care plan included monitoring weight and notifying the Registered Dietician (RD) and Medical Director (MD) of any weight changes. However, the facility did not adhere to this plan. The Certified Nursing Assistant (CNA) and Licensed Practical Nurse (LPN) involved did not re-weigh the resident or notify the RD and doctor after the significant weight changes on specific dates. The RD was unaware of the weight changes and had previously recommended monitoring the resident's intake and weight trends. The facility's Weight Policy required re-weighing for any weight change of 5% or more since the last assessment, with immediate notification to the dietician if verified. The Director of Nursing (DON) confirmed that the nurse should have re-weighed the resident and notified the RD and doctor. The failure to follow these procedures resulted in the deficiency identified by the surveyor.
Latest citations in New Jersey
A resident with severe cognitive impairment, multiple comorbidities, and a stage 4 sacral pressure ulcer required staff assistance with ADLs and had a care plan specifying turning, repositioning, offloading, limited sitting time, and use of a ROHO cushion. While Documentation Survey Reports showed recorded interventions such as skin observation and turning/repositioning from January through March, the facility could not produce any ADL or POC documentation for turning, repositioning, or getting the resident out of bed for the preceding several months. CNAs, an LPN, and the DON reported that these interventions were performed and documented in the POC or progress notes, but the requested records for that time period were unavailable, contrary to facility policies on turning/repositioning and pressure injury prevention that require such care to be implemented and documented.
The facility failed to maintain sufficient kitchen staffing, resulting in days when no cook was on duty and the Food Service Director had to cover all meals. On one such day, residents reported receiving only cold items for all three meals, including cereal and milk for breakfast, cold cut sandwiches and chips for lunch, and cold cut ham wraps for dinner, with no cooked foods or vegetables provided. A Dietary Aide confirmed that both the scheduled cook and the FSD were ill that day, and the RD instructed use of only non-cook items, later acknowledging the meals did not meet daily nutritional requirements. Review of the monthly schedule showed only one cook on staff, with the FSD covering most cooking duties and no backup cooks despite the facility’s policy requiring nutritionally adequate meals even when a scheduled cook is absent.
A resident with dementia, psychotic disorder, seizures, and moderate cognitive impairment was hospitalized for anemia and AKI, where imaging revealed an acute displaced left femur fracture with associated hemorrhage, along with clinical findings of left leg swelling, redness, and tenderness. After being notified by a hospital RN of the fracture, facility leadership conducted an internal investigation, concluded there was no harm done in the facility, and remained unsure where or how the fracture occurred. The LNHA acknowledged that the cause of the injury was unknown, and the CEO confirmed that such an injury of unknown origin should be reported to the Department of Health. Despite a written abuse policy requiring immediate notification to the state and written follow-up within 72 hours when investigating possible abuse or neglect, the facility did not report this injury of unknown origin to the New Jersey Department of Health.
A resident with schizoaffective disorder, major depression, and a documented history of elopement risk had a Wander Guard in place and a care plan calling for frequent monitoring due to active exit-seeking. After the resident’s behaviors escalated, one-to-one monitoring was started but then discontinued when the resident was moved to a secured unit, where policy required controlled exit access. On an evening in question, staff on the secured unit allowed residents to leave unaccompanied to a soda machine on another unit, and the resident was last seen in their room around 9 p.m. By about an hour later, staff discovered the resident missing, and a nurse on another floor, not the secured unit staff, activated a Code Grey after hearing a door alarm. A subsequent head count confirmed the resident had left the building; the resident later stated they exited through a unit door, took an elevator to the front entrance, and used public transportation to visit a family member, demonstrating a failure to maintain a safe secured environment and adequate supervision to prevent elopement.
A resident with severe intellectual disabilities, obstructive and reflux uropathy, and an indwelling catheter was seen by a urologist, who recommended cystoscopy, laser lithotripsy of a bladder stone, and TURP, with a future OR schedule. Nursing documentation noted the recommendation, but there was no evidence in the EMR that staff followed up with the urologist or the physician to schedule the procedures. Central supply staff, responsible for scheduling, reported making weekly calls and tracking them on paper that was not retained and had no EMR access, and leadership confirmed there was no policy for scheduling out-of-facility appointments and no completed follow-up form because the urology office was expected to schedule surgery. The resident was later sent out with cloudy urine, poor intake, and lethargy and was admitted to the hospital with an obstructed Foley, bilateral hydronephrosis, and acute kidney injury, and the lack of documented follow-up conflicted with the facility’s charting policy requiring the medical record to support interdisciplinary communication.
