Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
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 Meadowbrook Respiratory And Nursing Center during CMS and state inspections, most recent first.
A resident with multiple comorbidities experienced deficiencies in wound care when staff failed to follow WCP recommendations for wound cleansing and did not update physician orders to reflect changes in treatment. Additionally, a skin tear on the resident's wrist was not treated for several days due to a delay in obtaining a treatment order. Documentation of wound measurements was inconsistent, and staff could not explain the discrepancies or delays.
A resident with anxiety and depression was prescribed Valium as needed and fluoxetine daily, but staff failed to document behavior monitoring or the use of non-drug interventions prior to administering Valium, despite pharmacy recommendations and facility policy. Staff interviews and record reviews confirmed the lack of required documentation and monitoring.
A resident with hypertension and congestive heart failure received clonidine HCl outside of physician-ordered parameters on multiple occasions, as documented in the MAR. Despite orders to hold the medication if systolic blood pressure was below 130 or heart rate below 60, nursing staff administered the medication when these conditions were not met. Both the LPN and DON confirmed the medication was given outside of the prescribed parameters, contrary to facility policy.
Two residents were found living in rooms with significant, unfinished wall damage, including unpainted spackled patches and multiple long holes, which had persisted for weeks to months. Despite a computerized maintenance work order system and regular audits by staff, these repairs were not completed in a timely manner, resulting in a failure to provide a clean, comfortable, and homelike environment.
Surveyors found that kitchen equipment, including ovens and stove tops, was not cleaned according to policy, with visible grease, food debris, and residue present. The area above a knife block was also unclean, and the walk-in freezer contained open, undated food items and a tray with unclear labeling. The DODS and facility leadership acknowledged these sanitation and food storage deficiencies.
Surveyors identified that two residents did not receive care in accordance with professional standards: one resident did not have all prescribed doses of topical lidocaine documented as administered, and another had a PIC dressing that was not labeled or dated, with incomplete documentation of dressing changes. Interviews with LPN, DON, and Infection Preventionist confirmed that required documentation and procedures were not followed, as outlined in facility policy.
A resident with severe cognitive impairment sustained a head laceration after falling from a wheelchair and required hospital treatment with staples. The facility did not provide documentation that the incident was reported to the NJDOH as required.
Two residents with severe cognitive impairment and dependence on staff for ADLs and transfers did not receive consistent accommodation for their activity needs and preferences. Despite care plans requiring staff assistance and scheduled activity visits, documentation showed long gaps without recorded activities, and interviews confirmed that activities were not consistently provided or documented for these residents.
A resident with chronic respiratory failure and a tracheostomy activated the call bell for suctioning, but staff did not respond promptly despite the alarm being active and visible. The resident continued to cough until a respiratory therapist arrived several minutes later to provide suctioning, after the surveyor intervened. Staff interviews and facility policy confirmed that call bells, especially for urgent needs, should be answered immediately.
Failure to Follow Wound Care Recommendations and Delayed Treatment Orders
Penalty
Summary
The facility failed to follow wound care practitioner (WCP) treatment recommendations and did not document accurate wound measurements for a resident with significant medical conditions, including peripheral vascular disease, atherosclerotic cardiovascular disease, and cellulitis. After a new wound was identified on the resident's right lower leg, the WCP recommended cleansing the wound with Dakin's solution, applying calcium alginate, and covering with ABD and kling. However, the facility instead ordered and implemented cleansing with normal saline solution (NSS), contrary to the WCP's recommendations. Additionally, subsequent changes in the WCP's treatment recommendations were not reflected in updated physician orders, and the facility continued to use outdated treatments. There were also discrepancies in wound measurements documented by nursing staff and the WCP, with no explanation provided for these inconsistencies. In a separate incident, the same resident developed a skin tear on the left wrist. Although the physician and wound care team were notified and recommendations were made to cleanse the area with NSS and apply a xeroform dressing, no treatment order was entered or implemented for eight days after the wound was identified. The delay in obtaining and implementing a treatment order was confirmed by review of the treatment administration record and interviews with facility staff, who could not provide an explanation for the delay. Facility policies required immediate transcription and implementation of wound care orders, as well as accurate and complete documentation of wound assessments and treatments. Despite these policies, the facility did not ensure timely and accurate execution of wound care recommendations and orders, nor did it maintain consistent and accurate documentation regarding wound measurements and treatments provided.
