Lions Gate

F-F755

On 2/11/25 at 8:48 AM, the surveyor reviewed the medical record of Resident #197.

A review of the Admission Record, an admission summary, revealed the resident had diagnoses which included, displaced fracture of base of neck of right femur (the bone of the thigh, between the knee and the hip), subsequent encounter for closed fracture with routine healing, and repeated falls.

A review of the resident's most recent comprehensive Minimum Data Set (MDS), an assessment tool, dated 9/23/24, included the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated the resident's cognition was moderately impaired. Further review of the MDS revealed the resident had experienced occasional pain that was described as moderate that occasionally interfered with therapy activities and day to day activities and that had rarely or had not affected the resident's ability to sleep.

A review of the individual comprehensive care plan (ICCP) included a focus area, dated 9/24/24, that the resident had acute/potential pain related to (r/t) immobility/fracture. Interventions included: Be alert to verbal/non-verbal signs and symptoms (s/s) of pain. Notify Nurse as needed if resident complains of (c/o) or shows s/s of pain.

A review of the Order Summary Report (OSR) included the following physician's orders (PO):

-A PO, dated 9/19/24, for Tramadol HCL oral tablet 50 milligrams (MG) give one (1) tablet every six (6) hours as needed for moderate pain for 14 days pain management.

-A PO, dated 9/20/24, for Oxycodone HCL oral tablet five (5) MG give one (1) tablet by mouth every four (4) hours as needed for severe pain related to displaced fracture of base of neck of right femur, subsequent encounter for closed fracture with routine healing for 14 days.

On 2/11/25 at 8:48 AM, the surveyor reviewed the medical record of Resident #198.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 27 315499 Department of Health & Human Services Printed: 09/08/2025 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 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

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 0609 A review of the Admission Record revealed the resident had diagnoses which included, displaced trimalleolar (ankle) fracture of right lower leg, subsequent encounter for closed fracture with routine healing and Level of Harm - Minimal harm or unsteadiness on feet. potential for actual harm

A review of the most recent comprehensive MDS, dated [DATE REDACTED], included the resident had a BIMS score of Residents Affected - Few 15 out of 15, which indicated the resident's cognition was fully intact. Further review of the MDS revealed the resident had not experienced pain or hurting at any time in the past five days during a pain assessment interview.

A review of the ICCP included a focus area, dated 9/25/24, that the resident had a trimalleolar fracture right lower extremity (RLE) related to fall. Interventions included: Observed for verbal/nonverbal s/s of pain. Notify nurse as needed.

A review of the OSR included the following PO:

-A PO, dated 9/24/24, for Oxycodone HCL Tablet 5 MG give 1 tablet by mouth every 4 hours as needed for moderate pain (4-7) for 14 days.

-A PO, dated 9/24/24, for Oxycodone HCL Tablet 5 MG give two (2) tablets by mouth every 4 hours as needed for severe pain (8-10).

On 2/11/25 at 8:48 AM, the surveyor reviewed the medical record of Resident #199.

A review of the Admission Record revealed the resident had diagnoses which included, acute kidney failure, unspecified, chronic gout (a complex form of arthritis), low back pain, unspecified, and wedge compression fracture of first lumear vertebra (a type of spinal fracture), subsequent encounter for fracture with routine healing.

A review of the most recent comprehensive Minimum Data Set (MDS) dated [DATE REDACTED], included the resident had a BIMS score of 15 out of 15, which indicated the resident's cognition was fully intact. Further review of

the MDS revealed the resident had experienced occasional pain that was described as moderate that had rarely or had not affected the resident's therapy activities, day to day activities or the resident's ability to sleep.

A review of the ICCP included a focus area, dated 8/30/24, that the resident had a risk of pain related to deconditioning and gout. Interventions included: Administer meds as ordered. Monitor effectiveness and for any adverse side effects and Assess need for pain meds prior to activities of daily living (ADLs)/and or therapy.

A review of the OSR included the following PO:

-A PO, dated 9/16/24, for Oxycodone HCL oral tablet 5 MG Give 1 tablet by mouth every 4 hours as needed for moderate (mod.) pain for 14 days.

-A PO, dated 9/16/24, for Oxycodone HCL oral tablet 5 MG Give 2 tablets by mouth every 4 hours as needed for severe pain for 14 days.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 27 315499 Department of Health & Human Services Printed: 09/08/2025 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 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

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 0609 On 2/11/25 at 12:01 PM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM #1) who stated the oncoming nurse, and the outgoing nurse should both count the narcotics and sign the book to Level of Harm - Minimal harm or ensure that the narcotic count was right, and the medications had not been compromised. LPN/UM #1 potential for actual harm further stated that there was a recent problem with an agency nurse who signed out narcotics, but it was questionable whether the residents had received them. LPN/UM #1 stated that the incident was reported and Residents Affected - Few was investigated by the Director of Nursing (DON).

On 2/11/25 at 1:36 PM, the surveyor requested and received a copy of a Long-Term Care Reportable Event Survey that was reported to the New Jersey Department of Health on 10/4/24, for an event that occurred on 9/28/24 at 7:00 PM, six (6) days after the event, and detailed that there was a loss or theft of narcotics on the Rehab 1 Nursing Unit.

A review of a narrative report detailed that on 9/28/24, it was noted that three (3) residents had narcotics removed and signed off from their narcotic inventory record, and none of the doses were signed off on their medication administration record (MAR). Two of the residents denied being medicated for pain and stated

they were not medicated for pain by the nurse on this day. It was also noted that on 9/23/24, three doses of medication were removed from the inventory, however, were not signed off as administered and the resident stated that he/she has not taken anything for pain since 9/22/24. It was suspected that the same nurse removed these doses from inventory and changed the date and forged someone else's signature. The nurse was placed on the do not return list and it was reported to her agency.

