Above average — CMS composite of the measures below.
A standard survey is most likely before around December 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 New Jersey Veterans Memorial Home Menlo during CMS and state inspections, most recent first.
Improper Resident Labeling During Meal Service: Staff on the Independence Unit referred to residents who needed meal assistance as "Feeders" during lunch service and on assignment sheets posted at nurses' stations. A CNA, another CNA, and a CHN all used the term in the presence of residents, and staff interviews confirmed the label was routinely used to identify residents needing help with meals.
Failure to Invite Resident to Care Plan Meeting: A cognitively intact resident with diagnoses including dementia, DM2, Parkinson's disease, spinal stenosis, muscle weakness, and cellulitis was not shown to have been invited to participate in her care plan meetings. The resident stated she had never attended a care plan meeting since admission, and the SSD confirmed there was no charted evidence that she was invited, despite the facility's practice of verbal invites to residents and letters to resident representatives.
Two residents had code status records that did not match their current POLSTs. For one resident with dementia, the chart, roster, and dialysis notebook still showed Full Code even though the POLST and a physician order indicated DNR/DNI. For another resident with dementia and severely impaired cognition, the paper chart’s physician order summaries still showed Full Code despite a POLST indicating DNAR. Staff interviews showed inconsistent use of the POLST and outdated code status documents in the chart.
The facility failed to provide written transfer notices with required information for three residents who were sent to the hospital. Records and staff interviews showed that although transfer paperwork was sent to the hospital or family, there was no documentation that the residents received notice of the reason for transfer, appeal rights, or Ombudsman contact information. One resident was cognitively intact and another had an acute change in condition with hypotension and hypoxia before transfer.
Inaccurate Nutritional Assessment on MDS: A resident with severe cognitive impairment and Alzheimer’s disease had an MDS that incorrectly documented unplanned weight loss despite EMR weights showing significant weight gain over time. The RD identified the entry error, and the DCEO, DON, and MDSC confirmed the MDS was not accurate and that the nutritional status section should reflect correct resident information.
Wander Guard Used Without Supporting Elopement Risk Documentation: A resident with dementia and severe cognitive impairment had a physician order for a wander guard, but repeated elopement risk assessments showed no elopement risk and the chart contained no wandering or exit-seeking behaviors. Staff interviews confirmed the resident was confused but not exit seeking, yet the wander guard remained in place on the right ankle.
A resident with COPD and severe cognitive impairment was ordered continuous oxygen via nasal cannula and PRN nebulizer treatments, but observations showed the nasal cannula and nebulizer mask left uncovered and stored in inappropriate locations when not in use. An LPN confirmed the equipment was uncovered and said it should be bagged for infection control; the DON also stated respiratory equipment should be covered in a bag when not in use.
Incomplete dialysis communication and assessment documentation. A resident with ESRD receiving dialysis had multiple omissions on the dialysis communication record, including blank fields for access site assessment and, on one occasion, no vital signs documented. RN and DON interviews confirmed the facility nurse was responsible for completing the form, including vital signs and access questions, and the resident had two dialysis access sites.
A resident with dementia, depression, psychotic disorder, and severe cognitive impairment had side rails on the bed, but the facility had no side rail assessment process and no physician order for bilateral quarter side rails. Staff stated the facility used enablers instead of side rails, yet there was no documented discussion of risks and benefits, no signed informed consent, and no record of alternatives attempted before side rail use.
Improper Resident Labeling During Meal Service
Penalty
Summary
The facility failed to ensure staff used respectful and appropriate identifiers during meal service on the Independence Unit. During an observation of lunch service, staff members referred to residents as "Feeders" while pointing to residents and tables in the dining room, including a CNA stating, "They're a Feeder," another CNA asking if a resident was also a "Feeder," and a charge nurse stating that residents were "Feeders." On a separate observation, a CNA again pointed to the meal cart and asked whether a resident was now a "Feeder." Review of assignment sheets placed at nurses' stations on multiple units showed residents identified by name as "Feeders" on the meal assistance assignment sheets. Staff interviews confirmed that the term "Feeder" was used to identify residents who required meal assistance, and staff stated they were not aware whether the label was a dignity issue. The charge nurse confirmed she helped complete the assignment staffing form and that "Feeder" was used to identify residents needing meal assistance. The DON reviewed the assignment sheet and stated he would change the form to read "Assist with Meals," confirming that "Feeders" described an action and not a resident need and was not appropriate to say in the presence of residents.
