Gateway Care Center

F-F658 Residents Affected - Few Based on observation, interview, and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the morning medication administration

observation on 1/3/25, the surveyor observed three (3) nurses administer medications to six (6) residents. There were 27 opportunities, and two (2) errors were observed which calculated to a medication administration error rate of 7.4%. The deficient practices were identified for one (1) of six (6) residents, (Resident #122), that were administered medications by one (1) of three (3) nurses that were observed.

The deficient practices were evidenced by the following:

On 1/3/25 at 8:59 AM, during the morning medication administration pass, the surveyor observed Registered Nurse (RN#1) at the door of Resident #122's room with the medication cart. RN#1 stated that she was about to administer the resident's eye drops and patches. RN#1 showed the surveyor the container of eye drops, and two (2) packages labeled Max Strength Aspercreme with 4% Lidocaine pain relief patch (a topical patch containing Lidocaine used for pain relief) that were on the resident's overbed table. RN#1 stated that the resident had physician's orders (PO) for the Lidocaine patches to be applied to two (2) different sites, the right shoulder and the left shoulder.

At that time, the surveyor observed RN#1 open each Lidocaine 4% patch package and wrote the date on the patch and then applied one patch to the left shoulder and one patch to the right shoulder. The surveyor obtained one of the empty Lidocaine 4% patch packages for review. RN#1 then spoke to Resident #122 in

the resident's language. The surveyor observed the resident smiling and lifted both elbows halfway up in the air and then back down. RN#1 translated for the surveyor and stated that the resident had said that they felt that the pain was improving.

Upon returning to the medication cart, RN#1 showed the surveyor the electronic medication administration

record (EMAR) which revealed a PO dated 9/29/24 for Lidocaine External Patch 5% (Lidocaine) Apply to left shoulder topically one time a day for pain and remove per schedule. In addition, another PO dated 9/29/24 for Lidocaine External Patch 5% (Lidocaine) Apply to right shoulder topically one time a day for pain and remove per schedule. The surveyor then showed RN#1 the empty package of the Lidocaine patch which revealed the strength of 4%. RN#1 acknowledged that the Lidocaine 4% patches that she had applied to each site was not the 5 % strength that was ordered. The RN#1 stated, I gave the wrong amount. (ERROR #1 and ERROR #2)

The surveyor reviewed the medical record for Resident #122.

A review of the Admission Record revealed diagnoses that included, but not limited to, dementia and a history of falling.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 31 315177 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315177 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Gateway Care Center 139 Grant Ave Eatontown, NJ 07724

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 A review of a comprehensive quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date of 11/27/2024, reflected the resident had a brief Level of Harm - Minimal harm or interview for mental status (BIMS) score of five (5) out of 15, indicating that the resident had a severely potential for actual harm impaired cognition.

Residents Affected - Few A review of the Order Summary Report revealed two active PO's with a start date of 9/30/24 for Lidocaine External Patch 5% (Lidocaine) Apply to left shoulder topically one time a day for pain and remove per schedule and Lidocaine External Patch 5% (Lidocaine) Apply to right shoulder topically one time a day for pain and remove per schedule.

On 1/3/25 at 10:47 AM, the surveyor interviewed the Assistant Director of Nursing (ADON), who stated that

she was responsible for nursing staff education. The ADON stated that Lidocaine 5% patches were provided by the provider pharmacy and if the 5% patch was not available then the nurse would have to call the provider pharmacy to see why the medication was not available and the nurse would also have to call the physician for a follow up order as to what she should do. The ADON stated that the Consultant Pharmacist (CP) had provided information on Med Pass and would provide a med pass that was completed for RN#1.

On 1/3/25 at 12:11 PM, the ADON provided the surveyor with a completed medication pass for RN#1 and an inservice on Medication Pass that had been completed for the nurses. The ADON stated that she was aware RN#1 did not have Lidocaine 5% patches for Resident #122 and thought RN#1 had called the physician.

A review of a Medication Pass Observation dated 3/25/24 for RN#1 completed by the CP revealed that there were no errors observed and that the correct drug, correct amount, correct dosage form was administered

during that medication pass observation.

A review of the Inservice Log dated 9/25/24 for Med Pass completed by the CP revealed that RN#1 was in attendance.

On 1/3/25 at 1:27 PM, the surveyor interviewed the ADON, who acknowledged that she spoke with RN#1, and she had administered the wrong dose of Lidocaine patch to each site. The ADON added that the physician was called and allowed the Lidocaine 4% patches. The ADON added that there may have been a problem with insurance and was unsure why the Lidocaine 5% patches were not available.

On 1/6/25 at 12:12 PM, the surveyor, with the Director of Nursing (DON), who stated that she was unaware that the surveyor had shown the RN#1 the strength of the two patches that had been applied on the resident's shoulders was not 5% as ordered. The DON verified that there was a medication error report being completed.

On 1/6/25 at 2:16 PM, the surveyor interviewed the CP via the telephone who stated that she had been the CP for a while. The CP stated that the nurse cannot interchange 4% Lidocaine patches for the 5% Lidocaine patches and that the nurses must follow the PO for the correct strength. The CP added that if the Lidocaine 5% patch was not available then the nurse should have called the physician for a follow-up order as to what to do. The CP also stated that she had completed medication observations with some of the nurses and reviewed the instructions with them. In addition, the CP stated that she had also provided the facility with a handout that she used for the inservices.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 31 315177 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315177 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Gateway Care Center 139 Grant Ave Eatontown, NJ 07724

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 A review of the Medication Pass handout that was reviewed during the Med Pass inservice by the CP on 9/25/24 revealed that for accuracy the rights of med pass included ensuring the right dose. In addition, the Level of Harm - Minimal harm or handout indicated Medication checked against the MAR/eMAR before administering. potential for actual harm

On 1/8/25 at 2:37 PM, the survey team met with the administrative team. The DON questioned that the error Residents Affected - Few that occurred for the strength of Lidocaine be considered one error due to being the same medication. The DON acknowledged that the Lidocaine 5% patch had POs for applications to two different sites and was considered two opportunities for the medication nurse to follow the correct medication pass procedures for assuring that the right dose was administered.

A review of the facility undated policy for Medication Administration provided by the DON had not reflected procedures for ensuring the administration of the correct dosage.

NJAC 8:39-11.2(b), 29.2(d)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 31 315177 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315177 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Gateway Care Center 139 Grant Ave Eatontown, NJ 07724

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 40042

Residents Affected - Many Based on observation, interviews, and review of pertinent facility documents, it was determined that the facility failed to ensure a.) the facility's Registered Dietitian (RD) reviewed and approved the menus (American and Korean) for nutritional adequacy and in accordance with nationally accredited standards, and b.) residents received care planned and physician ordered fortified foods for 3 of 3 residents (Resident's #41, 71 and 118) reviewed for food. The deficient practice was evidenced by the following:

1. On 1/2/25 at 9:46 AM, two surveyors toured the kitchen with the Food Service Director (FSD), the Regional RD and the Assistant Licensed Nursing Home Administrator (ALNHA). At that time, the FSD stated that the facility followed a three-week cycle menu (a menu prepared in advance which was repeated after three weeks).