Further review of the Long-Term Care Reportable Event Survey revealed the Office of the Ombudsman for

the Institutionalized Elderly was notified of the event on 10/4/24 at 4:45 PM, six days after the event occurred.

Further review of the investigation included a Report of Theft or Loss of Controlled Substances (Drug Enforcement Agency (DEA) Form 106) which detailed that there were fourteen Oxycodone HCL immediate release (IR) 5 MG tablets reported stolen and one Tramadol HCL 50 MG tablet was reported stolen.

On 2/11/25 at 2:06 PM, the surveyor interviewed the DON who stated that LPN #5 and LPN #6 reported odd behavior from LPN #4 (an agency nurse) which included hyperactivity to the supervisor. The DON stated that LPN #4, was observed down the hall passing medication past the shift change and had the narcotic inventory book opened, as she looked in the computer for a long time. The DON stated that the narcotic inventory was accurate when LPN #6 and LPN #4 counted at 7 PM. The DON stated that LPN #5 noted that narcotic medications were signed out on the time that she worked that were not her signature and she stated

the forged signature raised a suspicion. The DON stated that the first instance was obvious for Resident #199, because the resident denied receipt of the medication and a review of the MAR did not reflect receipt.

The DON stated that the resident stated that their last dose was on 9/22/25.

At that time, the DON reviewed Resident #199's Individual Narcotic Record (INR) for Oxycodone IR 5 MG tablets which indicated that on 9/23/24 at 7 AM, on 9/23/24 at 11:30 AM, and on 9/23/24 at 4:00 PM, two tablets were signed out by someone other than LPN #5 who was assigned to the resident on this date, and

the signature did not belong to LPN #5, or anyone who worked on that date. The DON further stated that LPN #4 was assigned to Resident #199 on 9/28/24 and signed out two tablets of Oxycodone IR 5 MG to the resident at both 12:20 PM and at 6:12 PM, for a total of ten tablets.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 27 315499 Department of Health & Human Services Printed: 09/08/2025 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 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

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 0609 At that time, the DON stated that Resident #197 was unable to tell us if he/she was medicated for pain or not, but two tablets of Oxycodone and one Tramadol tablet were signed out on the INR and were not signed Level of Harm - Minimal harm or out on the MAR and there was an established pattern. potential for actual harm At that time, the DON reviewed Resident #198's INR with the surveyor which indicated that on 9/28/24 at Residents Affected - Few 9:30 AM and 6:40 PM, LPN #4 signed out two tablets of Oxycodone IR 5 MG tablets which had not been signed out on the MAR.

On 2/12/25 at 2:26 PM, in the presence of the Licensed Nursing Home Administrator (LNHA) and survey team, the DON stated that she did not know when she was required to notify the NJDOH and the Office of

the Ombudsman for the Institutionalized Elderly of a suspected and alleged drug diversion. The DON stated that it was not reported right away because of a delayed response on behalf LPN #4. The DON stated that

she was unable to immediately confirm diversion and wanted to interview LPN #4 because she was not sure if it were actual diversion, and did not want to create a false report. The 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)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 27 315499 Department of Health & Human Services Printed: 09/08/2025 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 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

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 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Level of Harm - Minimal harm or potential for actual harm 51707

Residents Affected - Some Based on observation, interviews and review of pertinent facility records, the facility failed to develop and implement an individualized comprehensive care plan for a resident that was requiring an anti-anxirty and anti-psychotic medication.

This deficient practice was identified for 1 of 5 residents (Resident #29) reviewed for medication regimen.

On 2/10/25 at 10:00 AM, during the initial tour, the surveyor observed Resident #29 awake, and alert, fully dressed, sitting in a wheelchar in their room.

The survyeor reviewed the medical record for Resident #29.

A review of the Admission Record, an admission summary, revealed that the resident had the diagnosis which included, Systemic Lupus Erythematous (an autoimmune disease where the body's immune system mistakenly attacks the body's healthy tissues), major depressive disorder (a depression characterized by persistent sadness, loss of interest, fatigue, feelings of worthlessness), protein calorie malnutrition (when the body does not get enough protein or calories.) and primary insomnia (difficulty sleeping not related to medical or psychological conditions.

A review of the resident's most recent quarterly Minimum Data Set (MDS), an assessment, dated 12/24/24, included the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident's cognition was intact. Further reveiew in Section M of the MDS indicated that the resident was receiving antipsychotic and antianxiety, and antidepressant medication.

A review of the active Order Summary Report (OSR) for February 2025, included the following physician orders:

A PO, dated 10/13/24, for Xanax 0.5 milligrams (mg), give 1 tablet by mouth as needed for major depressive disorder related to major depressive disorder.

A PO, dated 10/14/24, for Abilify 2 mg by mouth.

A review of the February 2025 Medication Administration Record (MAR) revealed that Resident #29 was receiving Abilify 2 milligrams (mg) by mouth daily and Xanax 0.5 mg by mouth at bedtime.

A review of individualized comprehensive care plan (ICCP) did not include a care plan including interventions for an antipsychotic or antianxiety medication.

On 2/10/25 at 11:00 AM, the surveyor requested from the Director of Nursing (DON) a copy of Resident #29's ICCP. Futher review of the ICCP, included a focus area for the use of Abilify and Xanax initiated on 2/10/25 after surveyor inquiry.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 27 315499 Department of Health & Human Services Printed: 09/08/2025 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 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

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 0656 On 2/11/25 at 10:40 AM, the surveyor conducted an interview with the Registered Nurse (RN #3) who stated that when a resident had any suicidal ideation or behavior issues the Unit Manager (UM) should initiate a Level of Harm - Minimal harm or care plan immediately. She then stated that she could initiate the care plan as well. potential for actual harm

On 2/11/25 at 10:56 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #8) who stated that a Residents Affected - Some resident with suicidal ideation or behavior should be care planned. She then stated that she would have to look at the policy.

