Inspection Reports for
Meadowbrook Respiratory And Nursing Center
38 Freneau Avenue, Matawan, NJ, 07747
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
12 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
131% worse than New Jersey average
New Jersey average: 5.2 deficiencies/year
Deficiencies per year
40
30
20
10
0
Occupancy
Latest occupancy rate
78% occupied
Based on a July 2023 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Notice
Deficiencies: 0
Date: 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
Deficiencies: 4
Date: May 20, 2025
Visit Reason
The inspection was conducted based on complaints NJ176627 and NJ184589/NJ184632 regarding medication administration errors, failure to follow wound care treatment recommendations, and delays in obtaining treatment orders for wounds.
Complaint Details
Complaint NJ176627 involved medication administration and PIC line care deficiencies. Complaints NJ184589 and NJ184632 involved failure to follow wound care treatment recommendations and delays in treatment orders for wounds.
Findings
The facility failed to administer medication as ordered and ensure proper care and documentation for residents with wounds and PIC line dressings. Specifically, medication doses were not documented as given, PIC line dressings were not dated, wound care treatment recommendations were not followed, and there was a delay in obtaining treatment orders for a skin tear.
Deficiencies (4)
Failure to administer medication according to physician's orders and document administration for 2 residents.
Failure to ensure PIC line dressing was labeled and dated as per policy for 1 resident.
Failure to follow wound care practitioner treatment recommendations and document accurate wound measurements for 1 resident.
Delay in obtaining treatment orders for a skin tear identified on the left wrist for 1 resident.
Report Facts
Residents reviewed for professional standards of practice: 27
Residents reviewed for accidents: 4
Wound measurements: 5
Skin tear measurement: 2
Skin tear measurement depth: 0.1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse/Unit Manager | LPN/UM | Interviewed regarding medication administration documentation and wound care treatment recommendations. |
| Director of Nursing | DON | Interviewed regarding medication administration documentation and wound care treatment discrepancies. |
| Wound Care Nurse Practitioner | WCP | Interviewed regarding wound classification, treatment recommendations, and discrepancies in wound care orders. |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: May 20, 2025
Visit Reason
The inspection was conducted based on complaints regarding failure to maintain a safe, clean, and homelike environment, medication administration errors, inadequate care for catheter sites, failure to act on pharmacy recommendations for psychoactive medications, medication errors related to blood pressure medication administration, and unsanitary kitchen conditions.
Complaint Details
The complaint investigation (NJ Complaint: NJ176627) was substantiated with findings including failure to administer medications as ordered, inadequate catheter site care, failure to monitor psychoactive medication use, medication errors with blood pressure medication, and unsanitary kitchen conditions.
Findings
The facility was found deficient in maintaining a homelike environment with unfinished wall repairs, failure to administer medications as ordered including missed documentation and administration outside physician parameters, inadequate care and documentation for catheter site dressings, failure to monitor and document behavior for residents on psychoactive medications, and unsanitary kitchen equipment and improper food storage. All deficiencies were cited with minimal harm or potential for actual harm to residents.
Deficiencies (5)
Failure to maintain residents' living environment in a clean, comfortable, homelike manner with unfinished wall repairs observed in resident rooms.
Failure to administer medication according to physician's orders and ensure care for midline catheter site consistent with orders and professional standards.
Failure to act upon Consultant Pharmacy recommendations to provide adequate monitoring for use of as needed psychoactive medications, including lack of documentation of non-drug interventions.
Failure to ensure blood pressure medication was administered according to physician ordered parameters, resulting in administration outside parameters.
Failure to maintain kitchen equipment in a clean and sanitary manner, including soiled ovens, stove tops, and undated, unsealed food items in the walk-in freezer.
Report Facts
Residents reviewed for professional standards of practice: 27
Residents affected: 2
Residents affected: 1
Residents affected: 1
Medication doses not signed off: 3
Dates medication administered outside parameters: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse/Unit Manager | LPN/Unit Manager | Acknowledged medication administration documentation requirements and deficiencies |
| Director of Nursing | DON | Acknowledged medication administration deficiencies and behavior monitoring issues |
| Licensed Nursing Home Administrator | LNHA | Confirmed facility audit processes and acknowledged surveyor concerns |
| Director of Maintenance | DOM | Confirmed maintenance work order system and repair timelines |
| Director of Dietary Services | DODS | Acknowledged unsanitary kitchen conditions and improper food storage |
| Infection Preventionist | Stated staff must follow dressing change orders to prevent infection |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 6, 2025
Visit Reason
The inspection was conducted based on a complaint (NJ00182326) regarding the facility's failure to timely report an injury of a severely cognitively impaired resident to the New Jersey Department of Health.