On 1/2/25 at 10:38 AM, the surveyor met with the facility Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON) and the Assistant DON (ADON). At that time, the LNHA informed the surveyor that their East Wing was the unit where their Korean population resided.

On 1/2/25, the FSD provided the surveyor with a copy of the American three-week cycle menus dated 12/22/24, 12/29/24 and 1/5/25. In addition, he provided the surveyor with a copy of menu extensions (listed portion sizes and substitutions based on physician prescribed diets) for week three dated 12/29/24 and week one dated 1/5/25. These extensions indicated that residents should be served a four-ounce portion of milk for lunch and dinner. Furthermore, the FSD provided the surveyor with copy of the undated Korean four-week cycle menus, which did not include beverages or the breakfast meal. None of the seven menus provided were signed and dated by the RD to ensure they were reviewed for adequacy.

On 1/3/25 at 11:06 AM, the surveyor met with six residents for the resident council meeting. Six of six residents stated that sometimes they received food items on their trays that did not match the meal ticket (with listed meal items and preferences).

On 1/7/25 at 1:07 PM, the surveyor interviewed the RD, in the presence of the survey team. The RD stated that the Food Service Department developed the American menus and she looked at them for nutritional adequacy by ensuring there was a protein, starch and vegetable. The RD stated that she chose to be more clinical and did not really get involved with the menu extensions. At this same time, the RD stated that she was unaware of who developed the Korean menus, nor did she know who reviewed and approved them to ensure they were nutritionally adequate.

On 1/7/25 at 2:14 PM, the surveyor interviewed the FSD, who stated the RD reviewed the American menus for adequacy and signed them; however, no one reviewed the Korean menus for nutritional adequacy.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 31 315177 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315177 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Gateway Care Center 139 Grant Ave Eatontown, NJ 07724

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 On 1/8/25 at 9:26 AM, the surveyor interviewed the FSD, in the presence of a second surveyor. The FSD provided the surveyor a Diet Manual (the 7th Edition), dated 2018 for review. The Diet Manual of the Level of Harm - Minimal harm or Dietetics in Health Care Communities of New Jersey (Compiled by a Committee of RD's) included the potential for actual harm purpose of the Regular diet was to provide a variety of foods to meet nutritional needs of individuals. The Diet Manual further reflected that This diet is nutritionally adequate in all nutrients when planned according to Residents Affected - Many Dietary Reference Intakes, established by the Food and Nutrition Board; Institute of Medicine, USDA Dietary Guidelines for Americans 2015-2020. These are consistent with the USDA Dietary Guidelines for Americans 2020-2025. It included that an eight-ounce portion of milk should be served at lunch and dinner.

On 1/8/25 at 12:33 PM, the surveyor observed the lunch trays on both the Korean wings and the North wing (American menu). The surveyor observed the trays on both wing with four-ounce portions of milk which was reflected on the menu.

On 1/9/25 at 9:52 AM, the survey team met with the Regional LNHA, LNHA, DON, Regional DON and the ADON. The Regional LNHA stated that the menus should have been reviewed by the RD or the consultant RD for nutritional adequacy. He further acknowledged that the menus were not reviewed by an RD for this building. The LNHA stated he was ultimately responsible.

2. On 01/02/25 at 11:31 AM, the surveyor observed Resident #41 in bed, awake and alert. The resident offered no concerns or complaints.

On 1/08/25 at 11:04 AM, the surveyor interviewed the resident in their room. The resident stated that they disliked fish but enjoyed shellfish (shrimp) and did not like meat other than chicken.

A review of the Admission Record (an admission summary) reflected Resident #41 had diagnoses that included but were not limited to; hypertension (high blood pressure), dysphagia (difficulty swallowing) and chronic obstructive pulmonary disease (lung disease that block airflow and make it difficult to breathe.)

A review of the quarterly MDS (Minimum Data Set), a tool to facilitate the management of care dated 12/6/24, reflected a Brief Interview of Mental Status (BIMS) score of 9 out of 15, which indicated an impaired cognition.

A review of the comprehensive care plan included a Nutrition care plan initiated on 5/9/23, which included to honor the resident's food preferences as needed and to provide fortified (provided additional calories and protein) pudding four ounces twice a day.

A review of the Medication Review Report reflected a physician's order (PO) dated 12/2/24, for a four-ounce fortified pudding twice a day.

A review of the Nutritional assessment dated [DATE REDACTED], reflected the resident disliked fish, including tuna but liked shrimp. In addition, the RD noted she recommended fortified pudding twice a day to prevent weight loss.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 31 315177 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315177 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Gateway Care Center 139 Grant Ave Eatontown, NJ 07724

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 A review of the list of labeled snacks the FSD provided to the surveyor on 1/2/25, did not include fortified puddings for the resident. A review of the resident's breakfast, lunch and meal tickets dated 1/7/25 did not Level of Harm - Minimal harm or include fortified pudding twice a day or the food preferences of disliking fish but liked shellfish (shrimp) and potential for actual harm did not like meat other than chicken which the resident verbalized to the surveyor on 1/8/25.

Residents Affected - Many A review of the resident's breakfast, lunch and dinner meal tickets dated 1/9/25, did not include fortified pudding twice a day. A review of the resident's breakfast, lunch and dinner meal tickets for 1/10/25, included fortified pudding twice a day after multiple surveyor inquiries.

3. On 01/02/25 at 11:38 AM, the surveyor observed Resident #71 in their room sitting in a chair, awake and alert. The resident offered no concerns or complaints.

A review of the Admission Record reflected Resident #71 had diagnoses that included but were not limited to; hypertension, moderate protein-calorie malnutrition, and chronic obstructive pulmonary disease.

A review of the quarterly MDS dated [DATE REDACTED], reflected a BIMS score of 7 out of 15, which indicated a severely impaired cognition.

A review of the comprehensive care plan included a Nutrition care plan initiated on 1/26/21, which reflected to provide fortified pudding at lunch and dinner - preferred vanilla.

A review of the Medication Review Report reflected a (PO) dated 9/3/24, for a four-ounce fortified pudding twice a day preferred vanilla as available.

A review of the Nutritional Assessment (quarterly) dated 11/7/24, reflected the resident received fortified pudding twice a day.

A review of the list of labeled snacks the FSD provided to the surveyor on 1/2/25, did not include fortified puddings for the resident. And a review of the resident's breakfast, lunch and meal tickets dated 1/7/25, did not include fortified pudding twice a day.

A review of the resident's breakfast, lunch and dinner meal tickets dated 1/9/25, did not include fortified pudding twice a day. A review of the resident's breakfast, lunch and dinner meal tickets dated 1/10/25, included fortified pudding twice a day at lunch and dinner after multiple surveyor inquiries. Furthermore, it did not reflect the resident's preference for vanilla.

4. On 1/2/25 at 11:13 AM, the surveyor observed Resident #118 sitting in a wheelchair in the day room with their eyes closed.

On 1/3/24 at approximately 12:40 PM, the surveyor observed the resident eating lunch in the dayroom. The pureed meal intake was approximately 25% completed and when the surveyor inquired if the resident was hungry or had an appetite, the resident shook their head no.

