Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Dellridge Health & Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to maintain proper sanitation and food safety standards, with expired beverage boxes, improper hair restraint use, and inadequate cleaning practices observed. A dietary staff member was found without a beard restraint, and clean dishes were improperly stored, raising contamination concerns. Additionally, food items in the nutrition refrigerator lacked proper labeling, and the cleaning log was not signed, indicating lapses in protocol adherence.
A survey revealed deficiencies in a facility's adherence to professional standards, including failure to follow meal tickets for residents, improper medication administration, and inadequate disposal of excess medication. A resident did not receive a prescribed supplement, and another was given medication without following the manufacturer's guidelines. The facility's policies lacked guidance on proper medication disposal.
The facility failed to follow proper hand hygiene and PPE practices, as observed in multiple instances involving staff members. A Recreation Aide improperly wore a mask and reused hand wipes, a Physician did not disinfect equipment or perform hand hygiene, and housekeeping and dietary staff changed gloves without washing hands. These actions violated the facility's infection control policies.
The facility failed to provide meals in a dignified manner for two residents. One resident did not receive hand hygiene assistance before their meal, while another had to wait ten minutes for their meal, which lacked a diet slip. The Director of Nursing acknowledged that residents should eat simultaneously and that hand hygiene should be offered. Facility policies on food service and hand hygiene were not followed, leading to these deficiencies.
A facility failed to document a resident's advance directives, leaving a POLST form undated and unsigned, with no indication of the resident's desired status. Interviews revealed ongoing efforts to ensure documentation, but difficulties in obtaining physician signatures for full code residents. A progress note was added after surveyor inquiry, updating the resident's code status.
A resident with dysphagia, dementia, and malnutrition was readmitted without wounds, but later developed multiple wounds, including a DTI. The facility failed to notify the Resident's Representative (RR) of this change in condition, as required by policy. Documentation of the notification was missing from the medical record, and the investigation form where it was allegedly recorded was not part of the medical record.
The facility failed to maintain a safe, clean, and homelike environment for residents, as observed in several deficiencies. A resident's room had peeling wood on dressers, a missing heater grill cover, and a soiled bed frame, with no maintenance records for these issues. Another resident's room was missing a closet door, with no work order submitted for replacement. Additionally, a resident reported persistent cobwebs and dust, despite previous complaints. The facility lacked formal maintenance and cleaning policies, leading to delays and unaddressed issues.
A resident with severe cognitive impairment and a history of cerebral infarct and vascular dementia was observed unshaven on multiple occasions, indicating a failure by the facility to provide necessary grooming services. Despite requiring substantial assistance for personal hygiene, inconsistencies in care were noted, with staff citing occasional refusal by the resident but also acknowledging that proper explanation could lead to compliance.
A facility failed to complete a stat chest x-ray (CXR) and notify a physician of a resident's low blood pressure (BP). The resident, with multiple diagnoses including diabetes and dementia, had a stat CXR ordered for congestion, but it was not completed, and no results were documented. Additionally, low BP readings were not communicated to the physician, contrary to facility protocols requiring notification of acute condition changes. This deficiency highlights a lapse in following professional standards and facility policies.
A facility failed to document the date and time of oxygen tubing changes for a resident receiving oxygen therapy. The resident, with a history of chronic respiratory failure, was observed using oxygen without a label indicating when the tubing was last changed. Despite a physician's order for weekly tubing changes, there was no evidence of compliance on the specified date. The facility suggested the label might have fallen off, but their policy did not specifically require labeling the tubing.
A resident with end-stage renal disease did not receive consistent care for dialysis, as the facility failed to ensure proper documentation and administration of Zofran for nausea. The medication was sent with the resident to the dialysis center without a physician's order, and there were discrepancies in the documentation of its administration. The facility's policies on medication administration and dialysis care were not followed, leading to this deficiency.
The facility failed to ensure the 24-hour staffing report was accurate and prominently posted. Surveyors found outdated reports and inadequate visibility in accessible areas. The DON and UC were responsible for postings, but inconsistencies were noted, especially on weekends. The LNHA acknowledged the issue, and additional posting areas were added, but no specific policy was in place.
A facility failed to maintain complete medical records for a resident with multiple wounds. The resident's medical record lacked documentation of wound care for a three-week period, despite weekly visits by a wound PA. The missing notes were only uploaded after a surveyor's inquiry, highlighting a lapse in maintaining accessible medical records.
