Lions Gate

survey team, the DON stated that she did not know when she was required to notify the NJDOH and

behalf LPN #4.

The DON stated that she was unable to immediately confirm diversion and wanted to

false report.

The LNHA stated that she was not sure of what the required reporting timeframe was for notifying both the NJDOH and the Office of the Ombudsman for the Institutionalized Elderly of an alleged or suspected drug diversion.

The DON further stated that the day that she reported, was the day she decided that she was going to treat it as drug diversion when LPN #4 failed to comply with a face-to-face interview.

The DON further stated that she had not provided a summary and conclusion to the NJDOH yet because they had not requested it.

A review of the facility's undated Reportable Event Policy included: Mandatory reporting of incidents that can affect the health, safety, or well-being of residents is required. .Reporting Procedure: .External Reporting: The Director of Nursing or Healthcare Administrator will determine the appropriate bodies that need to be informed such as the NJDOH, Ombudsman, Policy, Physician, local health department, and family.

A review of the facility's undated Drug Diversion and Prevention Policy included: .Reports of confirmed drug diversion will be submitted to the NJDOH, law enforcement, and licensing boards as required .

NJAC 8:39-9.4(f)

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Lions Gate 1100 Laurel Oak Road Voorhees, NJ 08043

that a resident with suicidal ideation or behavior should be care planned.

She then stated that she

On 2/12/25 at 1:23 PM, the surveyor interviewed the DON who stated that when she was making

plan.

The DON then stated that she could not provide copies of the ICCP without updating the care plan.

The DON stated that the care plan should have been initiated within a short period of time. and that the Unit Manager, MDS coordinator or anyone could have initiated the care plan.

A review of facility's Behavioral Management policy dated May 2024, included, that all residents receive care and services to assist him or her to reach their highest level of mental and psychosocial functioning through interdisciplinary evaluation and assessments.

Procedure Guidelines 7. the RAI [Resident Assessment Instrument] care plan process resident behavior management plan, interventions and effectiveness will be reviewed.

NJAC 8:39-11.1

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Lions Gate 1100 Laurel Oak Road Voorhees, NJ 08043

and the weight obtained was 117.8 lbs.

The RD and the doctor was made aware of the weight change.

weights.

The note reflected that the weight loss likely due to a decline in intake and limited

meals.

The RD will honor preferences to encourage intake, will continue to monitor intake, weight trends and labs as available.

On 2/12/25 at 12:15 PM, the surveyor interviewed the Director of Nursing (DON) who stated that when there was a discrepancy in Resident #51's weight obtained on 2/1/25, 2/6/25 and 2/10/25, the nurse should have reweighed the resident to confirm the weight loss, then notified the RD and the doctor.

A review of the facility's Weight Policy, undated, included that any weight change of 5% or more since the last weight assessment is retaken for confirmation. If the weight is verified, nursing will immediately notify the dietician.

NJAC 8:39 - 27.2 (a)

change to prevent discrepancies and ensure resident safety .

Narcotic Count at Shift Change: At the beginning and end of each shift, the oncoming and outgoing licensed nurses shall conduct a joint count of all controlled substances.

Both nurses shall verify the count against the narcotic record.

Documenting and Record-Keeping: .All narcotic administration shall be documented in the resident's medication administration record .

A review of the facility's undated Receipt, Usage, Disposition, and Reconciliation of Controlled Medications Policy included: .Each administration must be recorded in the Medication Administration Record (MAR) and the narcotic record. .A shift-to-shift controlled medication count shall be conducted and documented by outgoing and incoming licensed nurses.

Monthly audits shall be performed to ensure compliance and identify any discrepancies.

Any discrepancies must be reported immediately to the Nurse Manager or Nursing Supervisor and DON or Facility Administrator .

A review of the facility's undated Crash Cart Policy policy included, 5.

Routine Inspections: To ensure readiness .Weekly Checks: Review expiration dates and replace as necessary.

A review of the facility's undated Emergency Cart Inspection and Inventory policy included, Procedures 2.

Routine Inspections .Any missing, damaged, or expired items shall be replaced immediately.