Surveyors found that multiple residents did not receive meals and beverages as listed on their tray tickets, including missing biscuits, condiments, and diet sodas, as well as incorrect items such as apple products despite a documented "no apple" order and food preferences like "no gravy" not being honored. Residents with conditions such as protein-calorie malnutrition, DM, CKD, and other chronic diagnoses had care plans directing staff to provide diets as ordered and honor food and beverage preferences, yet trays frequently did not match tray cards. Kitchen staff acknowledged running out of certain items, and leadership confirmed that trays and tray tickets were expected to match and that meals should follow documented preferences.
A resident with multiple medical conditions and moderate cognitive impairment required substantial assistance with toileting and was care planned for incontinence management and skin integrity. Facility records showed that required documentation of bladder continence, bowel continence, bowel movements, and toilet use was missing on multiple shifts, with no related entries in progress notes. CNAs, who were responsible for providing and documenting toileting and incontinence care in the EMR, and nursing leadership confirmed that all care should be documented and verified by supervisors, yet a CNA reported sometimes forgetting to chart when busy. This failure to follow the facility’s documentation policy resulted in an incomplete and inaccurate medical record.
A resident with dementia, depression, mixed anxiety disorder, and severely impaired cognition, who depended on staff for ADLs and communicated via written questions due to hearing impairment, reported that a male CNA had touched them inappropriately in the groin while providing a shower and that they had informed staff or the administrator shortly thereafter. The resident’s care plan was later updated to prohibit male CNAs, and documentation showed showers were provided by a male CNA on several occasions. The facility conducted an internal investigation and concluded there was no evidence to support sexual abuse, but did not notify the NJDOH as required by its abuse/neglect policy and state regulations, a failure confirmed by the DON and administrator during surveyor interviews.
A cognitively intact resident with mental health diagnoses reported that a CNA pushed them to the floor when they entered another resident’s room after hearing yelling, later seeking ED care where an abrasion of the upper extremity and a visit reason of battery were documented. An LPN documented hearing yelling, seeing the resident grabbing the CNA’s arm, and calling 911, while the CNA stated the resident aggressively grabbed her and denied assaulting the resident. Despite the resident’s repeated written complaints to the DSS and LNHA alleging assault and expressing anger when seeing the CNA, the facility did not follow its abuse policy requiring temporary suspension of employees under investigation, did not promptly obtain statements from other staff or residents on the CNA’s assignment, and allowed the CNA to continue working regular shifts, including on the unit where the resident resided.
A cognitively intact resident with psychiatric diagnoses reported that a CNA pushed them and knocked them down, after which an LPN heard yelling, entered the room, saw the resident grabbing the CNA’s arm, and then called 911 and notified the nursing supervisor. The resident requested hospital transport to document injuries and was treated in the ED for an abrasion of the upper arm and given a Tdap injection. The nursing supervisor was informed of the incident, and staff later received education on abuse and neglect policies; however, there was no evidence that the allegation of staff-to-resident physical abuse was reported to the state health department, and the ADON indicated she believed it was a resident-to-staff incident rather than a reportable staff-to-resident allegation.
Failure to Maintain ADL and Turning/Repositioning Documentation for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain documentation of Activities of Daily Living (ADL) tasks, specifically getting a resident out of bed and providing turning and repositioning, for a defined period. A resident with multiple complex medical conditions, including severe protein-calorie malnutrition, gastrointestinal hemorrhage, type 2 diabetes mellitus, dysphagia, a stage 4 sacral pressure ulcer, gastrostomy status, functional quadriplegia, iron deficiency anemia, and generalized muscle weakness, was assessed as having severely impaired cognition (BIMS score of 00) and requiring staff assistance with ADLs. The resident’s care plan, initiated in September 2025 and revised in March 2026, identified moisture-associated skin damage to the sacrum related to incontinence, immobility, poor cognition, peripheral vascular disease, and diabetes, and included interventions such as turning and repositioning, offloading per policy, limiting sitting time, use of a ROHO cushion, and treatment per physician orders. Review of the resident’s Documentation Survey Reports (DSRs) from January 2026 to March 2026 showed recorded interventions and tasks including skin observation, turning and repositioning, and amount eaten, with the DSR reflecting the days these tasks were performed. However, the facility was unable to produce any DSRs or other documentation of ADL tasks for September 2025 through December 2025, despite staff interviews indicating that turning, repositioning, and getting the resident out of bed were performed and documented in the Point of Care (POC) system or skilled progress notes. The DON stated that turning and repositioning were documented by CNAs in the POC and that the resident was turned and repositioned every two hours or more frequently, but could not provide more than one month of ADL task sheets, citing a recent program change. This lack of documentation occurred despite facility policies on Turning and Repositioning and Pressure Injury Prevention and Management that require implementation and documentation of turning and repositioning for residents at risk of or with existing pressure injuries.