A facility failed to accurately code the MDS for a resident, indicating an unplanned discharge to a hospital when the resident was actually discharged to home. The discrepancy was identified through a review of medical records and confirmed by the MDSC/LPN and MDSC/RN, who acknowledged the mistake. The issue was discussed with the facility's administration, but no further information was provided.
Sanitation and Food Safety Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to maintain proper sanitation and food safety standards, as evidenced by several observations during a kitchen tour. Expired beverage boxes were found in the juice dispenser area, with the Food Service Director (FSD) acknowledging that the diet lemonade was expired. Additionally, a fiber-like strand was found on a food processor machine in the food preparation area, which was identified as part of a hairnet. The FSD and Regional FSD confirmed that the items on the table were being prepared for the next meal. Furthermore, a small veggie steam pan was found soiled with dry, hard food-like debris, indicating a lapse in cleaning procedures. The surveyor also observed a dietary staff member with facial hair not wearing a beard restraint, which is required to prevent contamination. The FSD was unable to provide beard restraints for the staff member, and the staff member was instructed to wear a face mask instead. In the dishwashing area, clean dishes were improperly stored above a three-compartment sink filled with sanitizing solution, and a crumpled washcloth was found next to clean dessert bowls, raising concerns about cross-contamination. Additionally, several uncovered food bins were found with discolored stains and an accumulation of clear liquid, further indicating inadequate sanitation practices. In the nutrition refrigerator, food items were found without proper labeling, including the resident's name, room number, and date of storage. This lack of labeling made it difficult to determine the freshness and safety of the food items. The Housekeeping Director (HKD) admitted to not signing the cleaning log for the refrigerator, which is supposed to be cleaned every Friday. The facility's policies on hair restraints, cleaning, and food storage were reviewed, revealing gaps in adherence to these protocols. The facility failed to provide documentation supporting the use of expired beverage boxes, further highlighting deficiencies in food safety management.
Deficiencies in Meal Service and Medication Administration
Penalty
Summary
The facility failed to adhere to professional standards of clinical practice in several areas, as observed during a survey. During meal observations, it was noted that the facility did not follow the residents' meal tickets. Resident #41 did not receive a prescribed magic cup supplement during lunch, and the electronic Medication Administration Record (eMAR) was inaccurately signed as administered without noting the resident's refusal. Additionally, the physician's order for the magic cup was not clarified to include the amount or percentage of intake, which is considered best practice. Similarly, Resident #43 did not receive the specified nectar-thickened orange juice, and Resident #44 did not receive the two cups of coffee as indicated on their meal tickets. The facility staff, including the Food Service Director and the Director of Nursing, were unable to provide satisfactory explanations for these discrepancies. The survey also revealed issues with medication administration. During a medication pass observation, it was found that excess medication was not disposed of properly. LPN#1 was observed pouring excess guaifenesin DM into a second dose cup and disposing of it in the trash receptacle instead of the approved medication disposal system. Additionally, Resident #339 was administered Sucralfate without adhering to the manufacturer's specifications, which require the medication to be taken on an empty stomach. The resident had consumed at least 50% of their breakfast shortly before the medication was administered, which does not align with the requirement of taking the medication one hour before or two hours after a meal. The facility's policies and procedures were found lacking in guidance regarding the proper disposal of unused or excess medications. The surveyor's interviews with the Director of Nursing and the Consultant Pharmacist confirmed that medications should be disposed of in the approved medication disposal system, which was not followed in the observed instances. The facility's failure to adhere to professional standards in meal service and medication administration was documented, and the facility management was notified of these findings during the survey process.
Infection Control Deficiencies in Hand Hygiene and PPE Use
Penalty
Summary
The facility failed to adhere to proper hand hygiene and personal protective equipment (PPE) practices, as observed in multiple instances involving various staff members. A Recreation Aide was seen distributing lunch trays with a surgical mask improperly worn, not covering the nose, and using hand wipes without discarding them after use. The aide acknowledged the improper use of PPE and hand hygiene practices, despite having received education on these protocols. A Physician was observed performing an eye examination without following proper infection control practices. The Physician did not disinfect the table used for equipment placement, failed to perform hand hygiene after glove removal, and was unaware of the enhanced barrier precautions (EBP) posted in the resident's room. The Infection Preventionist Nurse and the Regional Director of Nursing acknowledged the Physician's failure to adhere to hand hygiene protocols and the facility's responsibility to inform providers and vendors about infection control practices. Housekeeping and dietary staff also demonstrated lapses in hand hygiene. A Housekeeper was observed changing gloves without performing hand hygiene between glove changes, despite acknowledging the requirement to do so. Similarly, dietary staff members were seen changing gloves without washing their hands during meal service. The facility's hand hygiene policy, which emphasizes handwashing as the primary means to prevent infection spread, was not followed by these staff members.