A review of the Admission Record reflected they had diagnoses that included but were not limited to; unspecified dementia, dysphagia and depression.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 31 315177 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315177 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Gateway Care Center 139 Grant Ave Eatontown, NJ 07724

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 A review of a significant change MDS dated [DATE REDACTED], reflected the resident had a short- and long-term memory problem with moderate impairment of cognitive skills for daily decision making. Level of Harm - Minimal harm or potential for actual harm A review of the comprehensive care plan included a Nutrition care plan initiated on 2/9/24, which reflected to honor the resident's food preferences which included lactose free milk, disliked tomatoes but liked tomato Residents Affected - Many sauce and hot sauce.

A review of the Order Summary Report reflected a PO dated 8/31/24, for a super mashed potatoes at lunch and dinner two times a day.

A review of the RD progress note dated 8/23/24, reflected the resident was lactose intolerant and would be provided lactose free milk per the resident's preference.

A review of the RD progress note dated 9/9/24, 9/25/24, 10/2/24, 10/15/24, and 12/6/24 reflected the resident recieved super mashed potatoes at lunch and dinner.

A review of the list of the resident's breakfast, lunch and meal tickets dated 1/6/25, did not include super mashed potatoes for lunch and dinner or the noted preferences.

A review of the resident's breakfast, lunch and dinner meal tickets dated 1/9/25, did not include super mashed potatoes for lunch and dinner. A review of the resident's breakfast, lunch and dinner meal tickets dated 1/10/25, included super mashed potatoes for lunch and dinner after multiple surveyor inquiries. Furthermore, it did not reflect the residents' preferences for lactose free milk, disliked tomatoes but liked tomato sauce and hot sauce.

On 1/7/25 at 1:07 PM, the surveyor interviewed the RD in the presence of the survey team. The RD stated when she recommended a resident to receive fortified food, she would give that request in writing to the nurse via a diet slip and nursing then contacted the physician for a PO. Then nursing sent a diet slip to the FSD. She then stated the Electronic Medical Record (EMR) was linked to the Food Service software program which automatically populated the information to the resident's meal tickets. The RD also stated that when she updated residents' food preferences, she provided that information to the FSD via a diet slip and when she conducted meal rounds, she ensured the residents received the accurate items.

During this same interview, the surveyor reviewed the meal tickets and labeled snacks for Resident #41, #71 and #118. She could not speak to why Resident #41's food preferences related to fish nor the PO for fortified pudding twice a day was not provided. She acknowledged the same for Resident #71. Furthermore, she stated she had just mentioned this yesterday to the kitchen. She stated when she was in the kitchen during

the tray line process (items are placed on the trays in accordance with the resident's diet order, menu, food and beverage preferences and POs for fortified foods), she observed that the fortified pudding was not listed

on Resident #71's meal ticket. In addition, the RD stated I just told them to add it; however, she could not speak to who them was and why she did not follow up. The RD also acknowledged that Resident #118's food preferences and PO for super mashed potatoes for lunch and dinner were not listed on the meal tickets.

The RD stated that in relation to these discrepancies, she would get on that right away.

The RD stated that she had no formal way to ensure recommendations she made for a fortified food PO and/or updated food preferences for residents were carried out and accepted.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 31 315177 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315177 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Gateway Care Center 139 Grant Ave Eatontown, NJ 07724

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 On 1/7/25 at 2:14 PM, the surveyor interviewed the FSD. He stated that the facility's EMR was linked to the FS software program and when there was a new or readmitted resident or a change in diet or supplements, it Level of Harm - Minimal harm or automatically populated to the kitchen software program. In addition, he stated that he also received a diet potential for actual harm slip (written communication) from the RD or nursing, when the resident had a change in food preferences and that would be added or changed manually in the FS software system. Residents Affected - Many

On 1/9/25 at 9:52 AM, the LNHA stated to the survey team that the RD had an emergency and would be unavailable for any follow up interviews. In addition, he acknowledged that he would have expected the RD to follow up on her recommendations and to have an audit and follow up system in place.

A review of an undated facility Job Description for the Dietitian included the following responsibilities:

-Ensure that menus are maintained and filed in accordance with established policies and procedures.

-Visit residents periodically to evaluate the quality of meals served, likes and dislikes, etc.

-Assist in planning regular and special diet menus as prescribed by the attending physician.

-Review therapeutic and regular diet plans and menus to assure they are in compliance with the physician's orders.

-Develop, implement, and maintain and ongoing quality assurance program for the Dietary Department.

A review of an undated facility policy Nutritional Procedure, reflected that all residents should receive appropriate nutrition tailored to their individual health needs and food preferences for overall health and quality of life. In addition, it included to maintain accurate and current records of all assessments, care plans, and residents' food preferences.

A review of an undated facility policy Interdisciplinary Care Planning Protocol, reflected that dietary should include an overview of their assessments of the residents needs and problems, which should be specific and individualized.

NJAC 8:39-17.1 (b), 17.2 (a), 17.4 (a) (1) (3) (e)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 31 315177 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315177 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Gateway Care Center 139 Grant Ave Eatontown, NJ 07724

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0836 Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted Level of Harm - Potential for professional standards. minimal harm 41858 Residents Affected - Many Based on observation, interview, and review of pertinent facility documents it was determined that the facility failed to notify CMS (Centers for Medicare & Medicaid Services) and receive authorization for a change in

the facility's name in accordance with 42 CFR (Code of Federal Regulations) 424.516.

This deficient practice was evidenced by the following:

According to 42 CFR 424.516 Additional provider and supplier requirements for enrolling and maintaining active enrollment status in the Medicare Program:

(a) Certifying compliance. CMS enrolls and maintains an active enrollment status for a provider or supplier when that provider or supplier certifies that it meets, and continues to meet, and CMS verifies that it meets, and continues to meet, all of the following requirements:

(1) Compliance with title XVIII of the Act and applicable Medicare regulations.

(2) Compliance with Federal and State licensure, certification, and regulatory requirements, as required, based on the type of services, or supplies the provider or supplier type will furnish and bill Medicare.

(3) Not employing or contracting with individuals or entities that meet either of the following conditions:

(i) Excluded from participation in any Federal health care programs, for the provision of items and services covered under the programs, in violation of section 1128 A(a)(6) of the Act.

(ii) Debarred by the General Services Administration (GSA) from any other Executive Branch procurement or nonprocurement programs or activities, in accordance with the Federal Acquisition and Streamlining Act of 1994, and with the HHS Common Rule at 45 CFR part 76

(d) Reporting requirements for physicians, nonphysician practitioners, and physician and nonphysician practitioner organizations. Physicians, nonphysician practitioners, and physician and nonphysician practitioner organizations must report the following reportable events to their Medicare contractor within the specified timeframes:

(1) Within 30 days -

(i) A change of ownership;

(ii) Any adverse legal action; or

(iii) A change in practice location.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 31 315177 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315177 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Gateway Care Center 139 Grant Ave Eatontown, NJ 07724

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0836 (2) All other changes in enrollment must be reported within 90 days.

