Inspection Reports for Meadowbrook Respiratory And Nursing Center
38 Freneau Avenue, NJ, 07747
Back to Facility ProfileDeficiencies per Year
20
15
10
5
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Notice
Deficiencies: 0
Nov 20, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of NJDHSS, including how their medical information may be used and disclosed, and their rights related to this information.
Findings
The notice details the types of information covered, reasons for use and disclosure of health information, individuals' rights to access and control their information, and the legal duties of NJDHSS to protect privacy.
Report Facts
Effective date: 2011
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer contact for questions about the notice |
Inspection Report
Complaint Investigation
Census: 101
Deficiencies: 3
Jul 18, 2023
Visit Reason
A complaint survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities, triggered by complaint NJ00165644.
Findings
Deficiencies were cited related to infection control practices, specifically failure to follow CDC guidance on PPE use and facility signage, and failure to maintain an effective Infection Control Program during an outbreak of multidrug-resistant organisms (MDRO). An Immediate Jeopardy situation was identified and subsequently removed after corrective actions were implemented.
Complaint Details
Complaint # NJ00165644. The complaint survey found the facility was not in compliance with infection control requirements, including failure to follow CDC PPE guidance and failure to maintain an effective Infection Control Program during an MDRO outbreak. Immediate Jeopardy was identified on 07/14/23 and removed on 07/18/23 after corrective actions.
Severity Breakdown
Immediate Jeopardy: 1
Level F: 1
Level S: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to follow CDC guidance related to infection control practices for PPE use and facility signage in resident rooms on transmission-based precautions. | Immediate Jeopardy |
| Facility Licensed Nursing Home Administrator failed to ensure the Infection Control Program was effectively implemented to prevent the spread of MDRO during an outbreak. | Level F |
| Failure to maintain required minimum direct care staff-to-shift ratios as mandated by the state of New Jersey. | Level S |
Report Facts
Census: 101
Sample size: 3
Staffing deficiencies: 14
Residents affected: 16
Inspection Report
Routine
Census: 114
Capacity: 114
Deficiencies: 17
May 8, 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 in multiple areas including investigation of abuse allegations, medication administration, infection control during tracheostomy care, psychotropic medication use, medication storage, food temperature and safety, resident record maintenance, emergency preparedness, life safety code compliance, fire alarm system, smoking regulations, and medical gas system maintenance.
Severity Breakdown
SS=D: 5
SS=E: 6
SS=F: 5
Deficiencies (17)
| Description | Severity |
|---|---|
| Facility failed to thoroughly investigate an injury of unknown origin to rule out abuse and neglect for a resident. | SS=D |
| Facility failed to communicate a recommendation for a decrease in administration frequency for a medication to the physician in accordance with professional standards. | SS=D |
| Facility failed to maintain proper infection control practices during tracheostomy care. | SS=E |
| Facility failed to ensure non-pharmacological interventions were attempted and specific target behaviors were monitored prior to administration of psychotropic medication. | SS=E |
| Facility failed to maintain medication carts free from unmarked and unwrapped medications and ensure shift-to-shift narcotic accountability count was completed; also failed to ensure accurate ordering and receiving of narcotic medications on DEA 222 forms. | SS=D |
| Facility failed to ensure safe and appetizing food temperatures during meal service. | SS=E |
| Facility failed to maintain kitchen equipment in a manner to prevent microbial growth, including use of deeply pitted cutting boards. | SS=E |
| Facility failed to maintain an accurate, complete, and easily accessible medical record, including missing neurological records and behavior monitoring forms. | SS=D |
| Facility failed to maintain required minimum direct care staff to resident ratios as mandated by the State of New Jersey. | — |
| Facility failed to ensure emergency preparedness policy included plan to maintain generator power/fuel during an emergency. | SS=F |
| Facility failed to ensure emergency lighting was provided for the generator transfer switch. | SS=F |
| Facility failed to ensure two hazardous area soiled linen room doors were self-closing. | SS=E |
| Facility failed to ensure fire alarm smoke detectors were installed at proper distance from air diffusers. | SS=F |
| Facility failed to complete smoke detection sensitivity test and make necessary alarm system repairs for all smoke detectors. | SS=F |
| Facility failed to ensure category 1 medical gas system was maintained and tested in accordance with NFPA 99. | SS=E |
| Facility failed to provide a Type I essential electrical system for critical care rooms where electric life support equipment is required. | SS=F |
| Facility failed to ensure safe ash trays and metal self-closing containers were provided in the smoking area. | SS=E |
Report Facts
Residents present: 114
Total licensed capacity: 114
Deficiency counts: 16
Staffing ratios: 12
Staffing ratios: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse | LPN | Named in medication cart deficiency and incident report process |
| Director of Nursing | DON | Named in multiple findings including medication cart, emergency preparedness, and medical record maintenance |
| Maintenance Director | Maintenance Director | Named in emergency preparedness, fire alarm, hazardous area doors, and medical gas system deficiencies |
| Licensed Nursing Home Administrator | LNHA | Named in staffing and medical record deficiencies |
| Dietary Supervisor | DS | Named in food temperature and kitchen sanitation deficiencies |
| Registered Dietitian | RD | Named in kitchen sanitation and food temperature deficiencies |
| Certified Consultant Pharmacist | CP | Named in psychotropic medication documentation deficiency |
| Unit Manager/Licensed Practical Nurse | UM/LPN | Named in psychotropic medication and behavior monitoring deficiencies |
Inspection Report
Complaint Investigation
Census: 99
Deficiencies: 6
Jan 6, 2023
Visit Reason
Complaint investigation due to failure to notify physician and document medication administration, failure to maintain minimum staffing ratios, and infection control deficiencies.