Complaint Details
Complaint NJ00182326 was substantiated as the facility failed to report an injury of a severely cognitively impaired resident to the NJDOH. The resident fell from a wheelchair, sustained a head injury with laceration requiring staples, and was hospitalized. The facility's Incident Report and subsequent documentation did not indicate notification to NJDOH. Interviews confirmed no evidence of notification.
Findings
The facility failed to report an injury sustained by Resident #1, who fell from a wheelchair and received a head laceration requiring staples, to the NJDOH. Documentation and interviews revealed no evidence that the NJDOH was notified despite the incident being investigated internally.
Deficiencies (1)
Failure to timely report suspected abuse, neglect, or injury to the proper authorities.
Report Facts
Staples received: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Regional Nurse | Interviewed regarding the incident and reporting to NJDOH. | |
| Assistant Director of Nursing (ADON) | Interviewed regarding the incident and reporting to NJDOH. | |
| Nurse Supervisor (NS) | Interviewed regarding the incident and reporting to NJDOH. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Feb 24, 2025
Visit Reason
The inspection was conducted based on complaints regarding the facility's failure to accommodate residents' needs and preferences related to activities and timely response to call bells.
Complaint Details
The complaint investigation found substantiated deficiencies related to failure to provide activities and delayed response to call bells, affecting a few residents.
Findings
The facility failed to provide scheduled activities to two residents with severely impaired cognition and did not ensure timely response to call bells for one resident, posing minimal harm or potential for actual harm.
Deficiencies (2)
Failure to accommodate residents' needs and preferences related to activities for 2 of 3 residents.
Failure to ensure residents' call bells were answered in a timely manner for 1 of 8 sampled residents.
Report Facts
Residents affected: 2
Residents affected: 1
Activity documentation dates: Jan 3, 2025
Activity documentation dates: Sep 4, 2024
Call bell response time: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Activities Director | Interviewed regarding activity schedules and documentation | |
| Certified Nursing Aide (CNA) | Interviewed about call bell response expectations | |
| Licensed Practical Nurse (LPN) | Interviewed about call bell response expectations | |
| Director of Nursing (DON), Regional DON, and Administrator | Interviewed regarding call bell response incident and staff behavior | |
| Respiratory Therapist (RT) | Responded to call bell and suctioned Resident #4 |
Inspection Report
Deficiencies: 0
Date: Jan 12, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction related to a regulatory inspection of Meadowbrook Respiratory and Nursing Center.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Census: 101
Deficiencies: 3
Date: 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.
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.
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.
Deficiencies (3)
Failure to follow CDC guidance related to infection control practices for PPE use and facility signage in resident rooms on transmission-based precautions.
Facility Licensed Nursing Home Administrator failed to ensure the Infection Control Program was effectively implemented to prevent the spread of MDRO during an outbreak.
Failure to maintain required minimum direct care staff-to-shift ratios as mandated by the state of New Jersey.
Report Facts
Census: 101
Sample size: 3
Staffing deficiencies: 14
Residents affected: 16
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Jul 18, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding an active outbreak of multidrug-resistant organisms (MDRO) including Carbapenem-resistant Acinetobacter baumannii (CRAB) and Candida auris (CA) in the facility, focusing on infection prevention and control practices.
Complaint Details
Complaint NJ #165644 regarding failure to provide and implement an infection prevention and control program during an active outbreak of CRAB and CA since January 2023.
Findings
The facility failed to effectively implement its Infection Control Program to prevent the spread of MDROs during an outbreak. Deficiencies included failure to follow CDC guidance on PPE use, incomplete and inaccurate infection surveillance line listings, inadequate staff education on infection control, and failure to notify local health authorities. These failures posed an immediate jeopardy to resident health and safety.
Deficiencies (4)
Failure to ensure infection control program was effectively implemented during an outbreak of CRAB and CA.
Failure to follow CDC guidance on PPE use and facility signage, resulting in staff not wearing appropriate PPE.
Failure to maintain accurate and complete infection surveillance line listings and failure to conduct investigations or notify local health department.
