Inspection Reports for Leisure Chateau Rehabilitation
962 River Ave, Lakewood, NJ, 08701
Back to Facility ProfileInspection Report Summary
The most recent inspection on October 11, 2024, identified deficiencies related to nutritional adequacy, staffing ratios, sanitary conditions, and several life safety code issues including fire alarm and sprinkler system maintenance. Earlier inspections showed a pattern of deficiencies involving staffing shortages, resident care concerns, infection control, and multiple life safety code violations. Complaint investigations included substantiated findings regarding restraint use and nutritional and safety concerns, but no fines or enforcement actions were listed in the available reports. Prior reports noted issues with resident rights, emergency preparedness, and equipment maintenance, with some improvements in infection control compliance during the COVID-19 pandemic. The overall trend suggests ongoing challenges with staffing and safety systems, with recent inspections continuing to cite similar types of deficiencies.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
7.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
38% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
72% occupied
Based on a October 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 175
Capacity: 243
Deficiencies: 7
Date: Oct 11, 2024
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities, including complaint investigations related to nutritional adequacy, staffing, and safety.
Complaint Details
The visit was complaint-related with multiple complaint numbers cited. The complaints involved nutritional inadequacies, staffing shortages, and safety concerns. The facility was found substantiated deficient in these areas.
Findings
The facility was found deficient in multiple areas including failure to meet nutritional needs as per menus, inadequate CNA staffing ratios, failure to maintain sanitary conditions in garbage storage, and life safety code violations such as malfunctioning horizontal sliding doors and missing sprinkler system components.
Deficiencies (7)
Menus did not meet resident nutritional needs; alternate meals were not provided as listed on the menu.
Facility failed to maintain required CNA staffing ratios on multiple dates.
Garbage storage area was not maintained in a sanitary condition; dumpsters were uncovered and gates left open.
Horizontal sliding doors failed to operate properly, posing a safety risk to residents.
Fire alarm system was not properly maintained; missing documentation and incomplete annual testing.
Sprinkler system maintenance and testing records were incomplete; missing quarterly inspections.
Electrical system maintenance records were incomplete; monthly generator testing was missed.
Report Facts
Census: 175
Total Capacity: 243
Deficiencies cited: 7
CNA staffing deficiencies: 7
Residents affected by staffing deficiency: 172
Residents affected by fire alarm deficiency: 172
Residents affected by sprinkler system deficiency: 172
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mike Cottrell | Cook | Named in relation to dishwashing and wet nesting deficiency. |
| Director of Nursing | Director of Nursing | Interviewed regarding staffing ratio requirements. |
| Assistant Administrator | Assistant Administrator | Involved in staffing and maintenance follow-up actions. |
| Maintenance Director | Maintenance Director | Involved in addressing door and fire safety deficiencies. |
Inspection Report
Annual Inspection
Census: 181
Deficiencies: 11
Date: May 12, 2023
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
Deficiencies were cited related to resident rights, Medicaid/Medicare coverage notices, safe/clean environment, notice requirements before transfer/discharge, accuracy of assessments, mobility, accident hazards, bowel/bladder care, respiratory care, and food safety.
Deficiencies (11)
Facility failed to maintain required minimum direct care staff-to-resident ratios for the day shift as mandated by the State of New Jersey for multiple weeks in 2022 and 2023.
Facility failed to follow upcoming policy changes within the timeframe provided to residents, affecting resident rights.
Facility failed to issue required beneficiary notices for Medicaid-eligible residents for discharge and Medicare non-coverage.
Facility failed to maintain a clean, comfortable, homelike environment including stained privacy curtains, peeling wallpaper, unclean blinds, and maintenance issues on the unit.
Facility failed to provide written notification of emergency transfer to resident, representative, and Ombudsman for one resident.
Facility failed to accurately code Minimum Data Set (MDS) assessments for three residents.
Facility failed to apply a physician ordered splinting device to a resident with contractures.
Facility failed to provide a resident who was a smoker with a protective device (smoke guard) while smoking.
Facility failed to appropriately store an indwelling catheter in a manner to prevent infection.
