New Jersey Veterans Memorial Home Menlo

Inspectors wroteBased on observation, record review, interviews, and policy review, the facility failed to ensure staff used respectful and appropriate identifiers during meal service on one of six resident units (Independence Unit) reviewed for dignity. This failure had the potential to contribute to a negative outcome related to the promotion and respect of resident well-being and quality of life.

Inspectors wroteBased on record review, and interviews, the facility failed to invite one resident (Resident (R)2) out of a total sample of 35 residents to participate in the care plan process. This failure had the potential to deny residents the opportunity to be able to make decisions about the care they receive.

Inspectors wroteBased on record review, interview, document review, and policy review, the facility failed to update the code status in all records to Do Not Resuscitate (DNR) for two of 33 (Resident (R)16 and R171) residents reviewed for code status out of a total sample of 35 residents. This failure increased the likelihood of causing severe harm or death if CPR (Cardiopulmonary Resuscitation) was performed against a resident's wishes if found unresponsive with no pulse or no breathing.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure a written transfer notice that contained all required information was provided for three of three residents and/or their representatives (Resident (R) 4, R1, and R6) reviewed for hospital transfer out of 35 sample residents. This failure had the potential to result in the resident and their Resident Representative (RP) not having the knowledge of where and why a resident was transferred and/or how to appeal the transfer, if desired.

Inspectors wroteBased on observations, record review, interviews, and policy review, the facility failed to accurately assess one resident (Resident (R)143) for nutritional needs regarding R143's weight gain out of a total sample of 35 residents This failed practice had the potential to cause unmet nutritional needs.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure one of one resident (Resident (R)133) reviewed for wander guards out of a total sample of 35 residents was appropriately screened and had documentation to support the use of the wander guard. This failure had the potential to restrict R133's movement about the unit when the alarm would sound when R133 was near an exit door.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure a resident's nasal cannula and nebulizer mask were stored properly when not in use for one of two residents reviewed for oxygen therapy (Resident (R) 94) out of a total sample of 35 residents. This failure had the potential to increase the risk of a respiratory infection for residents receiving respiratory therapies.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to have collaboration of care involving dialysis for one of three residents (Resident (R)16) reviewed for dialysis out of a total sample of 35 residents. This failure had the potential for inaccurate or missing clinical information not being communicated to the right people.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure residents received alternative measures prior to the installation of side rails, documented discussion related to risk versus benefits, and signed informed consent for one of four residents (Resident (R)133 reviewed for side rails out of 35 sampled residents. The lack of alternate side rail measures and proper assessment/consent could lead to potential restraint or side rail entrapment.

Inspectors wroteF658 remains a deficiency at a scope and severity of a D based on the following: Part D Based on observation, interview, and record review, it was determined that the facility failed to a.) assure accurate documentation of administration, and documentation of blood pressure (BP) parameters as ordered by the physician in accordance with professional standards, b.) administer Extended Release (ER) medication per manufacturer's guidelines, and c.) assure accurate documentation of administration and placement of a medication patch. This deficient practice was identified for 2 of 4 residents reviewed (Resident #15, #37), during medication pass and reconciliation (ensures accuracy of information) after a medication pass 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 wroteReference F 600, F 658, F 880 and F 886 Based on observations, interviews, review of medical records and review of facility documents, it was determined that the facility Licensed Nursing Home Administrator (LNHA) failed to ensure: [...]

Inspectors wrotePart A Based on interview and review of pertinent documents, it was determined that the facility, who has been in an active COVID-19 outbreak status since 11/23/21, failed to conduct immediate and thorough contact tracing to further prevent the spread of COVID-19 (a deadly virus) by failing to ensure: a.) a process was in place to conduct comprehensive contact tracing upon the identification of a single new case of COVID-19 in a staff or resident. b.) a facility contact tracing policy was completed and implemented, c.) appropriate staff were trained on the contact tracing policy, d.) the facility followed all Centers for Disease Control (CDC), local health department, state health department, and all current guidance related to infection control. [...]

Inspectors wroteBased on interviews and review of pertinent documents, it was determined that the facility failed to ensure: a.) a process was followed to initiate immediate action, and conduct COVID-19 testing upon the identification of a single COVID-19 positive result, b.) that staff who were exposed were COVID-19 tested prior to working at the facility, c.) Federal, State and infection control guidelines were followed, and d.) the facility Infectious Disease Outbreak Response Plan was followed to prevent exposure and mitigate the spread of COVID-19, a deadly highly transmissible infectious disease. [...]