Failure to educate staff adequately on infection control practices specific to CRAB and CA.
Report Facts
Residents affected: 16
Residents on ventilator unit: 22
Residents positive for CA and CRAB: 9
Residents on isolation list: 19
Residents on isolation list: 12
Residents on isolation list: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nursing Home Administrator | LNHA | Failed to ensure infection control program was effectively implemented and failed to review infection surveillance line listings. |
| Infection Preventionist Registered Nurse | IP RN | Was on vacation during outbreak, failed to conduct investigations, did not alert local health department, and did not maintain proper line listing. |
| Assistant Director of Nursing | ADON | Worked with LNHA and IP RN during outbreak, aware of PPE requirements, and involved in staff reeducation. |
| Nursing Assistant #1 | NA | Observed not wearing required PPE in isolation room, posing infection risk. |
| Licensed Practical Nurse #1 | LPN | Provided information on PPE requirements and infection control practices. |
| Certified Nursing Assistant #1 | CNA | Observed failing to remove soiled gloves and perform hand hygiene as required. |
| Regional Nurse | RN | Provided multiple versions of Surveillance Line Lists with inconsistent data. |
| Regional Registered Nurses | RRN | Unaware that Surveillance Line Listing was not being completed. |
| Regional Administrator | Administrator | Unaware that Surveillance Line Listing was not being completed. |
| Respiratory Therapist | RT | Observed wearing PPE gown not secured and unaware of isolation requirements for residents. |
Inspection Report
Routine
Census: 114
Capacity: 114
Deficiencies: 17
Date: 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.
Deficiencies (17)
Facility failed to thoroughly investigate an injury of unknown origin to rule out abuse and neglect for a resident.
Facility failed to communicate a recommendation for a decrease in administration frequency for a medication to the physician in accordance with professional standards.
Facility failed to maintain proper infection control practices during tracheostomy care.
Facility failed to ensure non-pharmacological interventions were attempted and specific target behaviors were monitored prior to administration of psychotropic medication.
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.
Facility failed to ensure safe and appetizing food temperatures during meal service.
Facility failed to maintain kitchen equipment in a manner to prevent microbial growth, including use of deeply pitted cutting boards.
Facility failed to maintain an accurate, complete, and easily accessible medical record, including missing neurological records and behavior monitoring forms.
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.
Facility failed to ensure emergency lighting was provided for the generator transfer switch.
Facility failed to ensure two hazardous area soiled linen room doors were self-closing.
Facility failed to ensure fire alarm smoke detectors were installed at proper distance from air diffusers.
Facility failed to complete smoke detection sensitivity test and make necessary alarm system repairs for all smoke detectors.
Facility failed to ensure category 1 medical gas system was maintained and tested in accordance with NFPA 99.
Facility failed to provide a Type I essential electrical system for critical care rooms where electric life support equipment is required.
Facility failed to ensure safe ash trays and metal self-closing containers were provided in the smoking area.
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
Deficiencies: 8
Date: May 8, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to thoroughly investigate an injury of unknown origin to rule out abuse and neglect for a resident, and other quality of care concerns including medication management, infection control, food safety, and medical record maintenance.
Complaint Details
The complaint investigation was triggered by concerns about failure to investigate an injury of unknown origin for Resident #14, with additional concerns about medication management, infection control, food safety, and medical record keeping.
Findings
The facility failed to thoroughly investigate an injury of unknown origin for Resident #14, failed to communicate medication recommendations timely for Resident #28, failed to maintain proper infection control during tracheostomy care for Residents #16 and #70, failed to ensure appropriate use and documentation of anti-anxiety medication for Resident #47, failed to maintain medication cart security and proper narcotic documentation, served food at unsafe temperatures, used damaged kitchen cutting boards, and failed to maintain accurate and complete medical records for Resident #88.
Deficiencies (8)
Failed to thoroughly investigate an injury of unknown origin to rule out abuse and neglect for Resident #14.
Failed to communicate a recommendation for a decrease in anti-anxiety medication frequency timely to the physician for Resident #28.
Failed to maintain proper infection control practices during tracheostomy care for Residents #16 and #70.
Failed to ensure non-pharmacological interventions were attempted and documented prior to administration of anti-anxiety medication and failed to monitor specific target behaviors for Resident #47.