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

the care plans for surveyor, she noted the anti-psychotic medications were not on the care plan. The 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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 27 315499 Department of Health & Human Services Printed: 09/08/2025 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 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

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 - Minimal harm or 41072 potential for actual harm Based on observation, interview, record review, and review of pertinent facility documents, it was determined Residents Affected - Few that the facility failed to obtain a re-weight according to the facility's policy for a resident with a history of significant weight loss.

This deficient practice was identified for 1 of 1 resident (Resident #51) reviewed for nutrition and evidenced by the following:

On 2/10/25 at 1:01 PM, the surveyor observed Resident #51 in the first-floor skilled nursing unit dining room being served breakfast. The resident received pancakes cut into bite sized portions. The resident complained that the pancakes were cold and did not eat the pancakes.

On 2/11/25 at 8:20 AM, the surveyor observed Resident #51 in the first-floor skilled nursing unit dining room being served breakfast. The resident received pancakes cut into bite sized portions. The resident ate about 50% of their meal.

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 27 315499 Department of Health & Human Services Printed: 09/08/2025 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 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

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 the Dietician Note (DN), dated 1/27/24, included the resident had a significant weight loss in one month with multiple weight fluctuations in the past few months. Intake remains good, consuming 50% of Level of Harm - Minimal harm or meals. Further review of the DN included recommendations to monitor intake, weight trends and increased potential for actual harm the supplement to twice a day.

Residents Affected - Few A review of the Weights and Vitals Summary, as of 2/10/25 included the following weights:

On 12/1/24, the resident weighed 127 lbs.(wheelchair)

On 1/1/25, the resident weighed 135 lbs. (wheelchair)- with incorrect documentation added by RD

On 1/8/25, the resident weighed 121.3 lbs. (wheelchair)- with incorrect documentation added by the RD

On 1/29/25, the resident weighed 133 lbs.(wheelchair)

On 2/1/25 the resident weighed 121. lbs.(wheelchair)

On 2/6/25, the resident weighed 107.9 lbs. (sitting)

On 2/10/25, the resident weighed 110.4 lbs. (standing)

A PO, dated 2/10/25, included an order to reweigh one time.

A review of the February 2025 Medication Administration Record (MAR) revealed that a weight of 121 lbs. was documented in the MAR on 2/20/25 at 3:28 PM.

A review of the Progress Notes (PN), dated 1/18/25 through 2/10/25, did not include evidence that a re-weight was attempted after the documented weight loss of more than five pounds, or that the RD or physician was notified of the significant weight loss on 2/1/25 and 2/6/25.

On 2/11/25 at 9:52 AM, the surveyor interviewed the Certified Nursing Assistant (CNA #4) who stated the nurse scheduled the weights that the CNAs needed to obtain weekly. The CNA further stated that she reports the weights to the nurse but does not look at the resident's weight history for comparison. CNA #4 explained that if a resident needed to be re-weighed, the nurse would instruct the CNA to obtain the weight at that time. CNA #4 stated that the nurse would put the weights in the electronic medical record (EMR).

On 2/11/25 at 9:56 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #3) who she was the nurse for Resident #51 that day. LPN #3 stated that the nurse would put the residents who needed weights

on the daily schedule, the CNA would obtain the weight, and the nurse would enter the weight into the EMR. If there was a significant weight change from the last weight, the nurse should reweigh the resident and if the weight was verified, then the nurse should contact the RD and the doctor. LPN #3 reviewed the documented weights with the surveyor and confirmed that the resident should have been reweighed and the RD and doctor should have been notified on 2/1/25 and 2/6/25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 27 315499 Department of Health & Human Services Printed: 09/08/2025 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 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

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 2/11/25 at 10:46 AM, the surveyor interviewed the RD who stated that the CNAs would obtain the weights, and the nurse would document the weights in the EMR. The RD explained that if a resident had a Level of Harm - Minimal harm or weight change since the last weight, a re-weight should be obtained immediately to confirm if the weight was potential for actual harm accurate. The RD further stated that for true significant weight losses, the nurse would notify the RD and the doctor. The RD stated she was unaware of the weight obtained on 2/1/25, 2/6/25 and 2/10/25. The RD Residents Affected - Few stated that on 1/27/25 she had increased the residents supplement to 2 times a day and had placed the resident on weekly weights and to monitor the resident's intake.

On 2/11/25 at 11:33 AM, LPN #3 stated that she and CNA#4 reweighed the resident in the wheelchair and

the weight obtained was 117.8 lbs. The RD and the doctor was made aware of the weight change.

A review of the Dietician Note (DN), dated 2/12/25, the RD questioned the accuracy of the above weights.

The note reflected that the weight loss likely due to a decline in intake and limited acceptance of prior supplement. The resident continued with fair appetite, consuming 25-50% of 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)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 27 315499 Department of Health & Human Services Printed: 09/08/2025 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 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

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 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 37547

Residents Affected - Some Complaint #NJ179408

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure a.) that the wound treatment cart was locked when not in use b.) accountability for the completion of the narcotic shift-to-shift count logs in accordance with the facility policy b.) an accurate account of the administration and documentation of controlled medications c.) properly dispose of medications at the time of resident refusal and d.) that expired medical supplies were not available for use in resident care in the medication storage room and in the emergency crash cart.