Findings
The facility was found not in substantial compliance with multiple regulatory requirements including failure to notify physicians of resident condition changes, failure to document medication administration accurately, failure to provide pain management as ordered, failure to document resident care activities, failure to maintain infection control practices including PPE use, and failure to maintain required minimum direct care staffing ratios.
Complaint Details
Complaint investigation based on allegations of failure to notify physicians, medication errors, inadequate staffing, and infection control violations. Substantiation status not explicitly stated.
Severity Breakdown
SS=D: 4
SS=B: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to notify and document physician notification when resident's medication was not administered as ordered. | SS=D |
| Failure to accurately document administration of routine medications for multiple residents. | SS=D |
| Failure to provide pain management according to physician orders and facility policy for a resident. | SS=D |
| Failure to consistently document Activities of Daily Living (ADL) care provided to residents. | SS=B |
| Failure to implement proper infection control practices including use of Personal Protective Equipment (PPE) by housekeeping staff. | SS=D |
| Failure to maintain required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey for 19 of 56 days reviewed. | — |
Report Facts
Census: 99
Sample Size: 20
Days with deficient staffing: 19
Residents reviewed for medication documentation: 9
Residents reviewed for ADL documentation: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Named in medication administration documentation deficiency |
| RN #2 | Registered Nurse | Named in pain management deficiency and medication administration documentation |
| UM #1 | Unit Manager | Interviewed regarding medication administration and infection control |
| UM #2 | Unit Manager | Interviewed regarding medication administration and infection control |
| HS #1 | Housekeeping Staff | Observed not following PPE protocols |
| Director of Nursing | Director of Nursing | Interviewed regarding medication administration, infection control, and staffing |
| Administrator | Administrator | Interviewed regarding staffing and infection control |
| Infection Control Preventionist | Infection Control Preventionist Nurse | Interviewed regarding infection control practices |
| CNA #1 | Certified Nursing Assistant | Interviewed regarding ADL documentation |
| LPN/UM #1 | Licensed Practical Nurse/Unit Manager | Interviewed regarding ADL documentation |
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 2
Jul 26, 2021
Visit Reason
The inspection was conducted based on complaint NJ146353 to investigate the facility's compliance with regulations regarding advanced directives and medication administration.
Findings
The facility was found not in substantial compliance with requirements related to formulating advance directives upon admission and following physician's medication orders. Deficiencies included failure to provide written information and documentation of advanced directives for one resident, and failure to administer medications as ordered for another resident, with inadequate documentation and communication with physicians.
Complaint Details
Complaint NJ146353 was substantiated based on findings that the facility failed to comply with advance directive requirements and medication administration policies.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to follow policies to formulate an advance directive prior to or upon admission for 1 of 3 residents reviewed. | SS=D |
| Failure to follow physician's orders for medication administration and facility policies for 1 of 3 residents reviewed. | SS=D |
Report Facts
Census: 87
Sample Size: 3
Deficiency Count: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) Unit Manager | Interviewed regarding POLST forms and code status. | |
| Assistant Director of Nursing (ADON) | Interviewed regarding POLST form procedures and medication order verification. | |
| Director of Nursing (DON) | Interviewed regarding POLST form requirements and medication policy adherence. | |
| Director of Social Services (DOSS) | Interviewed regarding responsibility for POLST forms and advanced directives. | |
| Vice President of Clinical Nursing (VPCS) | Interviewed regarding facility policies on POLST and advanced directives. | |
| Medical Director (MD) | Interviewed regarding physician response times for orders. | |
| Resident attending Physician | Interviewed regarding medication order verification and administration. |
Inspection Report
Annual Inspection
Census: 81
Deficiencies: 3
Mar 19, 2021
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
The facility was found deficient in food safety requirements, specifically failing to perform proper hand hygiene, properly wear hair restraints during meal service, store food items with appropriate use-by dates, and maintain kitchen equipment to prevent microbial growth and cross contamination.
Severity Breakdown
SS=F: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to perform hand hygiene and properly wear hair restraint during meal service. | SS=F |
| Failure to store food items with appropriate use-by dates. | SS=F |
| Failure to maintain kitchen equipment to prevent microbial growth, cross contamination and avoid potential for food borne illness. | SS=F |
Report Facts
Census: 81
Sample size: 28
Deficiency completion date: Mar 25, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Dietary | Present during kitchen tour and interviewed regarding deficiencies | |
| Infection Preventionist Registered Nurse (IPRN) | Interviewed about hand hygiene and food safety observations | |
| Dietary staff member | Observed failing to perform proper hand hygiene and hair restraint |
Inspection Report
Life Safety
Deficiencies: 0
Mar 19, 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 in compliance with the minimum Life Safety Code requirements as surveyed using CMS-2786R.
Inspection Report
Routine
Census: 78
Deficiencies: 0
Dec 21, 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: 5
Inspection Report
Routine
Census: 78
Deficiencies: 0
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.
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.
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