Failed to maintain medication carts free from unmarked and unwrapped medications and failed to complete shift-to-shift narcotic accountability count and proper DEA 222 form completion.
Failed to ensure food was served at safe and appetizing temperatures; multiple meals served below required temperature standards.
Failed to maintain kitchen cutting boards in a sanitary condition; cutting boards were deeply pitted, discolored, and improperly wrapped.
Failed to maintain accurate, complete, and easily accessible medical records for Resident #88, including missing and conflicting neurological records and missing behavior monitoring sheets.
Report Facts
Deficiencies cited: 8
Resident count reviewed for medication standards: 23
Resident count reviewed for unnecessary medications: 5
Resident count reviewed for tracheostomy care: 2
Temperature readings: 35
Temperature readings: 195
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Confirmed incident reports were original and complete; acknowledged deficiencies in investigation and documentation. |
| Licensed Nursing Home Administrator | LNHA | Acknowledged concerns regarding documentation and policies; confirmed lack of policy for maintaining active resident medical records. |
| Certified Consultant Pharmacist | Consultant Pharmacist (CP) | Reported lack of documentation system for psychotropic medication monitoring; confirmed audits showed poor documentation. |
| Unit Manager/Licensed Practical Nurse | UM/LPN | Provided information on medication and behavior monitoring processes; acknowledged missing behavior monitoring sheets. |
| Dietary Supervisor | DS | Conducted food temperature observations; acknowledged broken plate warmer and food temperature issues. |
| Dietary Director | DD | Acknowledged cutting board issues and food temperature complaints. |
| Respiratory Therapist Supervisor | RTS | Observed providing tracheostomy care with improper infection control practices. |
| Psychiatric Nurse Practitioner | Psych NP | Made medication recommendations; unaware of delays and lack of documentation. |
| Physician | Physician | Interviewed regarding medication orders and delays. |
Inspection Report
Complaint Investigation
Census: 99
Deficiencies: 6
Date: 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.
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.
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.
Deficiencies (6)
Failure to notify and document physician notification when resident's medication was not administered as ordered.
Failure to accurately document administration of routine medications for multiple residents.
Failure to provide pain management according to physician orders and facility policy for a resident.
Failure to consistently document Activities of Daily Living (ADL) care provided to residents.
Failure to implement proper infection control practices including use of Personal Protective Equipment (PPE) by housekeeping staff.
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
Date: 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.
Complaint Details
Complaint NJ146353 was substantiated based on findings that the facility failed to comply with advance directive requirements and medication administration policies.
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.
Deficiencies (2)
Failure to follow policies to formulate an advance directive prior to or upon admission for 1 of 3 residents reviewed.
Failure to follow physician's orders for medication administration and facility policies for 1 of 3 residents reviewed.
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
Deficiencies: 5
Date: Mar 19, 2021
Visit Reason
The inspection was conducted to assess compliance with food safety and hygiene standards in the facility's kitchen and food service areas.
Findings
The facility failed to perform proper hand hygiene and hair restraint use during meal service, improperly stored food items without use-by dates, and did not maintain kitchen equipment to prevent microbial growth and cross contamination, posing a potential risk for foodborne illness.
Deficiencies (5)
Failure to perform hand hygiene and properly wear a hair restraint during meal service.
Food items stored without use-by dates, including partially frozen chicken and frozen French toast.
Kitchen equipment (metal pans) were wet inside, which is improper maintenance.
Mold observed on a package of club rolls that should have been discarded.
Storage bins labeled with expired use-by dates and contained debris; one bin lid was cracked.
Report Facts
Use by date: 5
Dates on food items: Mar 11, 2021
Manufacture date: Dec 17, 2020
Received date: Feb 3, 2021
Use by date: Jan 3, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Dietary | Present during kitchen tour and provided information about food storage and handling. | |
| Dietary staff (DS) | Observed failing to perform hand hygiene and proper hair restraint during meal service. | |
| Infection Preventionist registered nurse (IPRN) | Interviewed regarding hygiene observations and confirmed deficiencies. |
Inspection Report
Annual Inspection
Census: 81
Deficiencies: 3
Date: 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.
Deficiencies (3)
Failure to perform hand hygiene and properly wear hair restraint during meal service.
Failure to store food items with appropriate use-by dates.
Failure to maintain kitchen equipment to prevent microbial growth, cross contamination and avoid potential for food borne illness.
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
Date: 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
Date: 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
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.
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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