Facility failed to assure that a resident received oxygen as ordered by the physician; oxygen tank was empty and resident was not receiving ordered oxygen.
Facility failed to properly handle and store potentially hazardous foods, maintain equipment and kitchen areas to prevent microbial growth and cross contamination, and maintain adequate infection control during food service.
Report Facts
Deficiencies cited: 11
Residents present: 181
Staffing ratios: 18
Staffing ratios: 20
Staffing ratios: 20
Staffing ratios: 15
Staffing ratios: 16
Staffing ratios: 21
Staffing ratios: 21
Staffing ratios: 19
Staffing ratios: 16
Staffing ratios: 20
Staffing ratios: 19
Staffing ratios: 20
Staffing ratios: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Andrea McCrayReid | Staffing Coordinator | Interviewed regarding staffing and recruitment efforts. |
| Director of Nursing | Interviewed regarding staffing, recruitment, and nursing staff responsibilities. | |
| Food Services Director | Interviewed regarding food storage, sanitation, and kitchen conditions. | |
| Licensed Nursing Home Administrator | Interviewed regarding beneficiary notices and staffing. | |
| Social Worker | Interviewed regarding beneficiary notices and MDS coding. | |
| Licensed Practical Nurse | Interviewed regarding resident care and catheter storage. | |
| Certified Nursing Assistant | Interviewed regarding resident care and smoking supervision. | |
| Director of Activities | Interviewed regarding smoking supervision and resident safety. |
Inspection Report
Life Safety
Deficiencies: 12
Date: May 12, 2023
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 05/02/2023 and 05/03/2023 to assess compliance with Medicare/Medicaid participation requirements and the 2012 NFPA 101 Life Safety Code for existing health care occupancies.
Findings
The facility was found to have multiple deficiencies including failure to provide battery backup emergency lighting at generator transfer switches, inadequate illuminated exit signage, failure of several stairwell doors to positively latch, non-self-closing hazardous area doors, lack of fire alarm notification in outside courtyards, missing ceiling tiles affecting sprinkler coverage, improperly installed portable fire extinguishers, corridor doors with gaps allowing smoke passage, and ventilation system failures in resident bathrooms. The emergency generator testing documentation was also incomplete for certain months.
Deficiencies (12)
Failed to provide battery backup emergency lights above two emergency generator transfer switch locations.
Failed to provide and maintain illuminated exit signs in multiple locations.
Five of eight exit access stairwell doors tested did not positively latch into their frames.
Fire-rated doors to hazardous areas were not self-closing and not separated by smoke resisting partitions.
Failed to provide fire alarm notification by audible and visible signals for two outside enclosed courtyards.
Missing ceiling tiles in multiple basement rooms compromised sprinkler system coverage.
Fourteen of forty-two portable fire extinguishers were installed higher than the required maximum height of 5 feet.
Two corridor doors had gaps allowing passage of smoke.
Two sets of smoke barrier doors had gaps or failed to close properly, allowing smoke transfer.
Three resident bathroom exhaust systems were not functioning properly and two bathrooms lacked exhaust systems.
One electrical outlet within 6 feet of a sink was not equipped with Ground-Fault Circuit Interrupter (GFCI) protection.
Emergency generator testing documentation lacked evidence of transfer of power within 10 seconds for October and November 2022.
Report Facts
Emergency generator load test frequency: 12
Number of emergency generator transfer switches missing battery backup lighting: 2
Number of illuminated exit signs missing or not working: 9
Number of stairwell doors failing to latch: 5
Number of portable fire extinguishers installed too high: 14
Number of corridor doors with gaps allowing smoke passage: 2
Number of smoke barrier door sets with deficiencies: 2
Number of resident bathrooms with ventilation failures: 3
Number of resident bathrooms lacking exhaust system: 2
Number of electrical outlets lacking GFCI protection: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Named in multiple findings including emergency lighting, exit signage, door latching, hazardous area doors, fire alarm system, sprinkler system, fire extinguishers, corridor doors, smoke barrier doors, ventilation, electrical outlets, and generator testing. | |
| Administrator | Involved in inservicing maintenance director and overseeing corrective actions. |
Inspection Report
Annual Inspection
Census: 189
Deficiencies: 5
Date: Apr 14, 2021
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
Deficiencies were cited related to failure to assist a resident with formulating an advance directive, failure to maintain resident equipment in a clean and sanitary condition, failure to identify a missing hearing aid for a resident, failure to provide respiratory care consistent with professional standards, and failure to don required personal protective equipment prior to entering a resident's room on transmission-based precautions.