This deficient practice was identified during the medication storage task for 1 of 2 medication carts on 1 of 4 nursing units (Rehab 1 Nursing Unit), 1 of 2 medication rooms (Rehab 2 Nursing Unit Medication Room), and

the Rehab 1 Nursing Unit Emergency Treatment Cart and was evidenced by the following:

1. On [DATE REDACTED] at 10:36 AM, the surveyor, in the presence of Licensed Practical Nurse (LPN) #5, observed that the wound treatment cart was not locked. When interviewed, LPN #5 stated that she had just completed

a wound treatment and had forgotten to lock the cart. LPN #5 stated that it was important to lock the Wound Treatment Cart when finished to ensure that no one accessed it.

2. On [DATE REDACTED] at 10:37 AM, in the top drawer of the medication cart, the surveyor observed a Lidocaine Patch (a topical pain relief patch) that was previously opened and was dated ,d+[DATE REDACTED]. When interviewed, LPN #5 stated that the Lidocaine Patch was endorsed by the ,d+[DATE REDACTED] nurse because the resident did not want

it at the time it was last scheduled. LPN #5 was unable to state which resident the Lidocaine Patch was ordered for.

3. On [DATE REDACTED] at 10:45 AM, the surveyor, in the presence of Licensed Practical Nurse (LPN) #5, reviewed the shift-to-shift Controlled Drugs-Count Record and the surveyor observed that on [DATE REDACTED] at 7:00 PM, the Nurse on Signature (oncoming nurse) was blank and the Nurse Off Signature (outgoing nurse) was signed by LPN #5. There was no further documentation on the form to indicate that the shift-to-shift narcotic count was performed on [DATE REDACTED]. LPN #5 stated that when she came in the outgoing nurse reviewed the Controlled Drug-Count Record and the oncoming nurse reviewed the narcotic count. LPN #5 stated that on [DATE REDACTED], she was the oncoming nurse and LPN #6 was the outgoing nurse who had forgotten to sign. LPN #5 stated that today both she and LPN #6 had completed the shift-to-shift narcotic count, but they had both forgotten to sign. LPN #5 further stated that there were no reported discrepancies identified in the narcotic count.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 27 315499 Department of Health & Human Services Printed: 09/08/2025 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 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

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 0755 Further review of the Controlled Drugs-Count Record revealed that on [DATE REDACTED], at 7:00 AM, the Nurse on Signature was blank, and a signature was noted in the space allotted for the Nurse Off Signature. On [DATE REDACTED] Level of Harm - Minimal harm or at 7:00 AM, the Nurse on Signature was blank, and a signature was noted in the space allotted for the Nurse potential for actual harm Off Signature. On [DATE REDACTED] at 7:00 PM, a signature was noted in the space allotted for the Nurse on Signature and the Nurse Off was blank. LPN #5 stated that it looks like they forgot to sign. LPN #5 stated that both Residents Affected - Some nurses should sign the Controlled Drugs-Count Record when they are finished counting.

4. At that time, in the presence of LPN #5, the surveyor reviewed the controlled substance logs for the Rehab 1 Nursing Unit medication cart and noted the following: Resident #201's prescription card (BINGO card, medication packaged in a blister package with cardboard backing) containing Tramadol HCL 50 MG (Half Tab=25 MG) tablets (opioid pain reliever) contained 20 tablets, but the declining inventory log indicated that there were 21 tablets remaining. LPN #5 stated that she must have gotten distracted and had forgotten to sign it out. LPN #5 stated that it was important to sign the medication out on the declining inventory sheet at

the time of administration to ensure that the narcotic count was correct. LPN #5 stated that she did sign the medication out as administered on the resident's Medication Administration Record (MAR).

Resident #201's prescription card containing Pregabalin 75 MG Capsule (used to treat nerve pain) contained 23 capsules, but the declining inventory log indicated that there were 24 capsules remaining. LPN #5 stated that she must have gotten distracted and had also forgotten to sign the dosages out.

On [DATE REDACTED] at 12:01 PM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #1 who stated that the oncoming nurse should count the narcotics, and the outgoing nurse should review the Controlled Drugs-Count Record Book to make sure that the narcotic count is right, and the medications are not compromised. LPN/UM #1 stated that the nurses were required to sign the book when they come in and when they go out. LPN/UM #1 stated that the Consultant Pharmacist came into the facility monthly and audited the narcotic book. LPN/UM #1 stated that the narcotic count has always been correct. LPN/UM # 1 stated that she would think that the nurses had not counted if they had not signed the Controlled Drugs-Count Record and narcotics could be missing.

At that time, LPN/UM #1 further stated that narcotics should be signed for when they were removed from the medication cart. LPN/UM #1 stated that it was good practice because the narcotic count may be off if the nurse did not sign the book and only signed the Medication Administration Record (MAR). At that time, LPN/UM #1 further stated that the wound treatment cart should be locked at all times so that patients or families can not take anything out of it.

On [DATE REDACTED] at 1:52 PM, the surveyor interviewed the Director of Nursing (DON) who stated that the nurses should count their controlled drug in the medication cart at the end of the shift for accuracy of narcotics. The DON further stated that the Unit Manager was responsible to review the narcotic book weekly for signatures being captured and to ensure accuracy of the documentation.