NJAC 8:39-29.7 ( c ); 29.2(d)

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Lions Gate 1100 Laurel Oak Road Voorhees, NJ 08043

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who stated she expected food items to be labeled and dated appropriately, food items to be discarded

items appropriately and discard expired food items.

A review of the facility's Operational Standards Refrigerator policy, revised 5/24, included, Food is properly stored in appropriate containers labeled with product name, date prepared/opened, use-by date and employee initials.

A review of the facility's Refrigerators and Freezers policy, undated, included, All food is appropriately dated to ensure proper rotation by expiration dates, and Expiration dates on unopened food are observed and 'use-by' dates are indicated once food is opened.

Further review of the policy included, Supervisors are responsible for ensuring food items in pantry, refrigerators, and freezers are not past 'use-by' or expiration dates.

A review of the facility's Pots, Pans, Utensils Washing and Air Drying policy, revised 5/24, included, All sanitized items must be air dried and cooled completely before stacking and storing.

NJAC 8:39-17.2(g)

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Lions Gate 1100 Laurel Oak Road Voorhees, NJ 08043

antibiotic).

Use 1 gram intravenously two times a day related to UTI for 7 days, with end date of

A PO, dated 2/11/25, to remove Midline.

A review of the Midline Insertion Documentation form from an outside company, dated 2/4/25, indicated the midline was placed to the right upper arm.

On 2/11/2025 at 10:03 AM, surveyor interviewed the Infection Preventionist (IP) who stated that a resident who had a Midline catheter for IV antibiotics should be on EBP.

The IP stated that Resident # 31 was not on EBP because she thought the resident had a peripheral IV site not a midline IV catheter.

On 2/12/2025 at 12:15 PM, the surveyor interviewed the DON who stated that a resident who had a midline IV catheter should be on EBP.

Reference: Center for Disease Control and Prevention, Long-Term Care Facilities, document titled Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions in Nursing Homes dated June 28, 2024, states, .22.

What is the definition of indwelling medical device? An indwelling medical device provides a direct pathway for pathogens in the environment to enter the body and cause infection.

Examples of indwelling medical devices include, but are not limited to, central vascular catheters (including hemodialysis catheters, peripherally inserted central catheters (PICCs)) .

Although the data are limited, CDC does not currently consider peripheral I.V.s (except for midline catheters) . as indications for Enhanced Barrier Precautions .

A review of the facility's Enhanced Barrier Precautions (EBP) policy, reviewed December 2024, included, EBP are required for patients with any of the following: 2.

Indwelling medical devices: Midlines, PICC lines, Central lines.

NJAC 8:39-19.4(n)

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Lions Gate 1100 Laurel Oak Road Voorhees, NJ 08043

The surveyor reviewed the medical record for Resident #51.

A review of the Admission Record, an admission summary, revealed the resident had diagnoses which included, vascular dementia, gastro-esophageal reflux disease (GERD) and dysphagia (difficulty swallowing).

A review of the quarterly Minimum Data Set (MDS), an assessment tool, dated 1/28/25, included the resident had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated the resident's cognition was moderately impaired.

Further review of the MDS revealed the resident had a weight loss of 5% or more in the last month, or 10% or more in the last six months, while not on a physician-prescribed weight loss regimen.

A review of the individual comprehensive care plan (ICCP) included a focus area, dated 5/29/24, that the resident had nutritional problem related to dementia, anxiety, depression, diabetes, dysphagia, and mechanical altered diet.

Interventions included: 5/29/24, monitor weight as ordered.

Notify Registered Dietician (RD)/ Medical Director (M)D as needed of weight gain/loss.

A review of the Order Summary Report (OSR), dated as of 2/11/25, included the following physicians' orders:

A PO, dated 12/9/24, for carbohydrate, controlled diet.

Mechanical soft- ground meat texture, thin liquids consistency.

A PO, dated 1/27/25, for a supplement two times a day for weight loss.

A PO, dated, 1/24/25, for weekly weights times 4 weeks one time a day every Wednesday for 4 weeks.

315499

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 315499 B.

Wing 02/13/2025

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

Lions Gate 1100 Laurel Oak Road Voorhees, NJ 08043