Level of Harm - Potential for Prior to the survey, the surveyor accessed the facility's website which listed the facility's name as Shore minimal harm Point Care Center at the address listed for the registered name Gateway Care Center.

Residents Affected - Many On 1/2/2025 at 9:10AM, upon arrival to the facility, the surveyor observed a facility sign and the name on the building written into the stone overhang in the front of the build that read, Shore Point Care Center. That name did not correspond with the CMS licensed, approved name and provider registered name Gateway Care Center.

On 1/2/2025 at 10:38 AM, the surveyor met with the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON) and the Assistant DON for entrance conference. The LNHA and the DON provided the surveyor with their business cards with the name of Shore Pointe Care Center on each card.

The LNHA stated the facility has been working as Shore Points Care Center for just under 3 years. He further stated that licensing (state department) was aware of this. The surveyor requested a copy of the facility's license.

A review of the facility provided license revealed the New Jersey Department of Health Division of Certificate of Need & Licensing issued a license to Gateway Care Center LLC (Limited Liability Company) was licensed to operate Gate Care Center, effective 11/1/2024, Expires 10/31/2025, issued: 9/23/2024.

On 1/2/2025 at 02:07 PM, the surveyor requested the NJ approved license and the application for the name change to CMS from the LNHA.

On 1/3/2025 at 9:05 AM, the LNHA informed the surveyor that he had requested the name change information from his corporate office.

On 1/6/2025 at 11:00 AM, the LNHA provided a copy of the alternate name documentation to the surveyor. A

review of the document revealed a document from the NJ Department of the Treasury.

On 1/6/2025 at 12:24 PM, the surveyor met with the LNHA and the Regional LNHA (RLNHA) and requested documentation that the New Jersey Department of Health Division of Certificate of Need was notified and the form 855B to CMS was completed. At that time, the RLNHA stated it wasn't done.

On 1/6/2025 at 12:57 PM, the surveyor met with the LNHA, who stated we do not have form 855 B, it (the name change) was intended for marketing purpose. He stated the facility will start operating under Gateway Care Center.

On 1/6/25 at 1:24 PM, the surveyor met with the RLNHA, who stated he

spoke with corporate and we are going to function under Gateway Care Center; the sign will be changed back to Gateway.

NJAC 8:39-5.1 (a)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 31 315177 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315177 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Gateway Care Center 139 Grant Ave Eatontown, NJ 07724

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 48964 potential for actual harm Based on observations, interviews, and record review it was determined that the facility failed to ensure that Residents Affected - Few staff wear the appropriate personal protective equipment (PPE) for residents on Enhanced Barrier Precautions (EBP)(designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes) to address the risk for infection transmission, in accordance with the facility policy and acceptable standards of infection control practice. This was observed for 2 of 3 unsampled residents (Resident #99 and #Resident #106) reviewed for EBP on 2 of 2 units (North Unit and East Unit) and was evidenced by the following:

1. On 1/03/25 at 07:58 AM, during incontinence rounds with the Acting Unit Manager / Infection Preventionist (UM/IP) on the North Unit, the surveyor observed the UM/IP approach unsampled Resident #99 who was lying in bed. The UM/IP donned gloves, asked permission to check the resident's brief, the resident granted permission. The UM/IP pulled down Resident #99's pants, opened the brief, pulled down the front of the brief, and allowed the surveyor to observe that the brief was wet, but not saturated and the pants were dry.

After the surveyor's observation, the UM/IP then pulled up the front of the brief, refastened the brief, and pulled the resident's pants up. The UM/IP then removed her gloves and performed hand hygiene. On the way out of the room, the surveyor observed an EBP sign which indicated gloves and a gown were required for High-Contact Resident Care Activities. Examples of High-Contact Resident Care Activites listed on the sign included changing briefs or assisting with toileting. The surveyor questioned the UM/IP about the sign, and she stated that the resident was on dialysis so therefore on EBP. When asked about wearing a protective gown, theUM/IP stated that she should've had a gown on.

On 1/03/25 at 08:46 AM, the UM/IP approached the surveyor to clarify that she had not worn a gown because she was just checking the brief, she was not changing the resident. She further stated that if the resident had been soiled, she would have then donned the required PPE for EBP.

A review of the admission record reflected that Resident #99 had diagnoses that include but not limited to; end stage renal disease on dialysis.

A review of the interdisciplinary care plan revealed an intervention dated 4/1/24 for Enhanced Barrier Precautions for Infection Prevention: Perform hand hygiene, don gloves and gowns during high contact resident care.

2. On 1/03/25 at 08:12 AM, during incontinence rounds with the East wing Unit Manager (UM), the surveyor and UM entered the room of unsampled Resident #106 to find a Certified Nursing Assistant (CNA) performing care on the resident. The incontinent brief was clean and dry and the CNA stated she had already changed the brief. The CNA noted to be wearing gloves and no protective gown. EBP sign was noted on the wall over the bed. When asked at that time, the UM stated the CNA should have been wearing

a gown for care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 31 315177 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315177 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Gateway Care Center 139 Grant Ave Eatontown, NJ 07724

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 On 1/03/25 at 12:05 PM, the CNA stated to the surveyor that this morning she was done with providing care and had to step out of the to get a brief so that's why she did not had a gown on when observed earlier. Level of Harm - Minimal harm or When the surveyor asked her what she did with that brief that she went out of the room for, the CNA stated potential for actual harm she then put the clean brief on the resident and did not need a gown at that time.

Residents Affected - Few On 1/03/25 at 12:11 PM, the surveyor observed the garbage can in Resident #106's room. There was noted garbage present in the can, no blue gown was noted in garbage.

A review of the admission record reflected that Resident #106 had diagnosis that include but not limited to; diabetes.

A review of the physician orders included an order dated 12/17/24 for EBP related to a sacral area wound.

A review of the interdisciplinary care plan revealed an intervention dated 12/13/24 for enhanced barrier precautions related to sacral wound: Staff to perform hand hygiene, don gown and gloves before performing high-contact resident care.

On 1/08/25 at 03:02 PM, the surveyor interviewed the Corporate Clinical Nurse, who stated that the UM/IP was only checking the brief of Resident #99, she had no intention of performing any high contact with the resident. She just opened the brief, she did not provide care.

On 1/08/25 at 03:02 PM, the surveyor interviewed the Director of Nursing (DON), who stated the CNA should have been wearing a gown to put a clean brief on Resident #106.

Review of facility provided policy Enhanced Barrier Precautions included:

Policy Statement: Gateway Care Center is committed to ensuring the safety of patients, visitors and healthcare personnel (HCP) by implementing effective measures to prevent the transmission of Multi Drug Resistant Organisms (MDROs) within our facility. This policy outlines the procedures for identifying, managing, and controlling MDRO infections and colonization, including the implementation of Contact Precautions, with targeted gown and glove use during high contact resident care activities.

Scope: EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing.