Insufficient Kitchen Staffing Led to Inadequate Meals
Penalty
Summary
The deficiency involves insufficient staffing in the food and nutrition services, resulting in the inability to safely and effectively carry out food service operations. During a Resident Council meeting, five of six alert and oriented residents reported that on one day the prior week there was no cook on duty and they were served cold food for all three meals. They stated that breakfast consisted of cereal and milk passed from a cart. On another day of survey observation, the Food Service Director (FSD) was observed preparing lunch and confirmed there was no cook on duty that day, so he was covering all meals himself. A Dietary Aide reported that on the day in question the scheduled cook called out sick and the FSD was also ill, leaving no cook available. The Registered Dietician (RD) was notified and instructed the Dietary Aide to use only items that did not require cooking, resulting in breakfast of cold cereal, milk, and juice; lunch of cold cut sandwiches and chips; and dinner of cold cut ham wraps, with no cooked items or vegetables provided. The RD later acknowledged that these meals did not meet daily nutritional requirements. Review of the March kitchen schedule showed only one cook scheduled for the month, with the FSD covering most cooking duties, including all breakfasts and all meals on certain days, and no backup cooks available after two cooks had quit. The facility’s own Dietary Emergency Staffing policy requires provision of safe, sanitary, and nutritionally adequate meals even in the absence of a scheduled cook, with the Administrator responsible for oversight and regulatory compliance.
Failure to Report Injury of Unknown Origin to State Authorities
Penalty
Summary
Surveyors determined that the facility failed to report an injury of unknown origin to the New Jersey Department of Health after a resident was found to have a left femur fracture. The resident had dementia with behavioral disturbances, a psychotic disorder with hallucinations, seizures, and chronic candidiasis, and was assessed on a recent MDS as moderately cognitively impaired with a BIMS score of 9/15. On 3/19/26, a hospital RN notified the facility that the resident, who had been admitted to the hospital with anemia and acute kidney injury, was also found to have left leg swelling, redness, and tenderness, and that a CT scan showed a left femur fracture. A facility document titled "Conclusion Summary of Investigation" described an acute displaced fracture of the left femur with a large adjacent hemorrhage and areas suspicious for active bleeding. During an interview, the LNHA stated that after being notified by the hospital of the fracture, the facility conducted an investigation and concluded there was no harm done in the facility, and that she was unsure where the fracture occurred, suggesting it may have happened during transfer to or at the hospital. When questioned about protocol for injuries of unknown origin, the LNHA acknowledged that the facility did not know how the injury occurred. In a separate interview, the President/CEO confirmed that an injury of unknown origin is supposed to be reported to the Department of Health and agreed that the resident’s fracture would be considered such an injury. The facility’s abuse policy, revised 1/1/2025, states that the New Jersey Department of Health and Senior Services must be called immediately to report that the facility is investigating an allegation of abuse or neglect, with written confirmation of the investigation results to follow within 72 hours. Despite this policy, the injury of unknown origin was not reported to the Department of Health.