Deficiencies (5)
Failure to assist a resident with formulating an advance directive.
Failure to maintain resident equipment (wheelchairs and chairs) in a clean and sanitary condition.
Failure to identify a missing hearing aid for a resident and failure to properly document and manage hearing aids.
Failure to provide respiratory care including tracheostomy care and tracheal suctioning consistent with professional standards.
Failure to don required personal protective equipment (PPE) prior to entering the room of a resident on transmission-based precautions.
Report Facts
Census: 189
Sample Size: 48
Deficiencies cited: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker Director | Responsible for oversight of social work intern and advanced directive compliance. | |
| Licensed Practical Nurse Unit Manager | Provided statements regarding advanced directive documentation and resident care equipment. | |
| Director of Nursing | Provided statements regarding chair cleanliness and respiratory care deficiencies. | |
| Licensed Practical Nurse Infection Preventionist | Provided statements regarding PPE use and infection control. | |
| Registered Nurse Unit Manager | Observed staff PPE compliance and provided education. | |
| Certified Nursing Assistant | Provided statements regarding resident care and PPE use. |
Inspection Report
Life Safety
Deficiencies: 0
Date: Apr 14, 2021
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code 101:2012 and emergency preparedness requirements for long term care facilities.
Findings
The facility was found to be in substantial compliance with Appendix Z-Emergency Preparedness and met the minimum Life Safety Code requirements as surveyed using CMS-2786R.
Inspection Report
Complaint Investigation
Census: 168
Deficiencies: 1
Date: Mar 19, 2021
Visit Reason
The inspection was conducted as a complaint investigation (Complaint # NJ 143250) to determine compliance with regulations related to residents' rights to be free from physical restraints.
Complaint Details
Complaint # NJ 143250. The facility was not in substantial compliance with requirements based on this complaint visit.
Findings
The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, based on failure to ensure residents were free from physical restraints and failure to follow their own restraint use policy for 2 of 5 sampled residents (Resident #3 and Resident #4). The report details observations, interviews, and record reviews showing inappropriate use of restraints and outlines corrective actions taken.
Deficiencies (1)
Failure to ensure residents were free from physical restraints and failure to follow the facility's policy titled 'Resident Safety/Restraint Use' for 2 of 5 sampled residents.
Report Facts
Sample size: 5
Restraint release frequency: 2
Physical therapy frequency: 5
Physical therapy frequency: 7
Occupational therapy frequency: 3
Occupational therapy duration: 12
Audit review frequency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Explained Resident #4's restraint use and monitoring; responsible for monitoring compliance with the plan of correction | |
| Unit Manager | Explained Resident #4's restraint use and history | |
| Licensed Practical Nurse (LPN) | Explained Resident #3's use of restraints | |
| Director of Rehabilitation | Acknowledged restraints are against regulations | |
| Safety Coordinator | In-serviced on proper use of audit tool and involved in monitoring restraint use |
Inspection Report
Routine
Census: 168
Deficiencies: 0
Date: Feb 25, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 7
Inspection Report
Routine
Census: 170
Deficiencies: 0
Date: Nov 20, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 3
Notice
Deficiencies: 0
Date: Apr 15, 2011
Visit Reason
This document serves as a Notice of Privacy Practices informing individuals about how their medical information may be used and disclosed by NJDHSS and related components, and describing their rights related to this information.
Findings
The notice explains the types of information covered, reasons for use and disclosure of health information, individuals' rights to access and control their information, legal duties of NJDHSS, and contact information for privacy concerns.
Report Facts
Effective date: Apr 15, 2011
Response time: 30
Disclosure accounting period: 6
Disclosure accounting period for electronic records: 3
Complaint filing address: 200
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, NJDHSS Privacy Officer | Contact person for privacy practices and complaints |
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