Failure to Provide Dignified Meal Service
Penalty
Summary
The facility failed to ensure that meals were consistently provided in a dignified and homelike manner, and that resident meal assistance was provided in a dignified manner. This deficiency was observed in the recreation dining room for two residents. During the survey, it was noted that one resident did not receive hand hygiene assistance before their meal, while another resident had to wait for ten minutes to receive their meal after others at the same table had already started eating. Additionally, the meal provided to the second resident lacked a diet slip, and there was confusion regarding the resident's room number and dietary requirements. The surveyor observed that the staff did not offer hand hygiene to one resident, and the staff proceeded to set up the resident's meal without it. When questioned, a recreation aide acknowledged that the resident should have been provided an opportunity for hand hygiene. For the other resident, the surveyor noted that the resident did not have a meal tray while others were eating, and there was a delay in providing the meal. The tray eventually delivered to the resident did not have a diet slip, and there was a mix-up with the room number, leading to potential confusion about the resident's dietary needs. The facility's Director of Nursing (DON) explained the process for dining services, which includes the recreation staff distributing trays and verifying meal tickets. The DON acknowledged that residents should eat simultaneously and that hand hygiene should be offered and assisted by the staff. The facility's policies on food service and hand hygiene were reviewed, indicating that staff should assist residents with hand hygiene before meals and verify meal accuracy. However, these procedures were not followed, leading to the observed deficiencies.
Failure to Document Resident's Advance Directives
Penalty
Summary
The facility failed to ensure accurate documentation of a resident's advance directives, specifically for one resident who was admitted with chronic respiratory failure, anxiety disorder, and type 2 diabetes mellitus. The resident's medical records, both electronic and paper, lacked a completed New Jersey Practitioner Orders for Life-Sustaining Treatment (POLST) form, which was undated and unsigned by the resident, attending physician, or facility staff. There was no documentation indicating the resident's desired advance directive status, and the physician's orders did not reflect any advance directive status either. Interviews with the Director of Social Services and the Licensed Social Worker revealed that the facility had an ongoing project to ensure all residents had completed advance directives and POLST forms, but there were difficulties in obtaining physician signatures for residents who were full code. The Licensed Social Worker acknowledged that the missing documentation for the resident could have been inadvertently missed. A progress note was later added to the resident's electronic medical record, updating the code status to full code after the surveyor's inquiry. The facility's Advance Directive Policy did not specifically address full codes and POLST/advance directives.
Failure to Notify Resident's Representative of Change in Condition
Penalty
Summary
The facility failed to notify the Resident's Representative (RR) of a change in condition for a resident who was admitted with diagnoses including dysphagia, dementia, and protein-calorie malnutrition. Upon readmission from hospitalization, the resident did not have any wounds, but a Physician Assistant (PA) noted multiple wounds, including a deep tissue injury (DTI), on 9/5/23. There was no documented evidence in the resident's medical record that the RR was notified of these DTIs, nor were there wound measurements or appearance documented for three weeks following the initial note. The Assistant Director of Nursing (ADON) confirmed that the notification of the RR was not documented in the electronic medical record, and the Facility Acquired Pressure Injury Investigation Form, where the notification was allegedly documented, was not part of the medical record. The facility's policy on acute condition changes required that the physician discuss the situation with the staff and the resident and/or family, but there was no evidence provided that this occurred. The surveyor's findings were confirmed by the ADON, Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and other facility representatives.
Deficiencies in Maintaining a Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by several deficiencies observed during a survey. In one instance, a resident's room was found with dressers that had peeling wood, exposing rough surfaces, and a heater unit without a front grill cover. Additionally, the bed frame was visibly soiled with a dry, brown substance. The resident, who had impaired cognition due to dementia and Alzheimer's, was unable to communicate these issues. Despite a maintenance log entry for a jammed drawer, there was no record of the peeling wood or missing grill cover being reported or addressed. Another deficiency involved a resident's room missing a closet door. The resident, who had severely impaired cognition due to vascular dementia, was unable to communicate the issue. The Unit Manager was unaware of the missing door, and there was no work order submitted for its replacement. The Director of Maintenance acknowledged the door was removed for replacement but was not logged in the maintenance book. The door was eventually replaced after a delay, highlighting a lack of formal maintenance policy and procedure. A third deficiency was reported by a resident during a Resident Council meeting, where they complained of cobwebs and dust in their room. Despite a previous grievance form being filled out, the issue persisted, with the surveyor observing dust and cobwebs in the resident's room. The resident, who had intact cognition, had previously reported the issue, but it was not adequately addressed. The facility's policy on cleaning and disinfecting residents' rooms was not followed, as surfaces were not cleaned regularly or when visibly soiled.