At that time, the DON further stated that narcotic medication should be signed out upon removing it from the medication cart in the book. The DON stated that it was not sufficient to just sign the medication out on the Medication Administration Record (MAR) because you are required to sign the medication out when it is removed. The DON stated that the mismanagement of narcotics or missing dosages were a concern if narcotics were not signed out from the cart at the time of removal.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 27 315499 Department of Health & Human Services Printed: 09/08/2025 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 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

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 0755 On [DATE REDACTED] at 11:53 AM, the surveyor interviewed the Consultant Pharmacist (CP) who stated that she was at the facility last week and reviewed three random medication carts for the narcotic count. The CP stated Level of Harm - Minimal harm or that she checked the signature logs at the back of the book and sometimes there was one missed signature potential for actual harm here and there. The CP stated that she had not performed medication pass observations at the facility as it was not part of their contract, but will going forward, as it was just initiated after surveyor inquiry. Residents Affected - Some

On [DATE REDACTED] at 11:30 AM, the DON provided the surveyor with a Medication Pass Observation dated form dated [DATE REDACTED], which revealed that LPN #5 had not received a medication pass observation on that date because the former CP indicated that LPN #5 had finished passing medications early due to a low census, and instead received a medication pass in-service with LPN #5 and reviewed administration of all types of meds. The facility failed to provide the surveyor with documented evidence that LPN #5 had received a medication pass observation when requested.

On [DATE REDACTED] at 2:41 PM, the DON stated that she was not aware that the CP was not doing medication pass

observations at the facility and that they needed to be requested.

At that time, the DON further stated that she was responsible to ensure that LPN/UM #1 completed the narcotic record review and had not informed the LPN/UM #1 that it was her responsibility to do so. The DON further stated that she was not aware of the frequency that the CP performed narcotic record review.

45589

5.) On [DATE REDACTED] at 10:03 AM, during a tour of the Rehab 2 Nursing Unit Medication Room, in the presence of LPN/UM #1, the surveyor observed the following expired supplies in the second drawer adjacent to the sink: culture swabs with an expiration date of [DATE REDACTED]; and greater than 25, disposable sampling swabs with an expiration date of [DATE REDACTED].

On [DATE REDACTED] at 10:23 AM, during a tour of the Rehab 1 Nursing Unit in the presence of LPN/UM #1, the surveyor observed the following expired items in the emergency crash cart:

three suction connection tubing with an expiration date of [DATE REDACTED];

one ChloraPrep swab with an expiration date of ,d+[DATE REDACTED];

one dial-a-flow tubing (a medical device used to control the flow of fluid via an intravenous line) dated [DATE REDACTED];

one box of size medium disposable examination gloves with an expiration date of ,d+[DATE REDACTED];

one box of size large nitrile disposable examination gloves with an expiration date of ,d+[DATE REDACTED].

On [DATE REDACTED] at 10:28 AM, the surveyor interviewed LPN/UM #1 who stated that supplies should be within date to ensure proper function. LPN/UM #1 also stated that the night shift 11:00 PM to 7:00 AM nurse was responsible to the check the crash carts and that a staff member from Central Supply checked the carts monthly for expired items.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 27 315499 Department of Health & Human Services Printed: 09/08/2025 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 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

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 0755 On [DATE REDACTED] at 12:15 PM, during tour of the first floor common area, inside of an emergency crash cart the following expired items were observed: two boxes of disposable examination gloves with an expiration date Level of Harm - Minimal harm or of ,d+[DATE REDACTED]. potential for actual harm

A review of the facility's undated Administering Medications policy included: Medications should be Residents Affected - Some administered in a safe and timely, manner, and as prescribed.

.The Director of Nursing Services will supervise and direct all nursing personnel who administer medications and/or have related functions .

.During administration of medications, the medication cart will be kept closed and locked when out of sight of

the medication nurse or aide .

A review of the facility's undated Narcotic Count Policy included: Purpose: To establish guidelines for the accurate and secure shift-to-shift counting of narcotics.

.The facility (name redacted) shall ensure the secure and accurate counting of narcotics at each shift 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:,d+[DATE REDACTED].7 ( c ); 29.2(d)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 27 315499 Department of Health & Human Services Printed: 09/08/2025 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 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

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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41260 potential for actual harm Based on observation, interview, and review of pertinent facility documents, it was determined that the facility Residents Affected - Some failed to ensure food served to residents was palatable.

This deficient practice was identified for 5 out of 5 residents (Resident # 29, #31, #37, #74 and #75) who attended the Resident Council meeting conducted by the survey team on 2/10/25 and confirmed during the lunchtime meal service on 2/11/25 for 1 of 4 nursing units (Skilled 1) tested for food palatability.

This deficient practice was evidenced by the following:

On 2/7/25 at 10:00 AM, during the initial tour of the Skilled 1 nursing unit, Resident #29 stated that the food was the worst and the meat was tough.

At 10:13 AM, Resident #37 stated that the food was cold, and the meat was tough and inedible.

At 10:34 AM, Resident # 31 stated that the food was inedible, cold, and the meat was tough.

On 2/10/25 at 10:37 AM, the surveyor conducted a resident council meeting with five alert and oriented residents (Resident # 29, #31, #37, #74 and #75). All five residents stated the food was not good and the meat was tough. All five residents further stated that they had previously complained about the food at the monthly resident council meetings, but nothing had improved. Resident #29 stated that the chicken is served

in a hard lump and cannot cut the chicken. Resident #75 added that the food stinks.