Failure to Monitor and Document Non-Drug Interventions for Psychoactive Medication Use
Penalty
Summary
The facility failed to act upon consultant pharmacy recommendations regarding the monitoring and administration of as-needed psychoactive medications for a resident with diagnoses including malnutrition, major depression, respiratory failure, and anxiety disorder. The resident was prescribed Valium as needed for anxiety and fluoxetine for depression. The care plan required monitoring and documentation of target behaviors and symptoms related to the use of these medications, as well as the use of non-drug interventions prior to administering Valium. However, a review of the Medication Administration Records over several months showed no evidence of behavior monitoring, and progress notes did not document any non-drug interventions attempted before administering Valium. Interviews with staff, including an LPN and the DON, revealed that behavior monitoring was expected to be documented on the MAR, but in this case, it was not done. The DON acknowledged that behavior monitoring and non-drug interventions were missed for this resident. The facility's own policy required the use of non-pharmacological approaches and monitoring for efficacy and adverse consequences of psychotropic medications, but these procedures were not followed for the resident in question.
Blood Pressure Medication Administered Outside Physician Parameters
Penalty
Summary
The facility failed to ensure that blood pressure medication was administered according to physician-ordered parameters for a resident with hypertension and congestive heart failure. The physician's order specified that clonidine hydrochloride should be held if the systolic blood pressure was less than 130 or if the heart rate was less than 60. Despite these clear parameters, the medication was repeatedly administered when the resident's blood pressure and/or heart rate were below the specified thresholds, as documented in the Medication Administration Record for multiple dates in April and May. The resident had a moderately impaired cognition, as indicated by a BIMS score of 8 out of 15, and was being treated for hypertension related to congestive heart failure. Interviews with nursing staff, including an LPN and the DON, confirmed that the medication was given outside of the prescribed parameters and acknowledged that the physician's orders were not followed. The facility's policy required medications to be administered as prescribed, including adherence to any parameters set by the prescriber. The deficiency was identified through review of medical records, staff interviews, and facility policy, all of which confirmed that the medication administration did not comply with the physician's orders.
Failure to Maintain Homelike Environment Due to Unfinished Wall Repairs
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for residents, as evidenced by observations on one of three nursing units. During the initial tour, one resident was found resting in bed with a wall behind them that had a large, unpainted, and unfinished spackled patch, which the resident reported had been present for at least a couple of months and expressed dislike for its appearance. In another room, a resident was observed sitting in a wheelchair with a wall behind their bed that had dried spackle and was severely damaged with multiple long holes, which the resident stated had been in that condition for about three weeks. Interviews with staff, including an LPN, the Director of Maintenance, and the Licensed Nursing Home Administrator, confirmed the use of a computerized maintenance work order system that notifies maintenance staff of needed repairs and that the facility conducts twice-weekly audits of resident rooms. Despite these systems, the wall repairs in the residents' rooms remained incomplete for extended periods, contrary to the facility's policy to maintain a homelike environment and provide timely housekeeping and maintenance services.
Failure to Maintain Kitchen Sanitation and Proper Food Storage
Penalty
Summary
Surveyors observed multiple instances of unsanitary conditions and improper food storage in the facility's kitchen. During a kitchen tour with the Director of Dietary Services (DODS), both convection ovens were found to be soiled with baked-on residue, and the six-burner and four-burner stove tops and ovens were covered with cooked-on grease, sediment, and food debris. The catch trays in these ovens were lined with foil that was also covered in burnt liquid and food debris. The DODS acknowledged that these items were not cleaned according to facility policy. Additionally, a wall above a mounted knife block had a sticky, colored substance, and while the knives themselves were clean, the area above the block had not been cleaned as required. Further inspection of the walk-in freezer revealed open and undated boxes of carrots and beef burgers, which the DODS acknowledged were susceptible to freezer burn and should have been sealed and dated. A metal tray containing an unidentified food item was also found, covered with torn plastic wrap and foil, with unclear dating. The DODS was unable to explain the labeling or the presence of the tray. The facility's sanitation policy requires all food service areas to be maintained in a clean and sanitary manner, but these observations demonstrated non-compliance with those standards. The Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) acknowledged the surveyor's concerns during the exit interview.
