Cycle 1
Health 2025-05-20 · Fire 2025-05-20
7 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
8 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Matawan, NJ
Meadowbrook Respiratory And Nursing Center
2-star overall rating with 2-star inspections with $48,266 in total fines with 7 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
38 Freneau Avenue, Matawan, NJ
(732) 765-5600
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
130
Certified beds
Average residents
99
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Atlas Healthcare
Operator or chain grouping
Approved since
2000-06-13
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
28 facilities
Chain averages 4 overall / 3 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.65
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
1.14
Licensed practical nurse staffing · state 0.94 · national 0.87
Aide hours / resident day
3.36
Nurse aide staffing · state 2.23 · national 2.35
Total nurse hours
5.16
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.79
RN + LPN hours · state 1.62 · national 1.54
Weekend hours
4.67
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.42
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.54
CMS adjusted RN staffing hours
Adjusted total hours
4.25
CMS adjusted total nurse staffing hours
Case-mix index
1.66
Higher values indicate more complex resident acuity
RN turnover
42%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,735
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
10.78
Composite VBP score used to determine payment impact.
Payment multiplier
0.9809
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.02
Baseline 21.45% · Performance 20.96% · Measure score 1.02 · Achievement 1.02 · Improvement 0.62
Healthcare-associated infections
0
Baseline 8.83% · Performance 8.79% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
1.95
Baseline 46.03% · Performance 55.70% · Measure score 1.95 · Achievement 1.95 · Improvement 0
Adjusted total nurse staffing
1.34
Baseline 2.64 hours · Performance 3.22 hours · Measure score 1.34 · Achievement 0 · Improvement 1.34
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.32% |
10.72%
1.4 pts better
|
No Different than the National Rate · Eligible stays 122 · Observed rate 8.2% · Lower 95% interval 6.98% |
| Discharge to community | 56.26% |
50.57%
5.7 pts better
|
No Different than the National Rate · Eligible stays 138 · Observed rate 39.13% · Lower 95% interval 47.69% |
| Medicare spending per beneficiary | 1.34 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 98.91% |
95.27%
3.6 pts better
|
Numerator 182 · Denominator 184 |
| Falls with major injury | 1.63% |
0.77%
0.9 pts worse
|
Numerator 3 · Denominator 184 |
| Discharge self-care score | 60.98% |
53.69%
7.3 pts better
|
Numerator 50 · Denominator 82 |
| Discharge mobility score | 53.66% |
50.94%
2.7 pts better
|
Numerator 44 · Denominator 82 |
| Pressure ulcers or injuries, new or worsened | 3.26% |
2.29%
1 pts worse
|
Numerator 6 · Denominator 184 · Adjusted rate 2.06% |
| Healthcare-associated infections requiring hospitalization | 8.79% |
7.12%
1.7 pts worse
|
No Different than the National Rate · Eligible stays 95 · Observed rate 20% · Lower 95% interval 6.14% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 122 |
| Staff flu vaccination coverage | 99.17% |
42%
57.2 pts better
|
Numerator 119 · Denominator 120 |
| Discharge function score | 56.1% |
56.45%
0.4 pts worse
|
Numerator 46 · Denominator 82 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 97 · Denominator 97 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 41 · Denominator 41 |
| Resident COVID-19 vaccinations up to date | 14.42% |
25.2%
10.8 pts worse
|
Numerator 15 · Denominator 104 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
2.1
0.1 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 3.6 · Expected 3.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
1.1
0.4 pts worse
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.7 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 68.0% |
93.0%
25 pts worse
|
93.4%
25.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 63.8% · Q2 66.7% · Q3 71.3% · Q4 70.1% · 4Q avg 68.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 89.0% |
97.2%
8.2 pts worse
|
95.5%
6.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 89.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.9% |
2.4%
1.5 pts better
|
3.3%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.1% · Q3 1.1% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 8.3% |
11.4%
3.1 pts better
|
11.4%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 6.7% · Q3 9.3% · Q4 12.8% · 4Q avg 8.3% |
| Percentage of long-stay residents who lose too much weight | 3.1% |
4.6%
1.5 pts better
|
5.4%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 6.0% · Q3 1.2% · Q4 0.0% · 4Q avg 3.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.8% |
19.0%
5.8 pts worse
|
19.6%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.6% · Q2 27.1% · Q3 23.2% · Q4 22.6% · 4Q avg 24.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.4% |
13.5%
0.1 pts better
|
16.7%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 14.3% · Q3 12.9% · Q4 12.1% · 4Q avg 13.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 2.6% |
9.8%
7.2 pts better
|
16.3%
13.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 4.5% · Q4 0.0% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.4% |
9.7%
3.3 pts better
|
14.9%
8.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.2% · Q2 6.6% · Q3 4.6% · Q4 4.7% · 4Q avg 6.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.7%
0.7 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 8.2% |
15.9%
7.7 pts better
|
19.8%
11.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 6.6% · Q3 10.0% · Q4 6.5% · 4Q avg 8.2% |
| Percentage of long-stay residents with pressure ulcers | 4.8% |
6.0%
1.2 pts better
|
5.1%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 5.6% · Q3 5.2% · Q4 5.6% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 19.6% |
78.7%
59.1 pts worse
|
81.7%
62.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 20.4% · Q2 22.2% · Q3 18.2% · Q4 17.6% · 4Q avg 19.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.8% |
8.2%
0.6 pts worse
|
12.0%
3.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.8% · Observed 11.5% · Expected 14.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.8% |
1.2%
1.6 pts worse
|
1.6%
1.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 3.8% · Q3 3.6% · Q4 0.0% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 43.4% |
80.1%
36.7 pts worse
|
79.7%
36.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 43.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.8% |