Procedures:

For residents for who EBP are indicated, EBP is employed when performing the following high-contact resident care activities:

o bathing/showering

o transferring

o providing hygiene

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 31 315177 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315177 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Gateway Care Center 139 Grant Ave Eatontown, NJ 07724

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 o changing linens

Level of Harm - Minimal harm or o changing briefs or assisting with toileting potential for actual harm o dressing Residents Affected - Few o device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator

o wound care: any skin opening requiring a dressing

NJAC 8:39-19.4(a)(2)(c)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 31 315177 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315177 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Gateway Care Center 139 Grant Ave Eatontown, NJ 07724

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0882 Designate a qualified infection preventionist to be responsible for the infection prevent and control program in

the nursing home. Level of Harm - Minimal harm or potential for actual harm 48964

Residents Affected - Many Based on the interview and review of pertinent facility documents, it was determined that the facility failed to ensure the designated Infection Preventionist (IP) was dedicated solely to the infection prevention and Note: The nursing home is control program (IPCP) from 8/9/24 and ongoing. This deficient practice was evidenced by the following: disputing this citation. Reference:

State of New Jersey Department of Health Executive Directive No 20-026-1 dated October 20, 2020, revealed the following:

ii. Required Core Practices for Infection Prevention and Control:

Facilities are required to have one or more individuals with training in infection prevention and control employed or contracted on a full-time basis or part-time basis to provide on-site management of the Infection Prevention and Control (IPC) program. The requirements of this Directive may be fulfilled by:

a. An individual certified by the Certification Board of Infection Control and Epidemiology or meets the requirements under N.J.A.C. 8:39-20.2; or

b. A Physician who has completed an infectious disease fell owship; or

c. A healthcare professional licensed and in good standing by the State of New Jersey, with five (5) or more years of Infection Control experience.

iv. Facilities with 100 or more beds or on-site hemodialysis services must:

1. Hire a full-time employee in the infection prevention role, with no other responsibilities and must attest to

the hiring no later than August 10, 2021.

On 1/07/25 at 11:07 AM, the surveyor interviewed the Infection Preventionist (IP), who indicated that she was also the acting Unit Manager on the North wing since August 2024. When asked how she splits her time, she stated that she usually spends an hour to an hour and half each day on her IP duties and the majority of her days is spent on her UM duties. She also stated that she felt it was enough time.

Review of facility provided job description for Infection Control Preventionist, revised 5/10 included:

Position Summary:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 31 315177 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315177 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Gateway Care Center 139 Grant Ave Eatontown, NJ 07724

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0882 The IP Nurse takes the management lead over infection Prevention of the facility by directing and supervising and coordination of all services and assist the DON/ADON with the managerial and clinical Level of Harm - Minimal harm or activities of units assigned. potential for actual harm Position Action Form, provided by the facility, dated 8/9/24, reflected that previous Unit Manager's last day of Residents Affected - Many work was 8/9/24.

Note: The nursing home is On 1/08/25 at 03:06 PM, the surveyor interviewed the VP of corporate clinical, who stated that the IP is a disputing this citation. part time position, and that the acting UM position was temporary. She also stated that the IP/UM was up to date on everything, both her IP and her UM duties. She has a desk nurse to assist her with the UM work. When asked if eight hours was enough for IP? The VP of corporate clinical stated she was not sure why the IP/UM said that as it is a 20 hour position and she is well aware of that.

On 1/09/25 at 09:53 AM, the surveyor interviewed the Director of Nursing, who stated the IP was up to date with infection control and the building was not affected negatively.

NJAC 8:39-19.1(b)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 31 315177

F-F759 Residents Affected - Few Based on observation, interview, and record review, it was determined that the facility failed to follow acceptable professional standards of clinical practice by borrowing a medication (Lidocaine 4% patch) from another resident's supply. The deficient practice was identified for one (1) of three (3) nurses observed

during medication administration for one (1) of six (6) residents, (Resident #122). The deficient practice was evidenced by the following:

Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for

the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist.

Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for

the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under

the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist.

On 1/3/25 at 8:59 AM, during the morning medication administration pass, the surveyor observed Registered Nurse (RN#1) at the door of Resident #122's room with the medication cart. RN#1 stated that she was about to administer the resident's eye drops and patches. RN#1 showed the surveyor the container of eye drops and two (2) packages of Max Strength Aspercreme with 4% Lidocaine pain relief patch (a topical patch used for pain relief) that was on the resident's overbed table. The RN#1 stated that the resident had physician's orders (PO) for the Lidocaine patches to be applied to two (2) different sites, the right shoulder and the left shoulder.

Upon returning to the medication cart, RN#1 showed the surveyor the electronic medication administration

record (EMAR) which revealed a PO dated 9/29/24 for Lidocaine External Patch 5% (Lidocaine) Apply to left shoulder topically one time a day for pain and remove per schedule. In addition, another PO dated 9/29/24 for Lidocaine External Patch 5% (Lidocaine) Apply to right shoulder topically one time a day for pain and remove per schedule.

After RN#1 acknowledged that she had administered the wrong strength of Lidocaine, she stated that Resident #122 had no Lidocaine patches in the medication cart and she had to borrow both Lidocaine patches from another resident. RN#1 then showed the surveyor a box of Max Strength Aspercreme with 4% Lidocaine pain relief patch labeled by the provider pharmacy for an unsampled resident that she had removed the two Lidocaine 4% patches to use for Resident #122.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 31 315177 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315177 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Gateway Care Center 139 Grant Ave Eatontown, NJ 07724

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 The surveyor reviewed the Order Summary Report for the unsampled resident and verified that there were active physician's orders (PO) with a start date of 11/13/24 for Lidocaine External Patch 4% (Lidocaine) Level of Harm - Minimal harm or Apply to left knee topically in the morning for pain and remove per schedule and Lidocaine External Patch potential for actual harm 4% (Lidocaine) Apply to lower back topically in the morning for pain and remove per schedule.

Residents Affected - Few On 1/3/25 at 10:47 AM, the surveyor interviewed the Assistant Director of Nursing (ADON), who stated that

she was responsible for nursing staff education. The ADON stated that nurses were not allowed to borrow any medications from another resident. The ADON stated that Lidocaine 5% patches were provided by the provider pharmacy and if the 5% patch was not available then the nurse would have to call the provider pharmacy to see why the medication was not available and the nurse would also have to call the physician for a follow up order as to what she should do. The ADON also stated that the facility had Lidocaine 4% patches as a house stock over the counter medication meaning that the facility had stock available for any resident that had a PO. The ADON added that some residents do get the Lidocaine 4% patches from the pharmacy if the insurance paid for them. The ADON stated that she would have to look into why the Lidocaine 5% was not available.

On 1/3/25 at 1:27 PM, the surveyor interviewed the ADON who stated that she was unsure why the Lidocaine 5% patches were not available for Resident #122, but the nurse should not have borrowed Lidocaine patches from another resident.

On 1/6/25 at 12:12 PM, the surveyor, with the Director of Nursing (DON), reviewed the EMAR for Resident #122. The DON explained that the RN#1 had not signed that she administered the Lidocaine 5% patches to

the left and right shoulders because RN#1 had realized she had applied the wrong strength and had obtained a one-time PO for the 4% patch. The DON added that there should be documentation indicating what RN#1 had done. The DON stated that the nurses were not to borrow medications but was unsure if there was a policy.