Failure to Adhere to Medication Administration and Catheter Care Standards
Penalty
Summary
The facility failed to administer medication according to physician's orders and did not ensure proper care and documentation for a midline catheter site, as required by professional standards. For one resident with a diagnosis including malignant neoplasm of the left renal pelvis and urinary retention, the medical record review showed that several doses of lidocaine hydrochloride gel, ordered for topical application twice daily, were not signed off as administered on the Medication Administration Record (MAR). Interviews with the LPN/Unit Manager and the Director of Nursing confirmed that the absence of documentation indicated the medication was not given, and there was no alternative documentation to support administration of the missed doses. In another case, a resident with chronic respiratory failure, anoxic brain damage, and neurogenic bladder had a peripherally inserted catheter (PIC) in the left forearm. Observation revealed the dressing was not labeled or dated as required. Review of the Treatment Administration Record (TAR) showed that the dressing change and site check orders were not consistently documented, with missing signatures on the TAR and an undated dressing at the time of observation. The Infection Preventionist and DON both stated that dressings should be dated to prevent infection and ensure proper treatment completion. Facility policies reviewed by the surveyor required that medications be documented as administered or withheld, and that IV dressings be labeled with the date and time of change. The failures identified were confirmed through interviews and record reviews, with staff acknowledging the lack of documentation and adherence to policy in both medication administration and catheter site care.
Failure to Report Resident Injury to State Authorities
Penalty
Summary
A facility failed to report an injury involving a severely cognitively impaired resident to the New Jersey Department of Health (NJDOH). The resident, who had diagnoses including Alzheimer's Disease, dementia, and hypertension, had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating severe cognitive impairment. According to the medical record and incident report, the resident was found face down on the floor after falling from a wheelchair while reaching for candy, resulting in a head laceration. The resident was transferred to the hospital, where they received seven staples to the forehead for the injury. Review of the incident report and facility documentation did not show evidence that the NJDOH had been notified of the incident, as required. During interviews, facility staff stated that the incident had been investigated and reported to the NJDOH by a previous administrator, but no documentation was provided to confirm this. The surveyor did not receive any additional documentation indicating that the NJDOH had been contacted regarding the incident.
Failure to Accommodate Resident Activity Needs and Preferences
Penalty
Summary
The facility failed to accommodate the needs and preferences related to activities for two residents with severe cognitive impairment and dependence on staff for activities of daily living and transfers. Both residents had care plans indicating a need for staff assistance to participate in activities, cognitive stimulation, and social interaction, with interventions specifying that all staff should assist and invite them to scheduled activities. However, documentation revealed that one resident had not had a documented activity since early January, and the other since early September, despite scheduled activity visits. Interviews with the activities director confirmed that activities for bedbound residents were only completed 2-3 times a week and that documentation was often lacking due to time constraints. Additionally, an interview with one resident and a family member confirmed that the resident had not left the room to participate in scheduled activities, nor were any activities provided in the room. The activities director acknowledged the importance of activities for socialization and engagement but admitted that documentation was inconsistent and that there should be some form of documentation for activity encounters. No further documentation was provided to support that the scheduled activity visits actually occurred for the two residents in question.
Delayed Response to Call Bell for Resident with Tracheostomy
Penalty
Summary
A deficiency was identified when staff failed to answer a resident's call bell in a timely manner. The resident, who had chronic respiratory failure, a tracheostomy, and was dependent on a ventilator, was observed in bed with a call light within reach. The resident activated the call light and later began coughing, stating a need for suctioning. Despite the call light being on and the alarm sounding at the nurses' station, staff did not respond immediately. The surveyor observed a nurse and other staff in the hallway, with the call light indicator visible, but no one entered the room until prompted by the surveyor. The respiratory therapist arrived several minutes later to provide suctioning, after which the resident reported relief. Interviews with staff confirmed that call bells should be answered immediately or as soon as possible, especially in urgent situations. The facility's policy requires calls for assistance to be answered as soon as possible, but no later than five minutes, with urgent requests addressed immediately. The delay in responding to the resident's call bell, particularly given the resident's respiratory needs, constituted a failure to provide appropriate and timely care as per facility policy and physician orders.
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What surveyors actually found near you
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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 Matawan
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Complete Care At Madison, Llc | 1.3 mi | ★★★★★ | 14 | 0 |
| Complete Care At Bayshore Llc | 2.3 mi | ★★★★★ | 2 | 0 |
| Careone At Holmdel | 2.8 mi | ★★★★★ | 0 | 0 |
| Anchor Care And Rehabilitation Center | 2.9 mi | ★★★★★ | 0 | 0 |
| Preferred Care At Old Bridge, Llc | 4.6 mi | ★★★★★ | 2 | 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.