EATONTOWN, NJ - Gateway Care Center faced serious violations during a federal inspection in January 2025, including medication administration errors and a resident's dangerous 31-pound weight loss over one year that staff failed to adequately address.
Nurse Borrows Wrong-Strength Pain Patches From Another Resident
During the January inspection, surveyors discovered a registered nurse borrowing lidocaine pain patches from one resident's supply to give to another resident. The nurse administered 4% lidocaine patches instead of the prescribed 5% strength to a resident requiring pain relief for both shoulders.
The nurse acknowledged the error after being observed by surveyors, explaining that the intended recipient had no lidocaine patches available in the medication cart. Rather than following proper protocols, she removed two 4% strength patches from another resident's labeled supply to substitute for the unavailable 5% patches.
This medication substitution violated New Jersey nursing practice standards and facility policies. The Assistant Director of Nursing confirmed that nurses are prohibited from borrowing any medications between residents and should have contacted the pharmacy and physician when the prescribed medication was unavailable.
The facility's Consultant Pharmacist emphasized that such practices can lead to medication errors and stressed during staff training that borrowing medications between residents is never acceptable.
Resident Loses Over 30 Pounds in One Year
A more serious violation involved a resident who experienced progressive weight loss totaling 31.5 pounds over one year, dropping from 139 pounds in January 2024 to 107.5 pounds by January 2025. The facility failed to implement timely and effective interventions to address this dangerous decline.
The weight loss pattern showed multiple significant drops: 14 pounds (10.5%) over six months, followed by another 6.5 pounds (5.6%) in just one month. The resident's weight continued declining despite repeated documentation of the losses in monthly weight meetings.
Medical Analysis of Weight Loss Risks
Unintended weight loss of this magnitude presents serious health risks for nursing home residents. A loss exceeding 10% of body weight within six months is considered severe and can lead to:
- Compromised immune system function - Increased infection susceptibility - Muscle weakness and mobility decline - Poor wound healing - Cognitive impairment progression - Increased mortality risk
The resident's concurrent medical conditions, including heart disease and chronic kidney disease, made proper nutrition even more critical for maintaining health and function.
Cultural Food Barriers and Inadequate Interventions
The affected resident was Korean-speaking with severe cognitive impairment who had lost their sense of taste following COVID-19. Surveyors found that the facility relied heavily on food brought by family members who visited approximately once monthly rather than implementing systematic nutritional interventions.
The facility's registered dietitian acknowledged that no culturally appropriate Korean meal alternatives were available when residents refused regular meals. Staff could only offer American menu items as substitutes, limiting options for residents with specific cultural food preferences.
Several evidence-based interventions that could have helped were not implemented:
Fortified Foods: The facility had access to "Super Cereal" providing 511 calories and 11 grams of protein per serving, which could have replaced the regular hot cereal served at breakfast. This high-calorie option was never offered.
Enhanced Beverages: Instead of regular cranberry juice, the resident could have received calorically dense nutritional juices to increase caloric intake while maintaining familiar flavors.
Vitamin Supplementation: Despite documented poor meal intake, the resident was not prescribed a comprehensive multivitamin and mineral supplement.
Weekly Monitoring: The facility failed to implement weekly weight checks for closer monitoring once significant losses were identified.
Delayed Response to Documented Weight Loss
Documentation showed the dietitian was aware of progressive weight losses starting in February 2024 but did not implement new interventions until December 2024 - nearly 10 months later. During this period, the resident continued losing weight while staff attributed losses to diuretic medication effects and improved fluid retention.
Medical records showed the resident had only mild or trace fluid retention throughout the monitoring period, not severe enough to account for the substantial weight losses observed. The resident's diuretic medication dosage remained constant, suggesting fluid loss was not the primary factor.
The facility's Licensed Nursing Home Administrator acknowledged that weight losses should have been addressed more aggressively by dietary staff and that relying on monthly family visits for nutritional support was inadequate.
Medication Administration Documentation Gaps
Additional concerns emerged regarding supplement administration tracking. While the resident was prescribed nutritional supplements three times daily, medication records showed incomplete documentation of actual consumption amounts. Staff marked supplements as given but failed to record how much the resident actually consumed.
This documentation gap prevented accurate assessment of the resident's true nutritional intake and hindered efforts to adjust interventions appropriately.
Facility Response and Oversight
The facility conducted monthly weight meetings where the resident's losses were discussed, but interventions remained limited to increasing supplement frequency rather than addressing underlying food preference and cultural barriers.
Staff interviews revealed inconsistent understanding of available interventions. While the dietitian mentioned fortified foods and alternate options during the inspection, these resources were not utilized for the affected resident despite documented poor intake.
The inspection found the facility lacked written policies specifically addressing medication borrowing between residents, though staff universally acknowledged the practice was prohibited.
Industry Standards for Nutrition Management
Federal regulations require nursing homes to provide adequate nutrition tailored to individual health needs and food preferences. Facilities must:
- Conduct comprehensive nutritional assessments - Implement timely interventions for weight loss - Provide culturally appropriate food options - Monitor and document nutritional intake accurately - Adjust care plans based on changing needs
The regulations recognize that maintaining proper nutrition is essential for resident health, quality of life, and recovery from illness or injury.
Current Status and Oversight
Gateway Care Center must submit a plan of correction addressing both violations and demonstrate sustained compliance during follow-up inspections. The medication error was classified as having minimal harm potential, while the nutrition violation received an "actual harm" designation reflecting the serious impact on the affected resident.
State and federal oversight agencies will monitor the facility's implementation of corrective measures to ensure similar incidents do not recur. The violations highlight the importance of following established protocols for medication safety and implementing comprehensive approaches to address residents' nutritional needs, particularly for those with cultural preferences or communication barriers.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Gateway Care Center from 2025-01-09 including all violations, facility responses, and corrective action plans.
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