On 2/11/25 at 12:00 PM, the Director of Culinary (DC) provided the survey team with two meal trays from the Skilled 1 nursing unit satellite kitchen - a regular consistency tray and a pureed consistency tray. Three surveyors tasted the food and observed the following:

Regular Sloppy [NAME] - no concerns with palatability

Regular Cauliflower - tasted bland and mushy

Regular Peas/Carrots - tasted bland and the peas were hard

Pureed Sloppy [NAME] - tasted pasty and the flavor did not match the regular texture sloppy joe

Pureed Peas/Carrots - tasted bland

Mashed Potatoes - tasted bland and floury

On 2/11/25 at 1:08 PM, the surveyor informed the Licensed Nursing Home Administrator (LNHA), in the presence of the Director of Nursing (DON), of the above findings. The LNHA stated that everyone's taste is different, but would prefer the residents to enjoy their meals.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 27 315499 Department of Health & Human Services Printed: 09/08/2025 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 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

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 0804 Review of the facility's Food Presentation policy, undated, included, Policy: to ensure that food is served in a visually appealing, safe, and consistent manner; to have the food taste and look good. Level of Harm - Minimal harm or potential for actual harm NJAC 8:39-17.4(a)

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 27 315499 Department of Health & Human Services Printed: 09/08/2025 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 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

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 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41260

Residents Affected - Many Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to maintain kitchen sanitation in a safe and consistent manner to prevent food borne illness.

This deficient practice was evidenced by the following:

On [DATE REDACTED] at 9:50 AM, the surveyor conducted an interview with the Director of Culinary (DC) prior to the initial tour of the kitchen. The DC stated that items stored in the refrigerators and freezers should be labeled and dated with the received date, the opened dated, and the use-by date. The DC further stated that dishware should be inverted and air dried after washing.

On [DATE REDACTED] at 10:18 AM, the surveyor, accompanied by the DC, observed the following in the kitchen:

In the Meat Refrigerator:

1. A shallow two-inch hotel pan of tilapia which was sealed with plastic wrap. The pan was not labeled to identify the food item or dated with a use-by date. At that time, the DC discarded the tilapia.

In the Dairy Refrigerator:

2. Asiago cheese which was re-sealed with plastic wrap with a use-by date of [DATE REDACTED]. The DC discarded the cheese.

3. A pan of marinara which was sealed with plastic wrap with a use-by date of [DATE REDACTED]. The DC discarded the marinara.

4. A one-gallon container of creamed herring which was previously opened. The container was not labeled or dated with an opened or use-by date. The DC discarded the container of creamed herring.

5. A 16-ounce jar of capers which was re-sealed with plastic wrap. The jar was not labeled or dated with an opened or use-by date. The DC discarded the jar of capers.

In the Dairy dish drying area:

6. Seven sixth pans stacked on the drying rack which were wet nested. The surveyor lifted the top pan which revealed liquid between the pans.

7. Three third pans stacked on the drying rack which were wet nested. The surveyor lifted the top pan which revealed liquid between the pans.

In the Meat dish drying area:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 27 315499 Department of Health & Human Services Printed: 09/08/2025 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 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

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 0812 8. Two stacks of hotel pans on the drying rack which were wet nested. The surveyor lifted the top pans of each stack which revealed liquid between the pans. Level of Harm - Minimal harm or potential for actual harm On [DATE REDACTED] at 9:33 AM, the surveyor, accompanied by Dietary Service Aide (DSA) #1, observed the following

in the freezer portion of the refrigerator located in the Rehab 1 dining room: Residents Affected - Many 9. A three-gallon tub of vanilla ice cream. The lid of ice cream tub was lifted and not properly sealed. The container was not labeled with an opened or use-by date.

10. A three-gallon tub of strawberry ice cream. The lid of the ice cream tub was lifted and not properly sealed. The container was not labeled with an opened or use-by date.

11. Four small, disposable cups covered with lids. The DSA identified the cups as ice cream which was previously portioned out and prepared. The containers were not labeled with a use-by date.

At that time, DSA #1 discarded the ice creams.

On [DATE REDACTED] at 9:44 AM, the surveyor, accompanied by DSA #2, observed the following in the refrigerator located in the Skilled 2 dining room:

12. A 46-ounce container of nectar thick water which was labeled with a use-by date of [DATE REDACTED].

13. A 46-ounce container of nectar thick lemon-flavored water which was labeled with a use-by date of [DATE REDACTED].

At that time, DSA #2 discarded the containers and stated that the DSAs and dietary supervisors were responsible for maintaining the refrigerators in the dining rooms.

On [DATE REDACTED] at 9:52 AM, the surveyor, accompanied by DSA #3, observed the following in the refrigerator located in the Rehab 2 dining room:

14. Three 46-ounce containers of nectar thick lemon-flavored water which had an expiration date of [DATE REDACTED].

15. A 46-ounce container of nectar thick water which had an expiration date of [DATE REDACTED].

At that time, DSA #3 discarded the containers and stated the DSAs and dietary supervisors were responsible for checking the refrigerators in the dining rooms.

On [DATE REDACTED] at 10:30 AM, the surveyor interviewed the DC who stated the DSAs were responsible for maintaining the refrigerators in the nursing unit dining rooms. The DC further stated that the DSAs should check the refrigerators to ensure opened items are labeled with the opened date and use-by date. The DC also stated that the DSAs should discard items that are expired or past the use-by date.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 27 315499 Department of Health & Human Services Printed: 09/08/2025 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 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

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 0812 On [DATE REDACTED] at 1:08 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated she expected food items to be labeled and dated appropriately, food items to be discarded upon Level of Harm - Minimal harm or expiration, and pans to be dried according to regulation. The LNHA further stated the dietary staff were potential for actual harm responsible for maintaining the dining room refrigerators and should label and date food items appropriately and discard expired food items. Residents Affected - Many

A review of the facility's Operational Standards Refrigerator policy, revised ,d+[DATE REDACTED], 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 ,d+[DATE REDACTED], included, All sanitized items must be air dried and cooled completely before stacking and storing.