Failure to Invite Resident to Care Plan Meeting
Penalty
Summary
The facility failed to invite one resident, who was cognitively intact with a BIMS score of 15 out of 15, to participate in the development and implementation of her person-centered care plan. The resident stated during interview that she had not been to a care plan meeting since admission and was not aware that residents were to be invited. Her record showed an annual MDS with an ARD of 07/09/25 and diagnoses including unspecified dementia, type 2 diabetes mellitus, Parkinson's disease, spinal stenosis of the cervical region, muscle weakness, and cellulitis of the right lower limb. The record review did not provide evidence that the resident was invited to the care meetings being held. The SSD stated that the facility uses a verbal invite with residents and sends a letter to the resident representative, but also stated that the facility did not chart that the resident was invited, so it could not be said that she was invited. The DCEO stated that residents should always be able to participate in care planning unless deemed not cognitively able to, and the DON stated that all residents should be invited to participate in the care plan meeting. The facility policy stated that an individualized comprehensive care plan is developed for each resident and reflects the resident's expressed wishes regarding care and treatment goals.
Code Status Not Updated to Match POLST
Penalty
Summary
The facility failed to update the code status in all records to DNR for two residents reviewed for code status. For one resident with dementia, the hard chart contained a POLST signed by the POA indicating DNR/DNI with long term artificial nutrition, and a physician order dated later also indicated DNR/DNI. However, the resident’s recapitulation physician order sheet, resident roster, and hemodialysis notebook still reflected Full Code, and the spine of the hard chart did not indicate the current code status. Staff interviews showed multiple employees relied on outdated roster information or old chart documents rather than the current POLST, and the DON stated the POLST superseded the recapitulation physician order sheet. For the second resident with dementia and severely impaired cognition, the EMR progress note documented a CPR attempt and no artificial nutrition, while the paper chart contained a POLST signed by a physician indicating DNAR. Despite this, two physician order summaries in the paper chart continued to show Full Code orders dated as of 04/01/15 and did not document the DNAR order from the POLST. Staff interviews showed the RN and UM used the POLST at the front of the chart to determine code status, and the UM stated the physician order documents were supposed to reflect the POLST. The DON stated the physician order summary was printed monthly by the pharmacy and that the code status order was an exception because the POLST was a separate order that could be updated at any time and superseded any orders on the physician order summary. The DON also stated the physician order summaries should have been updated to reflect the resident’s POLST. The report cited NJAC 8:39-4.1(a) and NJAC 8:39-27.1(a).
Missing Written Transfer Notices
Penalty
Summary
The facility failed to ensure that a written transfer notice containing all required information was provided to three residents and/or their representatives when the residents were transferred to the hospital. The record review, interviews, and policy review showed no evidence that the residents received written notice of the transfer, the reason for the transfer, appeal rights, or the State Long Term Care Ombudsman contact information as required. R4’s record showed admission to the facility and later discharge to the hospital on two occasions, but the EMR contained no evidence that a written transfer notice was provided to R4 or the resident representative. During interview, the SW stated she sent the bed hold policy and transfer notice to the family when a resident was discharged, but she did not keep a copy of what was sent and did not document the date or recipient in the medical record. R1’s record showed a cognitively intact resident with a BIMS score of 15 who was transferred to the ER after a change in condition with low blood pressure and hypoxia. The nursing notes documented the clinical change and physician order for transfer, but there was no documentation that R1 was given a written notice explaining the reason for transfer. R6’s record showed he was hospitalized and later readmitted, with intact cognition on MDS review, but the paper chart contained no transfer notice directed to him. Interviews with R6, LPN 1, and the SSD confirmed that the hospital transfer paperwork was sent to the hospital or mailed to family members, but the resident was not notified in writing and no documentation showed that appeal rights or Ombudsman information were provided.
Inaccurate Nutritional Assessment on MDS
Penalty
Summary
The facility failed to accurately assess one resident, R143, for nutritional needs related to weight gain. R143’s admission MDS, with an ARD of 06/17/25 and admission date of 06/11/25, documented severe impaired cognition with BIMS unable to assess, Alzheimer’s disease, a height of 70 inches, a weight of 160 pounds, and a finding of weight loss of 5% or more in the last month or 10% or more in the last six months, with no physician-prescribed weight loss regimen. The nutritional assessment in the EMR indicated a regular puree diet with nectar thick liquids and an admission weight of 160 pounds. A review of the resident’s weights showed 159.8 pounds on admission, 167.2 pounds on 07/10/25, and 174.2 pounds on 09/03/25, reflecting a 4.63% gain in one month and a 9.01% gain in three months. During interview, the RD stated there was an entry error on the MDS showing unplanned weight loss and stated the RD completes the nutritional status on the MDS. The DCEO, DON, and MDSC each confirmed that the MDS should contain accurate information, and the MDSC verified that the MDS was not correct and that a modification had to be completed to reflect R143’s status. The facility policy stated that comprehensive assessments are made at required intervals and that those completing portions of the MDS attest to the accuracy of the information.