Failure to Prevent Elopement From Secured Unit for Known High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision to prevent the elopement of a resident who was a known elopement risk. The resident had been identified as high risk for elopement since admission in 2024 and had a Wander Guard device in place. An Elopement/Wandering Risk Evaluation completed on 03/04/2026 documented a history of actual or attempted elopement, verbal expressions of wanting to go home, and exit-seeking behavior, as well as cognitive impairment with poor decision-making skills. The resident’s care plan, initiated in 2024 and revised in 2025, identified the resident as an elopement risk and wanderer with a Wander Guard on the ankle and called for monitoring of behaviors and frequent monitoring due to active exit-seeking. In early March 2026, the resident’s behavior escalated. On 03/03/2026, the resident requested transfer to a facility closer to a family member after that family member had reduced the frequency of visits. On 03/04/2026, the resident attempted to leave the floor and was hard to redirect, leading the facility to place the resident on one-to-one monitoring while awaiting a secured unit bed. The resident was then transferred to a secured third-floor unit on 03/04/2026, and the one-to-one monitoring was discontinued. Facility policy on safety and supervision stated that resident supervision is determined by assessed needs and that supervision may need to be increased with changes in mental status or behaviors. The Code Grey/Elopement policy emphasized controlling exit access on secured units, including the use of door codes to leave the unit. On the evening of 03/08/2026, the resident was observed on the secured unit by staff around 9:00 PM. One LPN reported last seeing the resident at about that time when providing a snack, after which the resident went to their room; a CNA also saw the resident in the room on the phone at 9:00 PM. Staff on the secured unit stated that residents there were allowed to go off the unit unaccompanied to a soda machine on another unit, despite the resident’s elopement risk and Wander Guard. Around 10:00 PM, staff discovered the resident was no longer in the room and could not be found on the unit. Staff on the secured unit reported not hearing any door alarm sounding prior to the activation of a Code Grey, and they did not initiate the Code Grey themselves. A nurse on another floor heard a door alarm at about 10:00 PM and activated Code Grey, after which a head count revealed the resident was missing from the building. The resident later reported having exited the secured unit through an exit door, taken the elevator to the front entrance, left the building while still wearing the Wander Guard, and used public transportation to travel to a family member’s home, where police subsequently located the resident. These events led surveyors to determine that the facility failed to maintain a safe environment on the secured unit with adequate supervision to prevent elopement, resulting in an Immediate Jeopardy finding under F689.
Removal Plan
- The DON and ADON provided immediate in-service training and began reeducation regarding safety and protocols for residents at risk for wandering and elopement.
- Upon the resident’s safe return, the resident was reassessed.
- A new Wander Guard with a secure band was placed on the resident’s ankle.
- The resident’s room was moved adjacent to the nurses’ station for monitoring.
- The resident was placed on 1:1 monitoring for all shifts.
- The DON and ADON provided facility staff education on the importance of monitoring residents’ doors on secure units to prevent residents from exiting.
- The DON and ADON in-serviced all staff on monitoring doors on secured units to prevent unauthorized exits.
- The DON and ADON in-serviced all staff that residents living on secured units need to be escorted by staff members when leaving the unit.
- Testing of all door alarms and door locks was completed and confirmed working as designed by Northeast Protection Partners.
- The Wander Guard installer completed testing of all Wander Guard alarms and magnetic locks and confirmed they are working as designed.
- A trained staff member will be stationed on all shifts in the hallway of the secured unit to supervise doors and prevent unauthorized exit by all residents living on that unit.
- All staff who work on the secured units were in-serviced by the DON and ADONs on monitoring doors on secured units to prevent unauthorized exits.
Failure to Document and Follow Up on Urology-Ordered Catheter-Related Procedures
Penalty
Summary
The deficiency involves the facility’s failure to provide timely follow-up management and care for a resident with an indwelling catheter after a urology consultation. The resident was admitted with obstructive and reflux uropathy, congenital malformation of the urinary system, and severe intellectual disabilities, and was dependent on staff for toileting with an indwelling catheter in place. A urology visit summary documented that the resident was to be scheduled for cystoscopy, laser lithotripsy of a bladder stone, and a transurethral resection of the prostate. Nursing notes indicated that the resident returned from the urology appointment with a recommendation for a future operating room schedule. However, there was no documented evidence in the electronic medical record that the facility followed up with the urologist or contacted the resident’s medical doctor regarding scheduling these procedures. Subsequently, the resident was admitted to the hospital with an obstructed Foley catheter, bilateral hydronephrosis, and acute kidney injury, and prior nursing documentation noted cloudy yellow urine, poor intake, and lethargy with an order to send the resident out for further evaluation. Interviews revealed that central supply staff, who were responsible for scheduling appointments, stated they called the urology office weekly but did not have access to the EMR and kept paper logs of attempts that were not retained. The infection preventionist, LNHA, and ADON acknowledged that there was no facility policy for scheduling out-of-facility appointments, that the process relied on central supply’s undocumented personal log, and that no consult follow-up form was completed because the urology office was expected to schedule the surgery. The facility’s charting documentation policy stated that the medical record should facilitate communication between the interdisciplinary team, but there was no documentation of follow-up attempts or escalation when the procedures were not scheduled.