25.4%
1.6 pts better
|
23.9%
0.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.8% · Observed 40.8% · Expected 40.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-05-08 · Fire 2023-05-08
10 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2021-03-19 · Fire 2021-03-19
3 health deficiencies
Top issue: Administration (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-20
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2025-06-17
F · Potential for more than minimal harm
2025-05-20
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-06-17
F · Potential for more than minimal harm
2025-05-20
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-06-17
F · Potential for more than minimal harm
2025-05-20
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-06-17
F · Potential for more than minimal harm
2025-05-20
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-06-17
F · Potential for more than minimal harm
2025-05-20
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-06-17
F · Potential for more than minimal harm
2025-05-20
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-06-17
E · Potential for more than minimal harm
2025-05-20
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-06-17
F · Potential for more than minimal harm
2023-05-08
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-06-09
F · Potential for more than minimal harm
2023-05-08
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-06-09
F · Potential for more than minimal harm
2023-05-08
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-06-09
F · Potential for more than minimal harm
2023-05-08
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-06-09
F · Potential for more than minimal harm
2023-05-08
K915 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper power supply for life support equipment.
Corrected 2023-06-14
E · Potential for more than minimal harm
2023-05-08
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-06-09
E · Potential for more than minimal harm
2023-05-08
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-06-09
E · Potential for more than minimal harm
2023-05-08
K907 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure medical gas and vacuum systems have documented maintenance programs.
Corrected 2023-06-09
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-05-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-17
E · Potential for more than minimal harm
2025-05-20
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-06-17
E · Potential for more than minimal harm
2025-05-20
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-06-17
D · Potential for more than minimal harm
2025-05-20
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-06-17
D · Potential for more than minimal harm
2025-05-20
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-06-17
D · Potential for more than minimal harm
2025-05-20
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-06-17
D · Potential for more than minimal harm
2025-05-06
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-05-30
D · Potential for more than minimal harm
2025-02-24
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-04-04
D · Potential for more than minimal harm
2025-02-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-04
L · Immediate jeopardy
2023-07-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-08
F · Potential for more than minimal harm
2023-07-18
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2023-08-08
E · Potential for more than minimal harm
2023-05-08
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-06-09
E · Potential for more than minimal harm
2023-05-08
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-06-09
E · Potential for more than minimal harm
2023-05-08
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-06-09
D · Potential for more than minimal harm
2023-05-08
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-06-09
D · Potential for more than minimal harm
2023-05-08
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-06-09
D · Potential for more than minimal harm
2023-05-08
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-06-09
D · Potential for more than minimal harm
2023-05-08
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-06-09
D · Potential for more than minimal harm
2023-05-08
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-06-09
F · Potential for more than minimal harm
2021-03-19
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2021-03-25
Penalties and ownership
What sits behind the stars
$48,266
2023-07-18
Fine
Fine · fine $48,266
Fine
Ownership
Mw SNF Operations Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Bak, Pinchos
Operational/Managerial Control · Individual
Bak, Pinchos
Corporate Officer · Individual
Cohen, Robert
Operational/Managerial Control · Individual
Goldberger, Shlomo
Operational/Managerial Control · Individual
Herzka, David
5% Or Greater Indirect Ownership Interest · Individual
Herzka, David
Limited Partnership Interest · Individual
Jmh Family LLC
5% Or Greater Indirect Ownership Interest · Organization
Jmh Family LLC
Limited Partnership Interest · Organization
Jmh Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Jmh Family Trust
Limited Partnership Interest · Organization
Malt Family Trust
Limited Partnership Interest · Organization
Manzoor, Adil
Operational/Managerial Control · Individual
Mls Family LLC
5% Or Greater Indirect Ownership Interest · Organization
Mls Family LLC
Limited Partnership Interest · Organization
Mls Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Mls Family Trust
Limited Partnership Interest · Organization
Morin, Victoria
Operational/Managerial Control · Individual
Mw SNF Opco Manager LLC
Operational/Managerial Control · Organization
Sgs 2010 Family Trust
Limited Partnership Interest · Organization
Sgs Family LLC
5% Or Greater Indirect Ownership Interest · Organization
Sgs Family LLC
Limited Partnership Interest · Organization
Sgs Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Sgs Family Trust
Limited Partnership Interest · Organization
Sonnenschein, Moshe
Operational/Managerial Control · Individual
Tyh 2017 Trust
Limited Partnership Interest · Organization
Nearby options
Other facilities in reach
#1
Complete Care At Madison, LLC
Matawan, NJ
4-star overall rating with 3-star inspections with 8 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#2
Complete Care at Bayshore LLC
Holmdel, NJ
4-star overall rating with 3-star inspections with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Careone At Holmdel
Holmdel, NJ
5-star overall rating with 4-star inspections with 6 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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