NJAC 8:,d+[DATE REDACTED].2(g)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 27 315499 Department of Health & Human Services Printed: 09/08/2025 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 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

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 51707 potential for actual harm Based on observation, interview, and review of facility documents, it was determined that the facility failed to Residents Affected - Some maintain proper infection control practices to ensure a.) staff performed appropriate hand hygiene during meal service for 1 of 4 dining rooms observed (First floor Skilled Nursing Unit ), b.) an ice scooper was used to obtain ice from the ice machine during dining observation of 1 of 4 dining rooms observed (First floor skilled nursing unit), c.) ensure respiratory equipment was stored in an appropriate way to prevent the spread of infection for 1 of

4 residents reviewed for use of respiratory equipment (Resident # 18) and d.) enhanced barrier precautions (EBP) was initiated for 1 of 4 residents (Resident #31) reviewed for infection control.

This deficient practice was evidenced by the following:

1.) On 2/10/25 at 12:31 PM, the surveyor observed the lunch meal service in the first-floor skilled nursing unit dining room. The surveyor observed the Dietary Service Aide (DSA#5) had removed dirty plates from an unsampled resident at Table #5, scraped the food form the plate into the trash, then proceeded to go into the refrigerator, removed a bottle of juice, poured the juice into a cup and served this juice to another unsampled resident without performing hand hygiene (HH).

On 2/11/25 at 8:12 AM, the surveyor observed the following during the breakfast meal service in the first-floor skilled nursing unit dining room.

1. DSA #5 cleaned a blue plastic tray with a rag, then poured coffee for Resident # 74, added cream and sweetener and placed a lid on the coffee cup without performing HH.

2. DSA #5 removed dirty dishes from another table and placed in the cart with the dirty dishes without performing HH.

3.DSA #5 served eggs and toast and jelly to Resident #55 without performing HH.

4. DSA #5 served oatmeal to Resident #29 without performing HH.

5.DSA #5 went to the refrigerator, removed a carton of milk, poured the milk into Resident #54's oatmeal bowl, without performing HH.

6. DSA #5 served the oatmeal to Resident #54, without performing HH.

7. DSA #5 walked to the refrigerator, removed a carton of honey thickened milk, and walked into the satellite kitchen area, poured the thickened milk into the oatmeal, added in sugar and stirred the oatmeal then served Resident #34 the oatmeal with performing HH

8. DSA #5 served oatmeal to Resident #71 without performing HH.

9. DSA #5 poured juice for Resident #34, then served an omelet and toast to Resident #74 without performing HH.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 27 315499 Department of Health & Human Services Printed: 09/08/2025 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 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

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 10. DSA #5 served pancakes to Resident #51 without performing HH.

Level of Harm - Minimal harm or 11. Resident #74 requested his/her toast be buttered, DSA #5 then donned (put on) gloves to both hands, potential for actual harm buttered the toast, then removed the gloves without performing HH.

Residents Affected - Some 12. DSA #5 served an omelet to an unsampled resident without performing HH.

13. DSA#5 served Resident #51 pancakes without performing HH.

14. DSA#5 served Resident #29 pancakes without performing HH

On 2/11/25 at 8:55 AM, the surveyor interviewed DSA #5 who stated that hand hygiene should be completed between serving residents. DSA #5 further stated that she washed her hands with soap and water in the sink

in the satellite kitchen.

On 2/11/25 at 10:03 AM, the surveyor interviewed the Infection Preventionist (IP) who stated that hand hygiene should be performed in the dining room in between serving the residents their meals.

On 2/11/25 at 10:55 AM, the surveyor interviewed the Director of Nursing (DON) who stated that hand hygiene should be completed in between serving residents their meals. The DON further stated that it was important to use hand hygiene between serving residents to prevent infection or contamination.

On 2/11/25 at 12:15 PM, the surveyor observed the following during the lunch meal in the first-floor skilled unit dining room:

1. DSA #5 served the lunch meal to an unsampled resident without performing HH.

2. At 12:18 PM, DSA #5 assisted Resident #31 put on his/her sweater then served soup to several unsampled residents without performing HH.

3. At 12:25 PM, DSA #5 scraped dirty dishes into the trash, placed the dirty dish into the dishpan then served Resident #37 their lunch meal without performing HH.

4. At 12:27 PM, DSA #5 scraped dirty dishes into the trash, placed the dirty dishes into a dishpan then served Resident #29 their meal without performing HH.

A review of facility's Handwashing/Hand Hygiene policy, reviewed December 2024 included, Indications for hand hygiene included: a. immediately before touching a resident, .c. after touching a resident, after touching

a resident's environment, and .g, immediately after glove removal.

A review of facility's Culinary Services Hand Washing Procedure revised May 024, included each employee will wash their hands frequently to eliminate visible dirt and to reduce bacterial load and cross contamination Before: .b. beginning a new task .and After O. removing or changing gloves, P. scraping trays, Q. physical contact with a residents, . and U. touching equipment such as, refrigerator doors or utensils that have not been cleaned or sanitized.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 27 315499 Department of Health & Human Services Printed: 09/08/2025 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 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

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 2.) On 02/10/25 at 12:20 PM, the surveyor observed the following during the lunch meal service in the first-floor skilled nursing unit dining room. The surveyor observed DSA #4 used a plastic drinking cup and Level of Harm - Minimal harm or with her bare hand, reached into the ice machine and scooped the ice into the plastic cup. potential for actual harm At 12:29 PM, the surveyor observed DSA #4 again used a plastic drinking cup with her bare hand, reached Residents Affected - Some into the ice machine and scooped the ice into the plastic cup.

On 2/11/25 at 9:24 AM, the surveyor interviewed DSA #4 who stated that an ice scooper should be used to dispense ice form the ice machine. DSA #4 further stated that a plastic cup should never be used in the ice machine to obtain the ice.