Wander Guard Used Without Supporting Elopement Risk Documentation
Penalty
Summary
The facility failed to ensure that one resident with dementia had appropriate screening and documentation to support the use of a wander guard. The resident was admitted with diagnoses including dementia, depression, and psychotic disorder, and the quarterly MDS reflected severe cognitive impairment. The care plan stated the resident had dementia, wanted to go home, and was at risk for wandering and elopement, with interventions to apply a code alert and complete an elopement risk assessment. However, the physician order dated 01/17/25 directed a wander guard to the right ankle, even though the resident's elopement risk assessments dated 04/14/25 and 07/15/25 both indicated the resident was not at risk for elopement. Review of the resident's general notes from 01/01/25 through 08/27/25 showed no documentation of wandering or exit-seeking behaviors. Staff interviews confirmed the resident was confused but not exit seeking, had never tried to get off the unit or leave the building, and liked to socialize and roll around the nursing station in a wheelchair. During observation, the resident was seen sitting in a wheelchair in the TV room, and CNA5 verified the wander guard was still in place on the right ankle. The DON stated that if a resident was assessed not to be an elopement risk, they should not have a wander guard.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to ensure that a resident's nasal cannula and nebulizer mask were stored properly when not in use. The resident was readmitted with a diagnosis of COPD, had a quarterly MDS indicating severe cognitive impairment, and was coded as receiving oxygen therapy. Physician orders included oxygen at 2 liters per minute via nasal cannula continuously and a nebulizer treatment three times daily as needed for shortness of breath and wheezing. Observations on two separate occasions showed the resident's oxygen nasal cannula lying uncovered at the foot of the bed and the nebulizer mask on the floor during one observation, then uncovered on the TV stand during another. An LPN verified that the cannula and nebulizer mask were uncovered and stated they should be covered in a bag for infection control. The DON stated that all nasal cannulas and nebulizer masks should be covered in a bag when not in use, and the facility policy required reusable respiratory equipment to be stored in plastic bags or per manufacturer recommendations after cleaning.
Incomplete dialysis communication and assessment documentation
Penalty
Summary
Safe, appropriate dialysis care/services were not provided for a resident with end stage renal disease requiring dialysis because the facility did not ensure complete collaboration of care on the hemodialysis communication record. The resident was readmitted with ESRD and was receiving dialysis while in the facility. The care plan identified dialysis three times weekly, monitoring of the left AV graft for bruit and thrill each shift, and monitoring of the access site for bleeding and infection. It also identified left arm precautions and that the right subclavian perma cath was to have a protective dressing except when being accessed. Review of the dialysis communication record showed multiple omissions in the section to be completed by the licensed nurse before dialysis treatment. On several dates, the nurse left blank the fields for access site swelling, drainage, pain, and AV fistula/graft bruit and thrill; on another date, the access was documented as none and no vital signs were documented. During interview, RN1 stated the facility nurse was to complete the top and bottom sections of the form and that the sections were not to be left blank. The DON stated vital signs were to be documented before dialysis and that the resident had two access sites, with the AV graft being used for dialysis at that time because the perma cath had recently been placed.
Failure to Assess and Obtain Consent Before Side Rail Use
Penalty
Summary
The facility failed to ensure that alternative measures were received prior to the installation of side rails, and failed to document discussion of risks versus benefits and obtain signed informed consent for one resident, R133, who was reviewed for side rails. R133 was admitted with diagnoses including dementia, depression, and psychotic disorder. Her quarterly MDS dated 07/20/25 showed severe cognitive impairment, and her care plan dated 10/09/24 identified her as at risk for falls with an intervention stating she preferred the upper 2 side rails up in bed to assist with mobility and transfers. Her physician orders dated 08/25/25 did not include an order for bilateral quarter side rails. During interviews, RN4 stated the facility did not have side rail assessments and had no process for side rail use, explaining that side rails were not used because they were restraints and that the facility used enablers instead. LPN2 stated the facility had enabler bars for repositioning, was restraint free, and had no process or assessment for them. UM2 stated the facility used enablers, did not use side rails, and that residents did not sign informed consent; there was no discussion of risks and benefits or alternatives attempted prior to side rail use. The DON was unsure of any process for side rail use and agreed there were side rails on some beds in the facility, including R133's bed. The facility policy required informing the resident or representative about benefits and hazards and obtaining informed consent before using bed rails, including documentation of assessed medical needs, risks, alternatives attempted, and alternatives considered but not attempted.
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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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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Roosevelt Care Center | 0.2 mi | ★★★★★ | 3 | 0 |
| Brighton Gardens Of Edison | 1.7 mi | ★★★★★ | 1 | 0 |
| St Joseph's Home Al & Nc, Inc | 2.4 mi | ★★★★★ | 0 | 0 |
| Hartwyck At Oak Tree | 2.7 mi | ★★★★★ | 0 | 0 |
| Spring Creek Healthcare Center | 3.1 mi | ★★★★★ | 0 | 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.