Inspectors wroteComplaint #NJ156886 Based on interview, record review, and review of other facility documents, it was determined that the facility failed to ensure a resident who sustained a fall with a possible fractured arm received a timely recommended medical follow-up by failing to: a.) thoroughly review the After Visit Summary (discharge hospital summary) and communicate the recommendations to the physician, and b.) thoroughly review an X-Ray report received on 07/13/22, and alert the physician of the recommended follow-up with more films to confirm the possible fracture detected on the X-Ray. This deficient practice occurred for 1 of 47 sampled residents reviewed (Resident #44) who sustained a fall with a hematoma (collection of blood outside of blood vessels) on the forehead on 07/12/22. There was a 12 day delay from 07/13/22 to 07/25/22. [...]

Inspectors wroteBased on observation, interviews and review of facility documentation it was determined that the facility failed to a.) properly handle and store potentially hazardous foods in a manner that is intended to prevent the spread of food borne illnesses and b.) maintain equipment in a manner to prevent microbial growth and cross contamination. This deficient practice was observed and evidenced by the following: On 08/16/22 from 10:29 AM to 12:43 PM, the surveyor toured the kitchen in the presence of the Assistant Food Service Director (AFSD) and observed the following: 1. In refrigerator #2, there was a wheeled metal cart that was covered with an unlabeled and undated clear plastic bag, that the AFSD identified as the breakfast cart, which contained: [...]

Inspectors wroteBased on interview and document review it was determined facility failed to: a.) ensure that the facility Quality Assurance Improvement Program (QAP), identified, developed and implemented Quality Assurance Improvement Plans (QAPI) to address areas related to infection prevention and control related to an ongoing COVID-19 outbreak that began on 11/23/21, b.) ensure all infections and antibiotic usage was monitored by the QAP, and c.) ensure the QAP monitored all 13 clinical areas per facility policy. The deficient practice impacted 5 of 5 currently occupied resident units and was evidenced by the following: Refer to 886L, 880L, 881F On 08/16 22 at 10:24 AM, during the entrance conference held with the facility administration, the administration informed the survey team that the facility was presently in an outbreak of COVID-19 which began on 11/23/21. [...]

Inspectors wroteComplaint # NJ00157129 B. Based on interviews, and record review, it was determined that the facility failed to ensure that care plan interventions were being followed and that direct care staff were consistently following the person-centered care plan. This deficient practice was identified for Resident #29 one of 2 residents reviewed for abuse and was evidenced by the following: On 08/16/22 at 11:45 AM the surveyor observed Resident #29 in bed. The head of the bed was elevated, Resident #29 was alert and able to answer some simple questions. On 08/19/22 at 11:00 AM, the surveyor conducted an interview with the Certified Nursing Assistant ( CNA ) assigned to Resident # 29. The CNA stated that Resident #29 was a total care, does not get out of the bed by choice, had behavior of being accusatory toward staff. [...]

Inspectors wroteBased on observation, interviews, and record review, it was determined that the facility failed to a.) ensure that the physician responsible for supervising the care of residents conducted face-to-face visits and wrote progress notes at least every thirty days for the first ninety days of admission. b.) Ensure all residents were seen by the physician or nurse practitioner every thirty days with a physician visit at least every sixty days. This deficient practice was observed for 14 of 47 residents (Resident #8, #24, #50, #59, #64, #83, #84, #78, #87, #92, #106, #122, #125 and #187) reviewed. Reference: [...]

Inspectors wroteBased on observation, interview, and review of clinical medical records it was determined that the facility failed to ensure that a resident received therapy services based on a physical therapy and occupational therapy resident screening that was done on 04/21/22, for a period of four (4) months. This deficient practice was identified for 1 of 1 resident (Resident #152) reviewed for rehabilitation and was evidenced by the following: The Resident Face Sheet indicated that Resident #152 was admitted to the facility in April of 2022. [...]

Inspectors wroteBased on interview and document review, it was determined that the facility failed to ensure: 1.) full implementation of the Antibiotic Stewardship (AS) program, including ongoing monitoring, and 2.) consistent use of a nationally recognized surveillance criteria prior to consulting with the prescriber as per facility policy. The deficient practice occurred for 3 of 3 months reviewed (May 2022, June 2022, and July 2022) for AS and was evidenced by the following: Refer to F865 F 1.) On 08/30/22 at 10:27 AM, the surveyor interviewed the Infection Preventionist Registered Nurse (IP/RN) regarding the AS program. The IP/RN stated that the AS program was started in either 2018 or 2019 and was being re-launched. [...]

Inspectors wroteBased on observations, interviews, review of clinical records and other facility documentation, it was determined that the facility failed to: a) provide nutritional supplements recommended by a Registered Dietician (RD) to address a weight loss b) obtain resident re-weights in accordance with the facility policy for a resident with a weight change of three or more pounds c) administer enteral tube feeding (allows food to enter the stomach or intestine through a tube) at the prescribed rate. This deficient practice was identified for 2 of 6 residents reviewed (Resident #152, Resident #59) for nutrition and was evidenced by the following: 1. On 08/16/22 at 11:05 AM during tour, Surveyor #1 observed Resident #152 who was seated in a wheelchair in the dayroom and appeared both thin and frail. [...]