On 2/11/25 at 12:22PM, the surveyor observed DSA #5 during the breakfast meal service in the first-floor skilled nursing unit dining room. The surveyor observed DSA #5 used a resident plastic drinking cup with her bare hand, reached into the ice machine and scooped the ice into the plastic cup.

On 2/11/25 at 10:55 AM, the surveyor interviewed the DON who stated that an ice scooper should be used when getting ice from the ice machine. The DON further stated that it was important to use an ice scooper to remove ice from the ice machine to prevent the spread of infection or contamination.

On 1/13/25, the facility provide the surveyor an in-service titled Ice Scoop Training which included that ice scoops are to be used in all ice machines for safety .2. Ice scoops are the only tool to use when getting ice from the ice machine, 3. DO NOT use- glasses, cups, spoons, plastic cups or anything that is NOT an ice scoop.

A review of the facility's Infection Prevention and Control policy revised December 2024, included S. Infection prevention and control program (IPCP) refers to a program (including surveillance, investigation, prevention, control and reporting) that provides a safe, sanitary and comfortable environment to help prevent

the development and transmission of infection.

45589

3.) On 2/7/25 at 10:37 AM, during the initial tour of the first-floor skilled nursing unit, the surveyor observed Resident #18 awake and alert sitting in his/her wheelchair in their room. The surveyor observed a nebulizer mask (a device that fits over the nose and mouth to deliver medication to the lungs) lying directly on the bedside table, not stored in a plastic bag.

On 2/11/2025 at 10:09 AM, the surveyor observed Resident #18 sitting in his/her wheelchair in his/her room with their eyes closed. The surveyor observed a nebulizer mask lying directly on the bedside table, not stored in a plastic bag

On 2/11/2025 at 10:10 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #3) who stated Resident #18 used the nebulizer as needed and would ask for it if needed. LPN #3 also stated that after using the nebulizer mask, the mask should be cleaned and then stored in a plastic bag. LPN #3 confirmed that the nebulizer mask in Resident #18's room was not stored in a plastic bag. LPN #3 further stated that it was important to store the nebulizer mask, when not in use, in a plastic bag for infection control.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 27 315499 Department of Health & Human Services Printed: 09/08/2025 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 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

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 2/11//2025 at 1:40 PM, the surveyor reviewed the medical record for Resident #18.

Level of Harm - Minimal harm or A review of the admission record, an admission summary, revealed the resident had diagnosis which potential for actual harm included, congestive heart failure, dementia, and anxiety.

Residents Affected - Some A review of the quarterly Minimum data Set (MDS), an assessment tool, dated 1/21/25, included the resident had a Brief Interview for mental status (BIMS) score of 15 out of 15, which indicated the resident's cognition was intact.

A review of the the physician's orders (PO) for Resident #18, which included the following:

A PO, dated 1/30/2025, for Albuterol Sulfate Inhalation Nebulization Solution 1.25 Milligram (MG)/3 milliliters (Albuterol Sulfate)-1 vial inhale orally via nebulizer every 6 hours as needed for wheezing.

A review of the individual comprehensive care plan (ICCP) included a focus area, dated 11/9/2023, that the resident had Congestive Heart Failure. Interventions included: to give medications (meds) as ordered.

On 2/12/2025 at 12:15 PM, the surveyor interviewed the DON who stated that after use, the nebulizer should be cleaned, dry at room air, then stored and maintained in a plastic bag. The DON also stated that this was important to store the nebulizer mask in a plastic bag when not in use to prevent contamination from the environment.

A review of the facility's undated Nebulizer Therapy Policy included, Procedures .3. Equipment Maintenance and Safety .Nebulizer mask and tubing shall be stored in a plastic bag when not in use and replaced weekly.

41072

4.) On 02/07/25 at 10:34 AM, the surveyor observed Resident #31 awake and alert, sitting in a wheelchair in their room. The surveyor observed an Intravenous (IV) pole located in the resident's room. Resident #31 stated that he/she had an IV inserted in his/her right upper arm about four (4) days ago for a Urinary Tract Infection (UTI). No Enhanced Barrier Precautions (EBP) signage was observed posted inside or outside the resident's room.

On 2/10/25 at 12:22 PM, the surveyor observed Resident #31 not in his/her room. At that time, the surveyor observed an empty bag of IV antibiotic medication hanging from the IV pole in the resident's room. No EBP signage was observed posted inside or outside the resident's room.

The surveyor reviewed the medical record for Resident #31.

A review of the Admission Record, an admission summary, revealed the resident had diagnosis which included, Multiple Sclerosis (a chronic, autoimmune disease that affects the central nervous system) and urinary tract infection.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 27 315499 Department of Health & Human Services Printed: 09/08/2025 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 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

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 A review of the resident's quarterly MDS, dated [DATE REDACTED], included the resident had a BIMS score of 15, which indicated the resident's cognition was intact. Further review of the MDS revealed the resident was always Level of Harm - Minimal harm or incontinent of urine. potential for actual harm

A review of the ICCP included a focus area, dated 1/31/2025, that the resident had an infection of the urinary Residents Affected - Some tract infection. Interventions included: administer antibiotic as per medical doctor (MD) orders. The care plan did not include EBP.

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

A PO, dated 2/4/25, for midline placement.

A PO, dated 2/4/25, to check midline site every shift for signs and symptoms of infection every shift

A PO, dated 2/3/25, to start on 2/4/25 for Aztreonam Injection Solution Reconstituted 1 Gram (an antibiotic). Use 1 gram intravenously two times a day related to UTI for 7 days, with end date of 2/11/25.

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)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 27 315499