A review of the resident's nursing progress notes dated 1/3/25 at 11:36 AM completed by RN#1 revealed Notified MD for lidocaine patch. New ordered received and carried out.

On 1/6/25 at 12:45 PM, the surveyor interviewed the DON, who stated that there was no policy regarding borrowing of medications.

On 1/6/25 at 2:16 PM, the surveyor interviewed the Consultant Pharmacist (CP), via the telephone, who stated that she had been the CP for a while. The CP stated that the nurses cannot borrow any medications from another resident. The CP added that if the Lidocaine 5% patch was not available then the nurse should have called the physician for a follow-up order as to what to do. The CP added that she tells the nurses

during her inservices and medication passes that they cannot borrow medications and that can lead to a medication error.

NJAC 8:39-11.2(b), 29.2(a)(d), 29.3(5)(6)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 31 315177 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315177 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Gateway Care Center 139 Grant Ave Eatontown, NJ 07724

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Provide enough food/fluids to maintain a resident's health.

Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 40042

Residents Affected - Few Based on observations, interviews, record review, and review of facility documents, it was determined that

the facility failed to prevent unintended insidious (gradual but with harmful effects) weight loss of 31.5 pounds (lbs.) in one year from 1/3/24 through 1/1/25, and significant weight losses to include a 14 lb./10.5% loss in 6 months from 4/2/24 through 9/2/24; a 15 lb./11.2% loss in 6 months from 5/5/24 through 10/1/24; a 6.5 lb./5. 6% loss in 1 month from 11/1/24 through 12/3/24; and an additional 4 lb. loss from 12/3/24 through 1/1/25; which was also a 16.5 lb./13.4% loss in 6 months from 8/1/24 through 1/1/25. The facility failed to prevent and address these weight losses in a timely manner, which included the failure to a.) ascertain (to find out) food preferences, b.) implement fortified foods (foods that are nutrient dense in calories and protein), c.) provide culturally appropriate alternate meal options d.) implement and monitor weekly weights, and e.) consistently monitor intake and record consumption of a physician prescribed supplement. In addition, the facility relied on cultural food brought in by family when they visited approximately once a month as a nutritional intervention. This deficient practice was identified for 1 of 5 residents (Resident #67) reviewed for weight loss.

The evidence was as follows:

A review of an undated facility policy Weight Management and Intervention Procedure, reflected that the interdisciplinary team would strive to prevent, monitor and intervene when a resident experienced an undesirable weight loss. It also included that a 5% weight loss in a one-month time frame was considered significant and a 10% loss within six months was considered significant and a weight loss greater than 10%

in six months was considered severe. In addition, it reflected that the registered dietitian (RD) would review residents' weights by the 15th of each month and the team would discuss and analyze negative trends and interventions at the monthly weight meetings.

A review of an undated facility policy Nutritional Procedure, reflected that all residents should receive appropriate nutrition tailored to their individual health needs and food preferences for overall health and quality of life. Nutritional assessments should include a resident's dietary habits, preferred foods, favorite meals and traditional foods from their cultural background. It also reflected that staff should report any changes in eating habits and weights to the RD promptly. In addition, it included to maintain accurate and current records of all assessments, care plans, and residents' food preferences.

A review of an undated facility policy Interdisciplinary Care Planning Protocol, reflected that dietary should include an overview of their assessments of the residents needs and problems, which should be specific and individualized.

On 1/03/25 at 12:46 PM, the surveyor observed Resident #67 in their room. There was an untouched lunch tray on the overbed table.

On 1/06/25 at 12:20 PM, the surveyor observed the resident lying in their bed. Upon inquiry, the Certified Nurse Aide (CNA #1) stated that the resident refused lunch and that an alternate was usually offered; however, there were no culturally appropriate alternate meals available.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 31 315177 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315177 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Gateway Care Center 139 Grant Ave Eatontown, NJ 07724

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 On 1/07/25 at 12:21 PM, the surveyor observed the resident lying in their bed and there was no lunch tray in

the room. Upon inquiry, the Licensed Practical Nurse (LPN #1) stated that the resident no longer ate well and Level of Harm - Actual harm the physician recently increased a supplement from three to four times a day, and also prescribed a medication to stimulate the appetite. Residents Affected - Few

On 1/08/25 at 12:15 PM, two surveyors observed the resident lying in their bed. At that time, the surveyor interviewed the Assistant Activities Director (AAD), who stated that the resident's daughter visited the resident every three to four weeks and brought in cultural foods. In addition, she stated that the daughter visited on Saturday and the resident ate very little but did drink the soymilk brought by the daughter. The AAD stated that ever since the resident had COVID-19, the resident lost their sense of taste and therefore appetite. She also added that she knew the resident liked marinated beef and did not like pork. In addition,

she added that the resident enjoyed their supplements, and liked juice. The Activities Director entered the resident's room as well and translated in the resident's native language. Resident #67 confirmed that they enjoyed and completed supplements, soy milk when brought by the daughter and enjoyed juices. The resident stated that they preferred beverages and not food due to loss of taste.

The surveyor reviewed the medical record for Resident #67.

A review of the resident's Admission Record (an admission summary) included diagnoses not limited to; hypertensive, heart and chronic kidney disease with heart failure.

A review of the quarterly Minimum Data Set, an assessment tool used to facilitate the management of care dated 12/3/24, reflected a Brief Interview for Mental Status score of 5 out of 15 which indicated severe cognitive impairment. It also reflected the resident had a significant weight loss not on physician-prescribed weight-loss regimen.

A review of the resident's comprehensive care plan reflected a nutrition care plan initiated 12/22/20. The focus reflected that the resident had weight loss related to diuretic use, advanced age and poor meal intake.

It also included that in 8/2024 and 9/2024, they had gradual weight loss, in 11/2024, the resident had gradual weight loss and a significant weight loss over six months, in 12/2024, the resident had a significant weight loss over a one- and six-month period of time, and in 1/2025, the resident had a significant weight loss over three and six months. The goals initiated on 12/22/20, included that the resident would maintain their weight with no significant weight changes and would consume at least 75% of meals and supplements. Interventions included to Encourage family to bring food/snacks, which was initiated on 6/12/23, by the facility RD and provide House Supplement 237 ml four times a day, this intervention was revised on 1/2/25, by the facility RD.

A review of the Order Summary Report (OSR) reflected the following physician orders (PO):

A PO dated 8/9/23, for Glucerna (a supplement with less sugar) 237 milliliters (mls) twice a day;

A PO dated 2/2/24, for Glucerna three times a day and record amount;

A PO dated 3/22/24, for House Supplement NSA (no sugar added) three times a day;

A PO dated 6/26/24, for House Supplement NSA (no sugar added) three times a day;

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 31 315177 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315177 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Gateway Care Center 139 Grant Ave Eatontown, NJ 07724

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 A PO dated 12/3/24, for House Supplement four times a day for supplement for poor appetite; and

Level of Harm - Actual harm A PO dated 12/27/24, for a Regular diet;

Residents Affected - Few A PO dated 12/27/24, for House Supplement four times a day.

