Lions Gate

In the surveyor’s words

From the most serious findings on record at Lions Gate, in the surveyor’s own words.

• Actual harm, isolatedF689Aug 26, 2021

  Complaint Intake NJ 1 Based on interviews, record reviews, and facility policy and hospice contract review, the facility failed to ensure the resident's environment remains as free of accident hazards as is possible, and that each resident received adequate supervision and assistive devices to prevent accidents or injury for one resident (Resident #1) out of four residents reviewed for falls. Specifically, the facility failed to ensure that Resident #1 who was identified by the facility as a fall risk had his/her fall intervention which included to have bed in lowest position and fall mats in place whenever the resident was in bed and was in place before nursing staff exited the resident's room. […]

• No harm, potential for more than minimal, widespreadF812Jun 12, 2026

  Based on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices in a manner to prevent food borne illness.This deficient practice was observed and evidenced by the following:On 6/4/26 at 9:36 AM, the surveyor conducted an interview with the Chief Executive Chef (CEC) prior to the initial tour of the kitchen. The CEC stated that the kitchen was Kosher which included separate kitchens, refrigerators, freezers, and dish machines for meat and dairy. On 6/4/26 at 9:48 AM, the surveyor in the presence of the CEC and the Food Service Director (FSD) toured the kitchen and observed the following:1. On the chef's preparatory table, there was a can opener with a black sticky residue. […]

• No harm, potential for more than minimal, widespreadF812Feb 13, 2025

  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] 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] at 10:18 AM, the surveyor, accompanied by the DC, observed the following in the kitchen: In the Meat Refrigerator: 1. […]

• No harm, potential for more than minimal, patternF656Feb 13, 2025

  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. […]

• No harm, potential for more than minimal, patternF755Feb 13, 2025

  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. […]