Failure to Provide Meals Consistent With Diet Orders and Documented Preferences
Penalty
Summary
The deficiency involves the facility’s failure to consistently provide meals and condiments in accordance with residents’ diet orders and documented food preferences as listed on tray tickets. During a breakfast observation, one resident reported missing items from their tray; review of the tray and ticket showed the resident did not receive a biscuit, pepper packet, or ketchup packet, despite these items being ordered. This resident had diagnoses including protein-calorie malnutrition, type 2 diabetes mellitus, and hypertension, and was on a no added salt, consistent carbohydrate diet with a care plan intervention to provide and serve diet as ordered. Another resident, observed eating breakfast in bed, reported both missing and incorrect items. The tray ticket called for a fruit cup, cranberry juice, a biscuit, salt, pepper, and ketchup, but these were not all present; instead, the resident received applesauce and apple juice, which were not on the ticket, and the ticket specifically indicated no apple products. On a subsequent breakfast observation, the same resident’s tray again lacked the ordered salt, pepper, and cranberry juice and instead contained apple juice, despite an order specifying no apple and an allergy to peach skin. This resident’s care plan included an intervention to provide food and beverage preferences. During a kitchen interview, the cook acknowledged not making enough biscuits and could not explain why condiments were missing. Additional residents experienced similar issues during lunch observations. One resident reported that a can of diet ginger ale listed on the lunch ticket was not provided, despite a care plan intervention to honor food preferences. Another resident stated they were given the wrong vegetable; chopped carrots were served instead of the chopped oriental vegetables listed on the tray ticket, even though the care plan directed staff to provide and serve diet as ordered and honor food preferences. A further resident reported receiving gravy on both roast pork and mashed potatoes when the tray ticket documented a preference for no gravy, despite a care plan intervention to honor food preferences. The Food Service Director and DON both stated that tray tickets and meal trays should match and that meals should be consistent with residents’ preferences as indicated on the tray cards, but were unable to explain the missing condiments.
Failure to Maintain Complete and Accurate Toileting and Continence Documentation
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for a resident with diagnoses including a cervical vertebra fracture, heart failure, and type II diabetes. The resident’s comprehensive MDS showed a BIMS score of 12/15, indicating moderate cognitive impairment, and documented that the resident required substantial assistance with toileting hygiene and toilet transfer. The care plan identified the resident as being at risk for skin breakdown, having incontinent episodes, and having a self-care performance deficit, with interventions such as routine incontinence checks, offering toileting every 2–3 hours, keeping the skin clean and dry, and providing one-person assistance for toileting and all transfers. The Documentation Survey Report for January specified that bladder continence, bowel continence, bowel movements, and toilet use were to be documented each shift. Record review showed missing documentation for multiple dates and shifts for bladder continence, bowel continence, bowel movements, and toilet use, with no corresponding entries in the progress notes to account for this care. Interviews with the LPN Unit Manager, a CNA, the DON, and the LNHA confirmed that CNAs were primarily responsible for providing toileting and incontinence care and were expected to document all care in the EMR, and that supervisors were responsible for verifying that documentation was completed. The CNA interviewed acknowledged sometimes forgetting to document care when busy. The facility’s charting and documentation policy required that all services provided to residents be documented completely and accurately, including treatments or services performed, which was not followed in this case, resulting in incomplete medical records for the resident.
Failure to Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
The facility failed to report an allegation of sexual abuse to the New Jersey Department of Health (NJDOH) as required by regulation and its own abuse/neglect policy. A resident with diagnoses including dementia, depression, and mixed anxiety disorder, and with severely impaired cognition per the most recent MDS, was dependent on staff for ADLs such as toileting hygiene, showering, and lower body dressing. During a surveyor interview conducted using written questions due to the resident’s hearing impairment, the resident stated they preferred only female CNAs to provide care and reported that a few months earlier a male CNA, whose name sounded like a specific individual, had touched them inappropriately in the groin area while giving a shower. The resident indicated they had reported this incident to either someone who changed them or to the administrator on or shortly after the day it occurred. The resident’s care plan, revised at a later date, included an intervention specifying no male CNAs, and point-of-care documentation showed the resident received showers on multiple dates, which the DON identified as having been provided by a specific male CNA. The facility initiated an internal investigation, including interviews, staff statements, and record reviews, and concluded there was no evidence to support the allegation of sexual abuse. However, the investigation file contained no documentation that the NJDOH was notified of the allegation. In interviews, the DON described the facility’s process for handling abuse allegations, including reporting to NJDOH within specified time frames if an event is deemed reportable, and the administrator acknowledged that the allegation should have been reported to NJDOH but was not. The facility’s written policy required immediate notification (as soon as possible but not to exceed 2 hours) to the Department of Health and Senior Services and the Office of the Ombudsman for residents 60 or over, followed by a written report within 5 days, which was not followed in this case.
