Meadowbrook Respiratory and Nursing Center

Inspectors wroteBased on observation, interview and review of pertinent facility documents, it was determined that the facility failed to act upon Consultant Pharmacy recommendations to provide adequate monitoring for the use of as needed psychoactive medications. This deficient practice was identified for 1 of 5 residents reviewed for unnecessary medications (Resident #55), and was evidenced by the following: On 5/12/25 at 11:15 AM, the surveyor observed Resident #55 self-propelling in a wheelchair on the first floor of the building. The resident told the surveyor they were just out on a smoking break. A review of the admission Record face sheet (an admission summary) revealed Resident #55 was admitted to the facility with medical diagnoses which included but were not limited to; malnutrition, major depression, respiratory failure, and anxiety disorder. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure blood pressure medication was administered in accordance to physician ordered parameters to prevent significant medication errors. This deficient practice was identified for 1 of 27 residents (Resident #7) reviewed for professional standards of practice, and was evidenced by the following: On 5/12/25 at 10:46 AM, during initial tour of the facility, the surveyor observed Resident #7 sleeping in their bed. On 5/13/25 at 10:10 AM, the surveyor reviewed the medical record for Resident #7. A review of the admission Record face sheet (admission summary) reflected that the resident was admitted to the facility with diagnosis that included but not limited to; hypertension (high blood pressure). [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to maintain the residents' living environment in a clean, comfortable, homelike manner. This deficient practice was identified on 1 of 3 nursing units observed, and was evidenced by the following: On 5/12/25 at 10:55 AM, during initial tour of the facility, the surveyor observed Resident #45 resting in bed. The wall behind the bed appeared to have a spackled and dried patch approximately two feet wide which was unpainted and unfinished. The resident stated that the wall had that appearance for at least a couple months and that the resident did not like it. On 5/12/25 at 11:06 AM, during initial tour of the facility, the surveyor observed Resident #24 sitting in a wheelchair and watching television in their room. [...]

Inspectors wroteNJ Complaint: NJ176627 Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) administer medication according to the physician's orders and b.) ensure a resident received care and services for the provisions of observation, documentation, measurements and dressing changes to a midline catheter (peripherally inserted catheter (PIC)) site consistent with a physician's order and professional standards of practice. This deficient practice was identified for 2 of 27 residents reviewed for professional standards of practice (Resident #60 & Resident #241), and was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to maintain kitchen equipment in a clean and sanitary manner, as evidenced by the following: On 5/12/25 at 10:04 AM, in the presence of the Director of Dietary Services (DODS), the surveyor observed the following during kitchen tour: 1. Two of two convection ovens were soiled with baked on brown coloring on the glass doors and interior of the unit. The DODS acknowledged and stated, it was not cleaned according to facility policy. 2. The six-burner stove top and oven were covered with cooked on grease and sediment crusted around the burners. The oven had food sediment and debris on the interior and the interior door. The catch tray that was lined with foil had burnt liquid, and food debris covering the entire tray and foil. [...]

Inspectors wroteComplaint #NJ184589, NJ184632 Based on interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to a.) follow the Wound Care Practitioner's (WCP) treatment recommendations for a newly identified wound and document accurate measurements after a wound was identified and b.) obtain a treatment order for a skin tear identified on the left wrist from 11/29/24 until 12/6/24. This deficient practice was identified for 1 of 4 residents reviewed for accidents (Resident #141), and was evidenced by the following: A review of the admission Record face sheet (admission summary) reflected that Resident #141 was admitted to the facility with the diagnoses which included but was not limited to; peripheral vascular disease (PVD; is a slow and progressive disorder of the blood vessels), atherosclerotic cardiovascular disease (ASCVD; [...]

Inspectors wroteCOMPLAINT#: NJ00182326 Based on observations, interviews, medical records review, and review of other pertinent facility documentation on 5/6/25 it was determined that the facility failed to report an injury of a severely cognitively impaired resident to the New Jersey Department of Health (NJDOH). This deficient practice was identified for 1 of 2 (Resident #1) residents sampled for falls and was evidenced by the following: Resident #1 was not at the facility at the time of the survey. A closed record review was conducted. The surveyor reviewed Resident #1's admission Record (AR) which revealed that the resident was admitted to the facility with diagnoses which included but were not limited to: Alzheimer's Disease, dementia, and hypertension. [...]

