Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
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.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Voorhees
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Echelon Care & Rehab | 0.3 mi | ★★★★★ | 0 | 0 |
| Voorhees Pediatric Facility | 0.3 mi | ★★★★★ | 2 | 0 |
| Autumn Lake Healthcare At Voorhees | 0.4 mi | ★★★★★ | 3 | 1 |
| The Subacute At Autumn Lake Healthcare | 0.7 mi | ★★★★★ | 19 | 3 |
| Complete Care At Kresson View, Llc | 2.2 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.