Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 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.
Unsafe and Unclean Shower Rooms: Surveyors observed multiple shower room deficiencies, including a ripped shower chair cover, broken and missing floor and wall tiles, heavy buildup on heater grills and vents, and an open wire outlet near shower equipment. The RN/UM acknowledged several of the concerns, and later observations found the shower rooms still had broken tiles while an alternate shower room had a strong urine odor.
The facility failed to follow physician orders for behavior and side effect monitoring for several residents receiving psychoactive and other medications. eMAR entries used check marks, initials, 0, N/A, and other inconsistent codes instead of the required Y/N responses, behavior counts, intervention codes, and effectiveness documentation. Staff, including an LPN, RN/UM, DON, and LNHA, acknowledged that the orders were unclear or not followed, and one resident’s order required clarification because the documentation system did not match the written instructions.
A facility failed to document education about the benefits and potential side effects of flu and pneumococcal vaccines for three residents. One resident with intact cognition had vaccine refusals documented, but education was not recorded and the flu refusal was entered despite a documented allergy. Two residents with severe cognitive impairment had no record of vaccine offer, administration, refusal, or representative education, and staff stated immunization tracking was not in place or was handled through mass email rather than the medical record.
A resident with anorexia and dementia, and a BIMS score of 00, had a PRN lorazepam order for anxiety that was not limited to 14 days and lacked documented rationale for extension. Staff gave conflicting statements about whether the order was to be reevaluated, renewed, or extended, while the facility policy stated PRN anxiolytics are for 14 days and then reviewed by the MD.
The facility failed to provide written bed hold notices that included reserve payment information for two residents who had hospital transfers. Records showed bed hold notifications in the eMR, but the notices reviewed did not include the payment details, and staff confirmed that some notices were for another resident or were missing for certain transfers. The AD stated the bed hold charge was $420 per night, while the LNHA acknowledged the reserve payment should have been included.
A resident’s comprehensive MDS assessment, care plan, and lock/acceptance were completed late, and a DRNA MDS was also transmitted late. The surveyor found the MDS dates were outside the required RAI Manual timeframes, and the RMDSC confirmed that red entries in the record indicated the assessments were late.
The facility inaccurately coded MDS assessments for several residents after surveyors found mismatches between the MDS and the medical record. Errors involved vaccine coding without supporting documentation, therapy services not captured in the look-back period despite active rehab orders and notes, and wound/skin findings such as MASD not reflected in the MDS. Staff interviews confirmed the MDS coordinator relied on record review, but the assessments still did not match the documented resident status.
A resident with severe cognitive impairment and a recent fall had video monitoring in place, but the room lacked required signage and the record did not contain written consent from the RR, despite staff stating verbal consent had been obtained. In a separate case, a hospice resident with dementia and repeated medication refusals had hospice recommendations to discontinue several meds and supplements, but the physician documentation only clearly addressed Eliquis and the remaining recommendations were not clarified in the record until after surveyor inquiry.
A resident with a facility-acquired Stage 3 PU, cerebral infarction, and malnutrition had an air mattress observed set at 260 despite weighing 126 pounds, and two LPNs confirmed the setting. The resident also had an IV Vancomycin order for wound infection with blank eMAR entries that were neither documented as administered nor held. The RN/UM and DON stated that blanks should not be present without proper hold documentation, and the facility policy required documentation when a medication is withheld, refused, or given at a different time.
A resident with multiple medical conditions, including CKD, afib, and a recent fracture, was ordered PRN O2 at 3 L/min via NC for SOB or low SpO2 and had O2 sat checks every shift. Surveyors observed the resident on O2, but the chart lacked required O2 sat documentation and did not show that the PRN O2 order was administered when the resident had SOB or when staff documented O2 in use. An LPN told surveyors the resident was on continuous O2, even though the order was PRN, and the RN/UM confirmed the O2 eMAR/eTAR should have been signed.
A resident admitted with a stage 4 sacral PU, malnutrition, and weakness had ongoing wound documentation in MDS, care plans, nursing notes, and a transfer form for failure to thrive and an unstageable sacral wound. However, the primary physician’s H&P and multiple follow-up visit notes documented skin as normal or stated PUs were absent, with no mention of the resident’s sacral or buttock wounds. An LPN confirmed the physician notes did not identify the skin impairments, and the RN/UM stated she did not know why the wounds were not documented.
A consultant pharmacist failed to identify and report irregularities during the monthly MRR for a resident with multiple sclerosis, sepsis, acute kidney failure, and depression. The resident had duplicate cornstarch orders for overlapping skin areas and overlapping wound care orders for the same site, including routine and PRN directions for the same treatments, and there was no documented clarification of the conflicting PO.
An infection prevention deficiency was identified when a housekeeper failed to perform hand hygiene and entered another resident room with used gloves after handling trash, and an LPN failed to perform hand hygiene before medication administration, did not disinfect a stethoscope or pulse oximeter, and used the same paper towel to turn off the faucet. The facility also lacked clear immunization tracking for a resident whose record showed incomplete COVID-19 vaccination documentation and no written consent evidence, with staff giving inconsistent answers about who tracked vaccines and where the tracking was kept.