Inspectors wroteBased on interviews and record review, as well as review of pertinent facility documents on 02/20/25, 02/21/25, and 02/24/25, it was determined that the facility failed to accommodate a residents' need and preference related to activities for 2 of 3 residents (Resident #2 and Resident #4). This deficient practice is evidenced by the following: 1. According to the admission Record, Resident #2 was admitted 10/2019 to the facility with diagnoses which included but were not limited to: Acute and Chronic Respiratory Failure, Tracheostomy Status (a hole a surgeon makes through the neck and into the windpipe, where a tube is placed to help with breathing), and Dependence on Respirator (Ventilator) Status. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure that residents' call bells were answered in a timely manner. This deficient practice was identified for 1 of 8 (Resident #4) sampled residents and was evidenced by the following: According to the admission Record, Resident #4 was admitted on 11/23 with diagnoses including but not limited to: Chronic Respiratory Failure, Tracheostomy status (a hole a surgeon makes through the neck and into the windpipe, where a tube is placed to help with breathing), and Dependence on Respirator (Ventilator) Status. The Minimum Data Set (MDS), an assessment tool, dated 11/30/24 revealed that Resident #4 had severely impaired cognition and was dependent on staff for Activities of Daily Living (ADL) and transfers. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents it was determined that the facility failed to maintain proper infection control practices during tracheostomy care. This deficient practice was identified for 2 of 2 residents observed for tracheostomy care (Resident #16 and #70), and was evidenced by the following: 1. On 4/26/23 at 10:21 AM, the surveyor observed Resident #16 in their room in bed. The resident had a tracheostomy (trach; a surgically made hole through the front of the neck into the trachea (windpipe) with a tube placed through the hole to help the person breath) which was attached to a ventilation system (breathing machine that helps or breathes for a person). The surveyor reviewed the medical record for Resident #16. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure: a.) non-pharmalogical interventions were attempted prior to the administration of an anti-anxiety medication; and b.) specific target behaviors were monitored prior to the administration of an anti-anxiety medication for a resident who received an anti-anxiety medication (Xanax) since March of 2023. This deficient practice was identified for 1 of 5 residents reviewed for unnecessary medications (Resident #47), and was evidenced by the following: On 4/26/23 at 11:47 AM, the surveyor observed Resident #47 sitting in a wheelchair in their room eating lunch. Resident #47 stated they had a diabetic foot ulcer and went to the dialysis center twice a week. The surveyor reviewed the medical record for Resident #47. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to ensure safe and appetizing temperatures of food for 4 of 5 entree meals observed during 2 of 2 meal observations (breakfast and lunch). This deficient practice was evidenced by the following: On 4/28/23 at 10:00 AM, the surveyor conducted a Resident Council meeting which included four residents (Resident #26, #31, #63, and #64). All four residents informed the surveyor that all meals served at the facility were cold. Resident #26 stated that the residents had been complaining for months at their council meetings to the facility about the cold food. On 5/3/23 at 11:32 AM, the surveyor informed the Dietary Supervisor (DS) they wanted to observe the lunch meal for the day including food temperatures. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to thoroughly investigate an injury of unknown origin to rule out abuse and neglect for a resident identified on 3/13/23. This deficient practice was identified for 1 of 6 residents reviewed for accidents (Resident #14), and was evidenced by the following: On 4/26/23 at 11:24 AM, the surveyor observed Resident #14 in their room. The resident was lying in bed with the head of the bed elevated, with the bed in the lowest position and a fall prevention mat on the floor next to the bed. On 4/26/23 11:41 AM, the surveyor interviewed Resident #14 who stated he/she could not walk at all and could not remember if they had any falls or injuries lately. The surveyor reviewed the medical record for Resident #14. [...]

Inspectors wroteBased on observation, interview, and review of pertinent documents, it was determined that the facility failed to communicate a recommendation for a decrease in the administration frequency for an anti-anxiety medication (Klonopin) used on an as needed basis to the physician in accordance with professional standards of practice. This deficient practice was identified for 1 of 23 residents reviewed for standards of practice (Resident #28) and was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of casefinding; [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) maintain medication carts free from unmarked and unwrapped medications, and ensure a shift to shift narcotic accountability count was completed for 1 of 3 medication carts observed (Second-Floor high-side) on 1 of 2 nursing units (Second-Floor); and b.) ensure an accurate ordering and receiving of narcotic medications on the required Federal narcotic acquisition forms (DEA 222 forms) were completed with sufficient detail to enable accurate reconciliation for 1 of 6 forms provided. The evidence was as follows: 1. On 4/27/23 at 12:45 PM, in the presence of the Licensed Practical Nurse (LPN), the surveyor inspected the Second-Floor nursing unit high-side medication cart and observed inside the top drawer, two tablets in a small plastic cup, unmarked. [...]

Inspectors wroteBased on observation, interview, and review of facility documentation, it was determined that the facility failed to maintain kitchen equipment in a manner to prevent microbial growth. This deficient practice was evidenced by the following: On 4/26/23 at 9:26 AM, the surveyor toured the kitchen with the Dietary Director (DD), Dietary Supervisor (DS), and Registered Dietitian (RD). The surveyor observed the following: The cutting board on the steam table tray line was discolored black, brown, and reddish with the plastic peeling off and deeply pitted. The DD stated that the facility used that cutting board to cut food such as sandwiches on the tray line during meal service. The DD stated that the dietary staff first wrapped the board in aluminum foil and plastic wrap prior to cutting food on it. [...]

Inspectors wroteBased on observation, interview, review of the medical record, and other facility documentation, it was determined that the facility failed to maintain an accurate, complete, and easily accessible medical record. This deficient practice was identified for 1 of 22 resident medical records reviewed (Resident #88), and was evidenced by the following: 1. On 4/26/23 at 12:10 PM, the surveyor observed Resident #88 sitting outside their room eating lunch. The surveyor attempted to interview the resident at this time who was non-responsive. The surveyor reviewed the medical record for Resident #88. A review of the admission Record face sheet (an admission summary) reflected the resident was admitted to the facility in March of 2023 with diagnoses which included unspecified fracture of the right femur (thigh bone); adjustment insomnia; bipolar disorder; [...]

Inspectors wroteBased on observation, interview, and document review, it was determined that the facility failed to a.) perform hand hygiene and properly wear a hair restraint during a meal service, b.) store food items in a manner to ensure they are not used beyond safe use by dates, and c.) maintain kitchen equipment in a manner to prevent microbial growth, cross contamination and avoid the potential for food borne illness. This deficient practice was evidenced by the following: On 03/11/21 at 9:55 AM, two surveyors completed an initial tour of the kitchen in the presence of the Director of Dietary (DD) and observed the following: 1. A box of partially frozen chicken was located on a shelf inside the walk-in refrigeration unit. The chicken had a white sticker that was dated 02/05/21 and did not contain a use by date. [...]