Failure to Provide Necessary Grooming Services for a Resident
Penalty
Summary
The facility failed to provide necessary grooming services for a resident who was unable to perform activities of daily living (ADL) independently. This deficiency was observed when the surveyor noted that the resident was unshaven on multiple occasions. The resident, who has severe cognitive impairment with a Brief Interview of Mental Status (BIMS) score of 2 out of 15, requires substantial assistance for personal hygiene. Despite the resident's need for total care, the Certified Nursing Assistant (CNA) responsible for the resident's care was not the regular aide and mentioned that the resident sometimes refused shaving, which contributed to the lack of grooming. The resident's medical records indicated a history of cerebral infarct, vascular dementia, adjustment disorder, and delusional disorders, which may affect their ability to communicate and cooperate with care. Interviews with staff revealed inconsistencies in the provision of grooming care, with some staff noting the resident's occasional refusal of care but also acknowledging that the resident would allow shaving if explained properly. The facility's policy requires that residents unable to perform ADLs receive necessary services to maintain grooming, which was not consistently adhered to in this case.
Failure to Complete Stat CXR and Notify Physician of Low BP
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident, as evidenced by the lack of documentation and follow-up on a stat chest x-ray (CXR) order and low blood pressure (BP) readings. The resident, who had diagnoses including type 2 diabetes mellitus with chronic kidney disease, dementia, colostomy, and anxiety disorder, was assessed to have moderate cognitive impairment. A physician's order for a stat CXR due to congestion was not completed, and there was no documentation of the CXR results in the resident's paper chart or electronic medical record (EMR). Additionally, the resident's BP readings were notably low on one occasion, but there was no documentation indicating that the physician was notified of this change in condition. The facility's Registered Nurse/Unit Manager (RN/UM) and Licensed Practical Nurse (LPN) stated that any change in a resident's condition should be communicated to the physician using the SBAR tool, but this protocol was not followed. The facility's policies required that the physician be notified of acute changes in condition and that appropriate treatments be authorized and monitored, but these steps were not documented. The facility's failure to ensure the stat CXR was completed and to notify the physician of the resident's low BP readings represents a deficiency in providing care according to professional standards and facility policies. The facility's Acute Condition Changes-Clinical Protocol Policy and Lab and Diagnostic Test Results-Clinical Protocol Policy did not adequately address the protocol for when a diagnostic test could not be performed, contributing to the deficiency.
Failure to Document Oxygen Tubing Change
Penalty
Summary
The facility failed to ensure proper respiratory care for a resident receiving oxygen therapy, as evidenced by the lack of documentation regarding the date and time the oxygen tubing was changed. During an initial tour, a surveyor observed a resident using oxygen via nasal cannula without any label indicating when the tubing was last changed. The resident, who was in the process of weaning off oxygen, was unsure about the frequency of tubing changes. The facility's policy required weekly changes of the oxygen tubing, with the date, time, and nurse's initials documented, but there was no evidence of this documentation for the observed date. The resident involved had a medical history that included chronic respiratory failure, anxiety disorder, and type 2 diabetes mellitus. The resident's cognitive assessment indicated no impairment, and the care plan noted the use of oxygen for breathing difficulties. Despite the physician's order for weekly tubing changes, the facility's records did not show that the order was followed on the specified date, as the PRN order for the tubing change was not signed. The facility's response to the surveyor's findings suggested that the missing label was an isolated incident and might have fallen off. However, the facility's oxygen administration policy did not specifically mention labeling the tubing with a date. The surveyor's inquiry into the labeling process revealed that the date was written on surgical tape, which could potentially become detached. The facility did not provide further documentation to support their claim that the label had been replaced.
