The investigation began when Licensed Practical Nurses noticed odd behavior from the agency nurse, including hyperactivity and spending excessive time with the narcotic inventory book open while looking at a computer. Two residents denied receiving their prescribed pain medication, though records showed the pills had been removed from inventory.
"The resident stated that their last dose was on 9/22/25," the Director of Nursing told inspectors about one victim who was prescribed Oxycodone for a spinal fracture. Records showed the agency nurse had signed out six tablets of the powerful painkiller on September 23, using forged signatures that didn't belong to any staff member working that day.
The theft occurred between September 23 and September 28, 2024. The agency nurse, identified only as LPN #4, removed 14 Oxycodone tablets and one Tramadol tablet from the medication supplies for three residents recovering from serious injuries, including hip fractures and ankle breaks.
Resident #197, who had a displaced fracture of the base of the neck of the right femur, couldn't tell staff whether pain medication had been administered. Two Oxycodone tablets and one Tramadol tablet were signed out on the inventory record but never documented as given to the resident.
Resident #198, recovering from a displaced ankle fracture, had four Oxycodone tablets signed out by the agency nurse on September 28 but no record of receiving the medication.
The most extensive theft involved Resident #199, who was prescribed Oxycodone for chronic gout and a spinal compression fracture. The agency nurse removed ten tablets over two days, signing fake names on narcotic logs. When questioned, the resident said no pain medication had been given since September 22.
Staff discovered the pattern when they noticed medications were signed out on inventory logs but not marked as administered on patient medication records. The forged signatures "raised a suspicion," according to the Director of Nursing, who began investigating after nurses reported the agency worker's strange behavior.
The facility didn't report the suspected drug diversion to the New Jersey Department of Health until October 4, six days after the theft was discovered. State regulations require immediate reporting of incidents affecting resident health and safety.
"The DON stated that it was not reported right away because of a delayed response on behalf LPN #4," the inspection report noted. "The DON stated that she was unable to immediately confirm diversion and wanted to interview LPN #4 because she was not sure if it were actual diversion, and did not want to create a false report."
The Director of Nursing told inspectors she didn't know when she was required to notify state authorities of suspected drug diversion. The Licensed Nursing Home Administrator also admitted uncertainty about reporting requirements.
The agency nurse was placed on a "do not return" list and reported to her employment agency. A Drug Enforcement Agency form documented the stolen medications as 14 Oxycodone immediate-release 5mg tablets and one Tramadol 50mg tablet.
Beyond the drug theft, inspectors found multiple medication safety violations throughout the facility. Nurses routinely failed to sign controlled substance count logs during shift changes, leaving gaps in the paper trail designed to prevent drug diversion.
On the day of inspection, nurses had forgotten to sign narcotic count records, and controlled substance inventories didn't match actual pill counts. One prescription card contained 20 Tramadol tablets while the log indicated 21 should remain. Another showed 23 capsules of Pregabalin when records indicated 24.
"LPN #5 stated that she must have gotten distracted and had forgotten to sign it out," the report noted about the missing narcotic documentation.
The facility's wound treatment cart was found unlocked during inspection, containing medications accessible to unauthorized personnel. An opened Lidocaine pain patch sat in a medication cart drawer with no identification of which resident it belonged to.
Expired medical supplies were discovered throughout the facility, including examination gloves, suction tubing, and antiseptic swabs past their expiration dates in emergency crash carts and medication storage areas.
Inspectors also documented failures in resident care planning. One resident receiving antipsychotic and anti-anxiety medications had no care plan addressing these powerful psychiatric drugs until inspectors requested the records.
"The DON stated that when she was making copies of the care plans for surveyor, she noted the anti-psychotic medications were not on the care plan," the inspection found. "The DON then stated that she could not provide copies of the ICCP without updating the care plan."
Food safety violations included unlabeled and expired items in kitchen refrigerators, improperly nested wet dishes that could harbor bacteria, and dietary staff using bare hands and drinking cups to scoop ice from machines.
During meal service observations, a dietary aide repeatedly served food to multiple residents without washing hands between contacts, violating basic infection control protocols designed to prevent disease transmission.
"DSA #5 stated that hand hygiene should be completed between serving residents," the report noted, though the worker continued serving meals without following proper procedures.
The facility failed to follow its own weight monitoring procedures for a resident with significant weight loss, missing opportunities to address potential malnutrition. Despite physician orders for weekly weighing due to weight loss, staff didn't obtain required re-weights when the resident's weight dropped from 133 pounds to 107.9 pounds over five days.
A nebulizer mask used by one resident was stored directly on a bedside table rather than in a protective plastic bag, violating infection control standards. Another resident receiving intravenous antibiotics through a midline catheter wasn't placed on enhanced barrier precautions despite facility policy requiring such measures.
The consultant pharmacist hadn't been performing medication pass observations, a key oversight mechanism for preventing medication errors and diversion. The Director of Nursing admitted she wasn't aware such observations weren't being conducted.
Lions Gate operates a 180-bed facility providing skilled nursing and rehabilitation services. The inspection was conducted February 11-13, 2025, following a complaint investigation.
All violations were classified as causing minimal harm or potential for actual harm to residents, though the drug diversion represented a serious breach of resident trust and medication security protocols designed to prevent exactly such incidents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lions Gate from 2025-02-13 including all violations, facility responses, and corrective action plans.
