Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Leisure Chateau Rehabilitation during CMS and state inspections, most recent first.
Laundry staff failed to perform hand hygiene immediately after removing PPE used while handling soiled linen before entering the clean laundry area and touching clean equipment and surfaces. An LT was observed loading soiled bed pads and mechanical lift slings into a washer, returning the soiled cart, removing PPE, and then moving into the clean area to retrieve and push a clean cart without washing hands. The LM and IP confirmed the lapse, and facility policy required hand hygiene after handling soiled linen and before handling clean linen.
Failure to Provide Advance Directive Information on Admission: The facility did not ensure that two residents were informed of and given written information about their right to formulate advance directives upon admission. One resident had moderate cognitive impairment on MDS review, and both residents’ records lacked completed POLSTs or other advance directive documentation. One resident stated he/she was not provided advance directive information or resources on admission, and an LPN UM confirmed the absence of valid POLST documentation.
Failure to provide proper NOMNOC notification occurred when a resident with severe cognitive impairment signed the SNF ABN instead of the representative. The resident had a BIMS score of 6, and the SSD stated residents with BIMS scores below 13 should not sign these forms. The DON agreed it was inappropriate for a resident with this level of impairment to sign the SNF ABN.
Improper Use of a Physical Restraint: A resident with Huntington's disease and moderately impaired cognition was placed in a Posey Net Bed after becoming disruptive and attempting to ambulate from a wheelchair. The EMR and care plan identified the Posey Net Bed as a restraint, and an LPN stated staff should have tried other interventions first, such as redirecting the resident, calling the spouse, or offering a snack. The LPNUM and DON stated restraints should not be used for resident behaviors and are only for safety and care.
Failure to provide bed hold and transfer notices after hospital transfers for three cognitively intact residents. One resident was transferred after a fall and later for increased behaviors, another was sent out after becoming unresponsive, and a third was sent out for a change in condition; in each case, the required notice was not given to the resident or RR in a timely manner, and one notice was sent to the Ombudsman instead of the resident.
The facility failed to timely submit discharge MDS assessments for two residents. Record review showed both discharge assessments were completed but not submitted, and the MDS Coordinator stated the CMS submission coding had not been updated. The DON stated MDS assessments were expected to be submitted timely after completion.
MDS coding was inaccurate for two residents. One resident’s MDS omitted active diagnoses related to osteomyelitis, Charcot foot, and diabetic foot findings despite admission records and wound documentation showing those conditions. Another resident’s quarterly MDS failed to capture a fall that occurred during the assessment period, even though nursing notes and fall-related assessments documented the event and the MDSC confirmed the omission.
A resident with Huntington's Disease and moderate cognitive impairment had no current order for side rails and a nursing evaluation stating side rails were not necessary, yet a side rail was observed in the up position on the bed during multiple observations. The LPNUM said the resident had been placed in a bed that already had a side rail after a unit change, and the DON stated residents should not have bedrails unless assessed to require them.
A surveyor identified deficiencies in food handling and sanitation practices at a facility. A dented can of beans was found in dry storage, and undated sliced turkey and bread were discovered in the meat walk-in. Plates and silverware were improperly stored, exposing them to contamination. Additionally, wet nesting of plates was observed, indicating improper dishwashing practices. The facility's policies on labeling, storage, and dishwashing were reviewed.
The facility failed to provide all menu items during a lunch meal, as observed by surveyors. The main entree and alternate meal were missing key components, such as zucchini stuffed tomato and potato salad, which were replaced with yellow squash and diced tomato. The Food Service Director acknowledged the oversight, noting that the potato salad was not prepared due to it not being listed on the kitchen sheets.
The facility failed to maintain a sanitary environment by leaving one of the garbage dumpsters uncovered, exposing bagged trash. The Food Service Director acknowledged that maintaining the garbage area is a joint responsibility between dietary, maintenance, and housekeeping. The facility's policy requires dumpsters to be covered to prevent the spread of bacteria, pests, and odor.