A review of the Medication Administration Record (MAR) reflected the above PO dated 6/26/24. Further

review of the MAR for the dates 6/27/24 through 8/1/24, reflected the House Supplement was administered three times a day (09:00 AM, 2:00 PM, 09:00 PM) with a check mark; however, there was an X marked for

the amt (amount consumed) row, which did not quantify the amount of supplement consumed.

The surveyor reviewed the weight record in the electronic medical record (EMR) which did not include weekly weight monitoring. Weights documented were as follows:

1/3/24 139 lbs.

2/2/24 135.5 lbs.

3/7/24 132.5 lbs.

4/2/24 134 lbs.

5/5/24 134 lbs.

6/5/24 128.5 lbs.

7/1/24 128 lbs.

8/1/24 124 lbs.

9/2/24 120 lbs.

10/1/24 119 lbs.

11/1/24 118 lbs.

12/3/24 111.5 lbs.

1/1/25 107.5 lbs.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 31 315177 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315177 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Gateway Care Center 139 Grant Ave Eatontown, NJ 07724

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 The Director of Nursing (DON) provided the surveyor with documentation that Resident #67 was discussed at a monthly weight meeting on 11/6/24, for a 16 lb./11.9% weight loss over six months. Interventions/Notes Level of Harm - Actual harm reflected the weight loss was expected due to diuretic use (a medication used to increase the production of urine, helping the body to get rid of excess fluid), the age of the resident and that the resident preferred food Residents Affected - Few from the family. In addition, the resident's weights were discussed at a weight meeting dated 12/9/24, for a 6. 5 lb./5.5% loss over one month and a 17 lb./13.2% loss over six months. Interventions/Notes reflected the weight loss was undesired, but that the resident was on a diuretic with improved edema (fluid retention); had poor intake of meals but good intake of supplements. At that time, there was a recommendation to increase

the supplement from three to four times a day.

Further review of the residents OSR, reflected a PO for the diuretic Furosemide 20 milligrams (mg) one tablet once a day with a start date 3/11/23 through 1/7/25. There was also no PO for a multivitamin and mineral supplement.

A review of the resident's meal tickets dated 1/7/24, for breakfast, lunch and dinner included whole milk not soy milk, no fortified foods and a Korean Meal, for lunch and dinner. It also included hot cereal at breakfast (not fortified hot cereal) and a four-ounce cranberry juice (not a calorically dense Nutritional Juice.)

A review of the resident's progress notes from 5/1/24 through 1/8/25 reflected the following documentation:

-Physician Progress Note Narratives reflected the resident had mild bilateral (both sides) edema on 7/18/24 at 4:23 PM and 8/19/24 at 12:27 PM.

-Physician Progress Note Narratives reflected the resident had improved bilateral edema on 9/6/24 at 10:29 AM and on 10/25/24 at 1:50 PM.

-CRNP [Nurse Practitioner] Progress Note Narratives reflected the resident had trace edema on the following dates and times: 5/9/24 at 1:54 PM, 5/13/24 at 1:35 PM, 5/30/24 at 10:52 AM, 6/27/24 at 11:46 AM, 7/2/24 at 11:22 AM, 7/24/24 at 11:48 AM, 8/1/24 at 1:35 PM, 8/15/24 at 2:00 PM, 8/16/24 at 11:21 AM, 8/20/24 at 1:36 PM, 8/28/24 at 4:42 PM, 9/4/24 at 11:21 AM, and 9/13/24 at 11:46 AM.

-Nursing Progress Note's reflected the resident had trace edema on 6/20/24 at 1:11 PM and 9/20/24 at 7:43 PM.

A review of multiple progress notes from the Physician, Nurse Practitioner, and Nurse reflected no documented evidence that the resident had more than mild or trace edema.

A Dietary progress note dated 2/2/24 at 11:54 AM, reflected the resident's weight was 135.5 lbs. which was a gradual undesired loss. It further reflected the resident was not a big breakfast eater. In addition, the RD noted that nursing informed her that the resident had good consumption of foods brought by the family, had poor to fair consumption of facility food and took 100% of the supplement Glucerna 237 ml twice a day. The RD would recommend increasing the Glucerna to three times a day.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 31 315177 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315177 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Gateway Care Center 139 Grant Ave Eatontown, NJ 07724

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 A quarterly Nutritional assessment dated [DATE REDACTED] at 8:55 AM, reflected the resident's weight was 132.5 lbs. which was a gradual undesired loss. It also included the residents usual body weight/goal weight at 135-145 Level of Harm - Actual harm lbs. and that the resident's meal intake met 26-100% of their estimated nutritional needs. It further reflected that the resident had poor intake of facility meals, but had good consumption of food and snacks brought by Residents Affected - Few the family when they visited.

A quarterly Nutritional assessment dated [DATE REDACTED] at 11:13 AM, reflected the resident's weight was 128.5 lbs., which was a gradual undesired loss and now their usual body weight/goal weight was 130-140 lbs. It reflected the resident's meal intake met 26-100% of the resident's estimated nutritional needs. It further reflected that the resident had poor intake of facility meals but had good consumption of food brought by the family. The RD notes the resident had trace edema and that she would continue to monitor the residents weights and intake.

A Dietary progress note dated 8/2/24 at 11:05 AM, reflected the resident's weight was 124 lbs. which was a gradual undesired loss. The RD further documented that the resident had good consumption of food brought by the daughter per a translator and had good intake of supplements and preferred to drink them at medication pass times. The RD indicated she would continue to monitor the resident's weight and intake of meals and supplements.

An annual Dietary note dated 8/30/24 at 8:50 AM, reflected the resident's weight was 124 lbs. The note reflected the resident received Vitamin C, Vitamin D and folic acid (but not a complete vitamin/mineral supplement). The RD further documented that the resident had good consumption of food brought by the daughter about once a month per a translator and had fair to good intake of supplements as per staff. The RD indicated she would continue to monitor the resident's weight and intake of meals and supplements.

A Dietary progress note dated 11/1/24 at 3:18 PM, reflected the resident's weight was 118 lbs. which was a gradual weight loss over one month and a significant weight loss over six months (16 lbs./11.9%). The RD documented that the loss was expected due to an improvement of edema as per a progress note dated 10/25/24. In addition, it reflected that the resident had poor intake of facility meals since the resident enjoyed foods brought by the daughter and was consuming 100% of the House Supplement NSA three times a day.

A quarterly Nutritional assessment dated [DATE REDACTED] at 12:42 PM, reflected the resident's weight was 118 lbs., which was a gradual weight loss over one month and a significant weight loss over six months (16 lbs./11. 9%). The assessment now indicated that the resident's usual body weight/goal weight fluctuates. The RD documented that the loss was expected due to an improvement of edema as per a progress note dated 11/15/24. It reflected the resident's meal intake met 26-100% of the resident's estimated nutritional needs. It further reflected that the resident had poor intake of facility meals since the resident enjoyed foods brought by the daughter. In addition, it reflected the resident had fair to good consumption of the House Supplement NSA 237 ml three times a day.

A Physician Progress Note Narrative dated 12/2/24 at 3:03 PM, reflected the resident had improved bilateral edema, check TSH (thyroid stimulating hormone, which is a test to check thyroid function), monitor weights and intake, RD to follow up.