Deficiency in Dialysis Care and Medication Administration
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received appropriate care consistent with professional standards. The deficiency was identified for a resident with end-stage renal disease who was dependent on renal dialysis. The resident was alert, oriented, and verbally responsive, attending dialysis three times a week. However, there were issues with the administration of Zofran, a medication prescribed for nausea, which was not consistently documented or administered as per the physician's orders. The Licensed Practical Nurse (LPN) and Registered Nurse/Unit Manager (RN/UM) were responsible for documenting the dialysis communication forms (DCF) and ensuring the medication was sent with the resident to the dialysis center. However, there were discrepancies in the documentation and administration of Zofran. On multiple occasions, the medication was noted as sent but not administered, and there was no physician's order (PO) for sending the medication with the resident. The RN/UM acknowledged the lack of documentation and the absence of an active order for Zofran to be sent to dialysis. The facility's policies on end-stage renal disease care and medication administration were not followed, leading to a lack of accountability and documentation for the Zofran medication. The surveyor noted that the administration time of the medication was unknown, and there was no PO for sending the medication with the resident. The facility's failure to adhere to its policies and ensure proper documentation and administration of medication resulted in the deficiency.
Inaccurate and Inaccessible Staffing Report Posting
Penalty
Summary
The facility failed to ensure that the 24-hour staffing report was accurate and prominently posted, as required by regulations. On multiple occasions, surveyors observed that the staffing report was not updated or visible in a location accessible to all residents and visitors. Specifically, on 12/15/24, the staffing report was outdated and not visible in the initial hallway or nursing station, and on 12/17/24, the report had not been updated for that day. The Director of Nursing (DON) and Unit Clerk (UC) were responsible for posting the reports, but there was a lack of clarity and consistency in their process, particularly on weekends when supervisors were supposed to manage the postings. The Licensed Nursing Home Administrator (LNHA) acknowledged the issue and stated that there was no specific facility policy for posting the staffing report, relying instead on general regulations. The LNHA and other staff members, including the Regional DONs and COO, discussed the visibility and accuracy of the postings, with the LNHA adding an additional posting area. Despite these discussions, the facility did not provide any additional information or documentation to address the deficiency noted by the surveyors.
Incomplete Medical Records for Resident's Wound Care
Penalty
Summary
The facility failed to maintain complete and readily accessible medical records for a resident, which was identified during a survey. The resident, who had been admitted with conditions including dysphagia, dementia, and protein-calorie malnutrition, had a gap in their medical records concerning wound care. After returning from a rehospitalization, the resident was noted to have multiple wounds, but there were no documented wound notes for a three-week period in the medical record. The Assistant Director of Nursing (ADON) acknowledged that the wound Physician Assistant (PA) visited weekly but did not document the wound care notes in the electronic medical record during that time. The ADON later uploaded the missing wound notes into the electronic medical record after the surveyor's inquiry. The facility's policy on medical records, which was reviewed in November 2024, requires that medical records be retained in accordance with applicable laws, but the facility did not provide additional information on the retention period. The surveyor's investigation revealed that the wound notes were not accessible in the computer system until after the surveyor's inquiry, indicating a lapse in maintaining complete medical records as per professional standards.
Inaccurate MDS Coding for Resident Discharge
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for a resident, which is a tool used to manage care in accordance with federal guidelines. The deficiency was identified during a review of the medical records of a resident who was admitted with diagnoses including a wedge compression fracture of an unspecified lumbar vertebra, pain in an unspecified joint, and surgical aftercare. The resident's most recent Discharge Return Not Anticipated (DRNA) MDS indicated an unplanned discharge to a short-term general hospital. However, a late entry in the progress notes, signed by the Director of Nursing (DON), revealed that the resident was actually discharged to home and picked up by the resident's representatives. Upon interviewing the MDS Coordinator/Licensed Practical Nurse (MDSC/LPN), it was confirmed that the facility followed the Resident Assessment Instrument (RAI) manual for MDS coding. The MDSC/LPN acknowledged the discrepancy and stated that the MDS and medical records should match. Further review by the MDSC/Registered Nurse (MDSC/RN) confirmed that the MDS should have been coded as a discharge to the community, not to the hospital, indicating a mistake in the coding process. The survey team discussed these findings with the facility's administration during an exit conference, but no additional information was provided.
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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 Paramus
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| New Jersey Veterans Memorial Home At Paramus | 0.4 mi | ★★★★★ | 2 | 0 |
| Careone At Ridgewood Avenue | 0.8 mi | ★★★★★ | 0 | 0 |
| Careone At Oradell | 1.7 mi | ★★★★★ | 3 | 0 |
| Bergen New Bridge Medical Center | 2.1 mi | ★★★★★ | 1 | 0 |
| Emerson Health Care Center | 2.2 mi | ★★★★★ | 0 | 0 |
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