Laundry Hand Hygiene Not Performed After Handling Soiled Linen
Penalty
Summary
The facility failed to ensure laundry staff performed hand hygiene immediately after removing PPE worn while handling soiled linen before contacting clean laundry equipment and areas. During a tour of the laundry area with the Laundry Manager, Laundry Technician 1 was observed transporting a commercial laundry cart containing soiled washable bed pads and mechanical lift slings, filled above the rim, from the soiled laundry area to the washer. The technician donned disposable PPE, loaded the items into a front-loading washing machine, then pushed the soiled laundry cart back into the soiled laundry area, removed gloves, gown, and mask, and exited the soiled area. Without performing hand hygiene, the technician proceeded into the clean laundry area, retrieved a clean laundry cart, and pushed the cart toward a dryer while touching clean equipment and surfaces. The Laundry Manager stated the proper process after handling soiled laundry included removing PPE and performing hand hygiene immediately afterward, and acknowledged the technician did not do so. The Infection Preventionist stated the facility follows CDC infection control guidelines, including standard precautions and hand hygiene, and that failure to perform hand hygiene after handling soiled laundry placed all residents at risk for cross-contamination. Facility policy required washing hands after handling soiled linen and before handling clean linen.
Failure to Provide Advance Directive Information on Admission
Penalty
Summary
The facility failed to ensure that residents were informed of and provided written information about their right to formulate advance directives upon admission for two residents, R95 and R201. Review of R95’s admission record showed admission to the facility with no advance directive reflected in the resident header. R95’s MDS showed a BIMS score of 8 out of 15, indicating moderate cognitive impairment, and a later SCIS MDS showed a prior BIMS of 15 out of 15. R95’s care plan indicated full code status and referenced following instructions as detailed on a POLST, but the EMR misc tab did not contain a NJ POLST or other advance directive documentation specifying healthcare wishes. There was no evidence that the facility informed R95 of or provided written information regarding advance directives upon admission. Review of R201’s admission record also showed no advance directive reflected in the resident header. R201’s care plan indicated full code status and referenced following instructions as detailed on a POLST, but the EMR misc tab did not contain a NJ POLST or other advance directive documentation specifying healthcare wishes. During interview, R201 stated a preference for full code status and reported not being provided information or resources regarding advance directives upon admission. The LPN Unit Manager stated the admission nurse is responsible for discussing resident preferences regarding life-sustaining treatment during admission and documenting those preferences on the POLST form, which must be signed and dated by the resident or representative and the physician to be valid. Review of both residents’ records with the LPN Unit Manager confirmed the absence of completed POLST forms or other advance directive documentation.
Failure to Notify Responsible Party for Medicare Non-Coverage
Penalty
Summary
The facility failed to ensure Notice of Medicare Non-Coverage (NOMNOC) notification was provided and that the responsible party was notified for one resident reviewed for beneficiary notification. Review of the resident’s admission record showed she was admitted to the facility on [DATE]. Her quarterly MDS, with an ARD of 02/16/26, showed a BIMS score of 06 out of 15, indicating severe cognitive impairment. Review of the SNF Beneficiary Notification Review form showed the Medicare Part A skilled services start date was 01/21/26 and the last day covered was 03/06/26, and that the resident signed the SNF ABN form on 03/04/26. During interview, the SSD stated residents with a BIMS lower than 13 should not sign their SNF ABN forms because of impaired cognition, and said the resident’s daughter told her to allow the resident to sign the form, but she had no documentation of that interview. The DON stated it was inappropriate for staff not to allow the representative to sign the SNF ABN for a resident with a BIMS of six and agreed it was inappropriate for the resident to sign.
Improper Use of a Physical Restraint
Penalty
Summary
The facility failed to ensure that one resident was free from the use of a physical restraint when Resident 125 was placed in a Posey Net Bed. The resident was admitted with Huntington's disease and had a quarterly MDS showing a BIMS score of 9 out of 15, indicating moderately impaired cognition. The resident's care plan stated, "I am in a posey net bed for increased safety/decrease falls risk," and the EMR classified the Posey Net Bed as a restraint. A nurse's note documented that the resident came out of the room without pants on, was returned to the room, and then attempted to ambulate out of the wheelchair, after which the resident was placed in the Posey Net Bed for safety. During interviews, the LPN stated that Posey Net Beds were considered a restraint and that staff should try different interventions when a resident is disruptive or unable to be redirected, such as calling the resident's wife or offering a snack. The LPN also stated it was not appropriate to place a resident in a Posey Net Bed because they could not be redirected, while the LPNUM and DON stated restraints should not be used for resident behaviors and are for safety only, not for staff convenience. The facility policy stated restraints should only be used after other alternatives have been tried unsuccessfully and never for discipline, staff convenience, or prevention of falls.