A Nursing Progress Note dated 12/2/24 at 3:21 PM, reflected the resident had a poor appetite and the resident's physician and daughter were notified.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 31 315177 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315177 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Gateway Care Center 139 Grant Ave Eatontown, NJ 07724

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 A Nursing Progress Note dated 12/2/24 at 8:12 PM, reflected the resident refused dinner but consumed 100% of the House Supplement. Level of Harm - Actual harm

A Nursing Progress Note dated 12/3/24 at 11:29 AM, reflected the RD and speech therapist were notified of Residents Affected - Few the resident's poor appetite.

A Dietary note dated 12/3/24 at 12:35 PM, reflected that the resident's weight was 111.5 lbs. which was an undesired significant weight loss of 6.5 lbs./5.5% over one month and 17 lbs./13.2% over six months. It reflected that edema improved and that as per the staff the resident's meal consumption was less than 25% and sometimes refused meals but consumed 100% of the supplements. The RD indicated that she would increase the supplements from three to four times per day and continue to monitor weights and intake of meals and supplements.

A Dietary note dated 12/25/24 at 9:54 AM, reflected the resident continued to have poor intake of facility meals and enjoyed food brought by family when they visited. Also, per nursing, the resident was taking the supplements well which was increased to four times a day on 12/3/24 (which was not evidenced in the OSR or MAR). The RD also documented that the resident did not have a history of diabetes and therefore requested the diet be liberalized to a regular not a diabetic diet and the same for the supplements.

A Dietary note dated 1/2/25 at 11:47 AM, reflected the resident's weight was 107.5 lbs. which reflected a gradual four pound weight loss over one month, a significant weight loss of 11.5 lbs./9.7% over three months and a 20.5 lb./16% significant weight loss over six months, all of which were undesired. The RD included that

on 12/27/24, the diet was liberalized to regular, and the supplement was changed to a regular House Supplement 237 ml to four times a day. She included that the resident had variable intake of facility meals and enjoyed food brought by the family. Intake of supplements was 100% and that nursing requested the physician order a medication to stimulate the appetite. In addition, it reflected the RD would continue to monitor the resident's weight and intake of meals and supplements.

There was no documented evidence that the RD implemented interventions related to the residents insidious and significant weight changes since the 2/2/24, Dietary progress note until December 2024 (10 months later).

A Nursing Progress Note dated 1/1/25 at 12:40 PM, reflected the resident did not eat breakfast or lunch and only consumed the House Supplement in the morning and at lunch. In addition, the resident's daughter and physician were notified.

A Nursing Progress Note dated 1/3/25 at 9:16 PM, reflected the resident had a poor appetite and consumed 25% of their meals.

A Nursing Progress Note dated 1/5/25 at 3:40 PM, reflected the physician ordered a medication to stimulate

the appetite for Resident #67.

A Nursing Progress Note dated 1/7/25 at 3:21 PM, reflected the resident refused lunch despite two attempts.

The resident did consume 90% of the House Supplement and the resident's daughter and physician were notified.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 31 315177 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315177 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Gateway Care Center 139 Grant Ave Eatontown, NJ 07724

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 On 1/07/25 at 1:07 PM, the surveyor interviewed the RD in presence of survey team. She stated that she was aware that the resident had weight loss but was not sure of the details. She stated that there were no Level of Harm - Actual harm alternate Korean meals available if a resident refused a meal; there was only American items available. The RD stated that if a resident was not eating, she would order supplements. She stated a House Supplement Residents Affected - Few was either Ensure Plus or Boost Plus. The RD acknowledged that she should have tried foods first. The RD stated that when she obtained food preferences, she relayed that information to the kitchen and ensured the resident received them via meal rounds. The RD stated that the family brought in food; however, she could not speak to how often or what foods. In addition, she stated that the facility had fortified foods which were calorically dense and served as a nutritional intervention to abate and/or reverse unplanned weight loss. She could not answer why fortified foods were not tried for Resident #67; such as Super Cereal as that was a calorically dense hot cereal that could have replaced the hot cereal the resident received each morning. In addition, the RD could not answer why she did not try a calorically dense juice to replace the resident's regular juice which the resident enjoyed. Furthermore, she could not answer why the resident was not ordered a multivitamin and mineral supplement since their meal intake was inadequate. The RD stated she would have to get back to the surveyor regarding what interventions she put into place for the resident's weight loss which was now significant. She could not answer why the resident was not placed on weekly weights for closer monitoring.

On 1/09/25 at 9:52 AM, the survey team met with the administrative team: the DON, the Regional DON, the Assistant DON (ADON), the Licensed Nursing Home Administrator (LNHA) and the Regional LNHA. The LNHA stated the RD would not be available for a follow up interview since she had an emergency. The administrative team acknowledged that residents and families were made aware that the always available meal substitute items were from the American menu and acknowledged that residents on the Korean unit received American breakfast. The administrative team stated that the residents supplement was changed from Glucerna to Ensure Plus on 12/3/24. The LNHA stated that his expectation was that the RD would have identified weight losses and the causation, update food preferences, reassess, implement interventions and follow up. The DON stated she could not answer whether the RD did this for Resident #67. She provided the surveyor with documentation that the resident was discussed at the November and December 2024 monthly weight meetings. She also stated that the resident should have been on weekly weights for closer monitoring. The Regional LNHA stated that when he spoke to the RD, she stated that she had interviewed

the resident, but did not document the conversations. In addition, he stated that the RD indicated that the family provided cueing at meals which increased the resident's meal consumption. Furthermore, he acknowledged that if the resident's family was visiting every three to four weeks, the facility could not rely on food brought from home or the family member cuing as nutrition interventions. The ADON stated that the physician was aware of the weight loss and ordered an appetite stimulant medication on 1/5/25. The LNHA stated that the resident's weight losses should have been addressed by the RD or Consultant RD, and that

he was ultimately responsible to ensure the RD had addressed the weight losses appropriately.

A review of the Korean units four-week menu cycle reflected that one meal choice was available for lunch and dinner.

A review of a recipe for the fortified food Super Cereal, reflected that a portion size of this hot cereal would have provided 511 calories and 11 grams of protein.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 31 315177 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315177 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Gateway Care Center 139 Grant Ave Eatontown, NJ 07724

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 A review of an unsigned and undated job description for Dietitian, reflected that job responsibilities included but were not limited to; provide substitute foods of similar nutritive value to resident's who refuse foods Level of Harm - Actual harm served, interview residents or family members as necessary to obtain diet history, participate in maintaining records of the residents food likes and dislikes, visit residents periodically to evaluate the quality of meals Residents Affected - Few served, likes and dislikes, etc., involve the resident's/family in planning dietary objectives and goals for the resident, and assist in developing diet plans for individual residents.

NJAC 8:39-11.2(e)(2), 17.1(c), 17.4(a)(1), 27.1(a)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 31 315177 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315177 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Gateway Care Center 139 Grant Ave Eatontown, NJ 07724

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater.

Level of Harm - Minimal harm or 34033 potential for actual harm REFER to