Failure to Remove Alleged Perpetrator and Fully Investigate Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from alleged abuse by a CNA and failure to implement its abuse policy after learning of the allegation. A cognitively intact resident with diagnoses including Bipolar Disorder, Anxiety Disorder, and Major Depressive Disorder reported that a CNA pushed them, causing them to fall, when they entered another resident’s room after hearing yelling and crying. An ED after-visit summary documented that the resident was seen for battery and diagnosed with an abrasion of the left upper extremity. The facility’s own abuse/neglect policy stated that employees under investigation would be temporarily suspended until the Administrator reviewed the results of the investigation, but this was not followed for the CNA involved. On the date of the incident, an LPN documented that they heard yelling from another resident’s room and, upon entering, observed the resident yelling and grabbing the CNA’s left upper arm. The LPN reported asking the resident to leave the CNA alone, then leaving the room to notify the Nursing Supervisor and call 911. The CNA’s written statement asserted that the resident grabbed her in an aggressive manner to cause physical harm and that she did not assault the resident. The facility administration later reviewed video footage and statements from the CNA and the LPN and concluded there was no merit to the resident’s accusatory statement, citing the resident’s mental health history, and asked the CNA to return to her scheduled shift. On multiple occasions following the incident, the resident sent emails to the Director of Social Services and the LNHA stating that the CNA had assaulted them and expressing distress that the incident was not addressed. Despite these communications, the facility did not obtain statements from other staff members beyond the alleged perpetrator, the LPN, and the Nursing Supervisor, and did not interview or obtain statements from other residents typically on the CNA’s assignment until after the surveyor requested investigation documents. Payroll and assignment records showed that the CNA continued to work regular shifts, including on the behavior unit where the resident lived, both immediately after the incident and after the resident’s written allegation of assault. Facility staff, including the DSS, LNHA, and ADON, acknowledged the resident’s ongoing anger when seeing the CNA on the unit and referenced the resident’s history of aggressive and explosive behavior, but the facility did not remove the CNA from resident care or from the resident’s unit in accordance with its abuse policy when the allegation was reported.
Removal Plan
- Resident #1 had a follow up consultation with the Statewide Clinical Outreach Program for the Elderly (S-COPE)
- ADON conducted abuse policy re-education for nursing staff post incident
- The Administrator and the ADON were re-educated on the Abuse Policy and Procedure and Federal deficiency F600 (free from abuse and neglect) by the President of Clinical Services
- The ADON and the Regional Nurse Consultant provided 1:1 re-education on the Abuse Policy to the Registered Nurse Supervisor involved in the incident
- ADON began facility-wide education for all staff on the Abuse Policy to protect all residents from abuse
- Unit managers and Nursing Supervisors were re-educated by ADON on the Abuse Policy and the requirement to report
- The Social Worker conducted additional interviews on the two units assigned to the CNA
Failure to Report Alleged Staff-to-Resident Physical Abuse to State Authorities
Penalty
Summary
The facility failed to report to the New Jersey Department of Health an allegation of physical abuse involving a resident and a CNA. The cognitively intact resident, with diagnoses including Bipolar Disorder, Anxiety Disorder, and Major Depressive Disorder, reported that a CNA pushed them and knocked them down. A behavior note documented that an LPN heard yelling and shouting in another resident’s room where the CNA was providing care, and when the LPN entered, the resident was observed grabbing the CNA’s arm. The LPN then exited the room to call 911 and notify the nursing supervisor. A facility event summary indicated that the resident called 911 and requested transport to the hospital to document injuries allegedly sustained from being physically assaulted by the CNA. Emergency department records showed the resident was treated for an abrasion of the left upper arm and received a Tdap injection. A nursing supervisor’s witness statement documented that she was made aware of an incident between the resident and the CNA. Facility documents showed that staff were in-serviced on abuse and neglect policies and procedures following the incident, but there was no evidence that the allegation of abuse was reported to the New Jersey Department of Health. During an interview, the ADON stated that the facility would notify the Department of Health for alleged abuse, major injury, and staff-to-resident abuse, but indicated she believed this incident was considered a resident-to-staff incident rather than a staff-to-resident allegation, and thus it was not reported as required.
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