Failure to Provide Bed Hold and Transfer Notices After Hospital Transfers
Penalty
Summary
The facility failed to ensure that three residents and their resident representatives were provided with a written bed hold policy and transfer notice after emergent hospital transfers. R10 was cognitively intact with a BIMS score of 15 out of 15 and was transferred to the hospital on 12/10/25 after a fall with an abrasion to the left side of the head, then returned later that morning; progress notes showed the facility called a contact on file and left a message, but no return call was documented. R10 was again sent to the ER on 12/13/25 for increased behaviors and returned later that day, and the Transfer/Bed hold notice was not provided for either visit. R12 was also cognitively intact with a BIMS score of 15 out of 15 and was transferred to the hospital on 02/23/26 after being unresponsive to verbal and tactile stimulation, then returned to the facility later that day. The Transfer/Bed hold notice was not sent to the POA until 03/10/26, although documentation showed the facility called the POA and made notification. R197, who also had a BIMS score of 15 out of 15, had a change in condition on 12/26/25 and was sent to the hospital for evaluation and treatment; the Notice of Emergency Transfer dated 12/26/25 showed it was sent to the Long-Term Care Ombudsman but not to the resident. During interview, the Receptionist stated R197 was not provided a copy of the transfer notice and one was not mailed to the emergency contact, and the DON stated the transfer notice should be provided to the resident or representative within 24 hours of discharge.
Late Submission of Discharge MDS Assessments
Penalty
Summary
The facility failed to ensure that discharge MDS assessments were submitted timely for two residents, R31 and R13, out of a sample of 40 residents. Review of R31’s record showed admission to the facility and later discharge to the hospital, and the discharge MDS with an ARD of 11/27/25 was completed but not submitted. Review of R13’s record showed admission to the facility and later discharge to the hospital, and the discharge MDS with an ARD of 11/16/25 was completed but not submitted. During interview, the MDS Coordinator stated both assessments were missed because the coding to submit to CMS had not been updated and said they should have been submitted after completion in November 2025. The DON stated that MDS assessments were expected to be submitted timely after completion. The facility policy stated comprehensive assessments are to be conducted in accordance with the criteria and timeframes established in the RAI User Manual.
MDS Coding Errors for Active Diagnoses and Falls
Penalty
Summary
The facility failed to ensure the MDS was coded accurately for two residents reviewed for MDS accuracy. For one resident, the admission record showed diagnoses including diabetes mellitus type II, chronic multifocal osteomyelitis of the left foot/ankle, and Charcot's joint of the left ankle/foot. The admission skin/wound note documented a chronic left lateral malleolus diabetic foot wound with Charcot deformity and chronic osteomyelitis, but the admission MDS with an ARD of 03/02/26 did not include osteomyelitis or Charcot's foot in Section I for active diagnoses and did not assess the resident as having a diabetic foot in Section M. During interview, the MDSC stated these diagnoses should have been listed and that the wound documentation should have included the venous/arterial ulcers, describing the omission as an oversight. For the second resident, the admission record listed spinal stenosis of the lumbar region, scoliosis, muscle wasting, and morbid obesity. The quarterly MDS with an ARD of 06/17/25 showed a BIMS score of 15 out of 15, but Section J did not reflect that the resident had sustained a fall during the assessment period. The fall-related records showed the resident slid from a wheelchair to a sitting position while trying to get back into bed on 06/01/25 and sustained no injuries. The LPN unit manager stated the resident had not had any falls since a prior fall last year, and the MDSC acknowledged the quarterly MDS did not reflect the fall that occurred during the assessment period.
Unassessed Bed Rail Left in Place for Resident
Penalty
Summary
The facility failed to ensure that one resident did not have a bed rail when the resident had not been assessed to require one. Resident R28 was admitted with Huntington's Disease and had an annual MDS showing a BIMS score of 10 out of 15, indicating moderate cognitive impairment. R28's care plan, dated 09/19/23, identified top half side rails on the right side of the bed, but the physician orders dated 03/18/26 did not include a current order for side rails. The quarterly/annual/significant change nursing evaluation packet dated 01/06/26 stated that side rails were not necessary at this time. Despite that assessment, side rails were observed on the left side of R28's bed in the up position during observations on 03/18/26, 03/19/26, and 03/20/26. The LPNUM stated awareness that the siderail assessment indicated R28 was not supposed to use side rails and explained that the resident had been placed in a bed that already had a side rail on it after changing units, but that it should be removed. The DON stated that a resident should not have bedrails unless assessed to require them. The facility policy titled Bed Safety and Bed Rails stated that the use of bed rails is prohibited unless the criteria for use have been met.
Deficiencies in Food Handling and Sanitation Practices
Penalty
Summary
The facility failed to handle potentially hazardous foods and maintain sanitation standards, as observed by a surveyor. In the dry storage area, a can of vegetarian beans was found with a significant dent, which was acknowledged by the Food Service Director (FSD) and removed to the designated dented can area. In the meat walk-in, a previously opened package of sliced turkey and a bag of sliced bread were found without dates, leading to their removal by the FSD. Additionally, plates and silverware were stored improperly, with eating surfaces exposed to potential contamination. The FSD confirmed that these items should be inverted or covered when not in use. Further observations revealed issues with dishwashing practices. Plates were found stacked while still wet, a condition known as wet nesting, which can lead to bacterial growth. The cook admitted to not allowing the plates to air dry before stacking, and the FSD directed the cook to re-wash, sanitize, and air dry the plates. The facility's policies on labeling, dating, dry storage, and handling clean equipment were reviewed, highlighting the need for proper labeling, checking of packaging conditions, and ensuring dishes are air-dried before storage.
Menu Discrepancy During Lunch Meal
Penalty
Summary
The facility failed to provide all the items listed on the menu during a lunch meal observed by the survey team. The main entree was supposed to include creamy carrot soup, cheese quesadilla, zucchini stuffed tomato, and cinnamon rice pudding, while the alternate meal was to consist of a grilled eggplant and roasted pepper sandwich, potato salad, and creamy carrot soup. However, the observed meal did not include the zucchini stuffed tomato or potato salad. Instead, the vegetable provided was yellow squash with diced tomato for both the main and alternate meals. During an interview, the Food Service Director (FSD) acknowledged the discrepancy, stating that the potato salad was not prepared because it was not listed on the sheets used by the kitchen staff. The FSD agreed that the vegetable served was not as indicated on the menu and expressed a desire to rectify the situation to avoid resident complaints. The facility did not provide a policy concerning menus, which may have contributed to the oversight.
Improper Garbage Disposal
Penalty
Summary
The facility failed to maintain a sanitary environment by not covering one of the two garbage dumpsters in the designated garbage area. During an observation, the surveyor noted that the front dumpster, which contained bagged trash, had both of its lids open, leaving the trash exposed. This area is located in the facility parking lot and is fenced in, with a residential housing complex situated directly behind it. The Food Service Director acknowledged the issue, stating that maintaining the garbage area is a joint responsibility between dietary, maintenance, and housekeeping departments. The facility's policy on garbage storage, dated September 2023, mandates that dumpsters must be covered and gates closed when not in use to prevent the spread of bacteria, pests, and odor.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lakewood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fountainview Care Center | 1 mi | ★★★★★ | 0 | 0 |
| Atlantic Coast Rehab & Health | 1.1 mi | ★★★★★ | 2 | 1 |
| Harrogate Village | 1.1 mi | ★★★★★ | 15 | 0 |
| Shore Gardens Rehabilitation And Nursing Center | 2.2 mi | ★★★★★ | 2 | 0 |
| Complete Care At Green Acres | 2.6 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.