Incomplete COVID-19 Vaccine Education and Documentation: The facility did not document COVID-19 vaccine education, offer, acceptance/refusal, or current immunization status for two residents reviewed. One resident had intact cognition and diagnoses including MS, sepsis, AKI, and depression, while another had dementia, psychosis, and severe cognitive impairment. The IPN, DON, and LNHA stated the facility used Care Feed notifications and general postings, but the eMR lacked documentation of resident or RR education, consent, and vaccine status as required by the facility protocol.
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.
Unsafe and Unclean Shower Rooms
Penalty
Summary
The facility failed to maintain residents’ environment in a safe, clean, comfortable, and homelike surrounding in 3 of 3 shower rooms in the long term care units. During tour observations, a shower chair in the A side shower room had a ripped back cover, there were broken floor tiles in the middle cubicle, and the heater grills had heavy accumulation of brownish, rusty-like substances. In the B side shower room, the ceiling vent above the sink had grayish accumulation, the heater grills had heavy rusty-brown accumulation, and the shower cubicle wall had an open wire outlet next to the hoyer lift battery and weighing scale. Another cubicle in that room had broken and missing tiles on the lower wall. The RN/UM accompanied the surveyor during the observations and acknowledged the broken tiles, the need to clean the vent, and that the shower chair cover should have been changed, but had no response regarding the uncovered wall outlet. On a later observation, the broken tiles in both A and B side shower rooms remained unrepaired, and signs were posted that the rooms were work in progress and not to use. The RN/UM stated both shower rooms were closed and would be renovated, and that residents would use another shower room at the end of the B side unit, where the survey team observed a strong smell of urine. The facility’s policy stated residents are to be provided a safe, clean, comfortable, and homelike environment, including cleanliness and order and pleasant, neutral scents.
Failure to Follow Ordered Behavior and Side Effect Monitoring
Penalty
Summary
The facility failed to follow physician orders for behavior monitoring and side effect monitoring for multiple residents reviewed for unnecessary medications, and it also failed to clarify a physician order according to the standard of clinical practice and the facility’s policies. Surveyors reviewed records, observed residents, and interviewed nursing staff and leadership, and found that the electronic medication administration record (eMAR) documentation did not match the specific requirements written in the orders. For one resident with diagnoses including cerebral infarction, atrial fibrillation, encephalopathy, diabetes, epilepsy, and depression, the care plan and physician orders required documentation of antidepressant-related behaviors and side effects each shift using specific codes and interventions. The eMAR showed inconsistent entries such as E, not applicable, 0, N, check marks, and X’s, even though the orders required recording the number of behaviors, the corresponding non-pharmacological interventions, and whether they were effective. Nursing staff stated the behavior monitoring system was confusing, and the DON and LNHA acknowledged that the orders were fuzzy, inconsistent, and needed revision. For another resident with dementia, psychosis, depression, and anxiety, physician orders required routine monitoring for side effects of antipsychotic, antianxiety, antidepressant, anticoagulant, and anticholinergic medications, as well as behavior monitoring tied to those medications. The eMAR showed check marks and initials instead of the required Y or N for side effects, and it did not document the required behavior counts, intervention codes, or effectiveness ratings. Staff acknowledged that the orders should have been followed and that the documentation was incorrect. Similar failures were identified for additional residents, including residents with intact cognition and residents with severe cognitive impairment, where ordered side effect monitoring and behavior monitoring were not documented as written, and one resident’s behavior monitoring order required clarification because staff were unsure how to document it. The facility’s own policy stated that behaviors should be tracked and documented by number of episodes or hours, and the medication administration policy required recording symptoms and results achieved.
Missing Vaccine Education and Documentation
Penalty
Summary
The facility failed to ensure that the medical record contained documentation showing that residents or their representatives were provided education about the benefits and potential side effects of influenza and pneumococcal immunizations for 3 of 5 residents reviewed. The deficiency involved Resident #6, Resident #7, and Resident #89, and was identified through record review and staff interviews during the survey. Resident #6 had diagnoses including multiple sclerosis, sepsis, extended spectrum beta-lactamase resistance, acute kidney failure, and depression. The resident’s cMDS showed a BIMS score of 15/15, indicating intact cognition, and the record showed pneumococcal vaccine was refused with education documented as not provided. Influenza vaccine was also documented as refused, even though the resident had a documented allergy to the influenza vaccine. The IPN stated education should be provided when a resident refuses a vaccine and acknowledged that the nurse reported education was given but not documented; the IPN also stated the influenza vaccine should have been documented as not indicated because of the allergy. Resident #7 had diagnoses including dementia, psychosis, depression, and anxiety disorder, and the qMDS showed a BIMS score of 0/15, indicating severe cognitive impairment. The eMR contained no documentation that flu or pneumococcal immunizations were offered, administered, or refused, and there was no documented evidence that the resident’s representative was educated about the benefits and potential side effects of either vaccine. Resident #89 also had severe cognitive impairment with a BIMS score of 0/15 and diagnoses including dementia and anxiety. The record showed the last influenza vaccine was given on 1/31/25, but there was no documentation that influenza vaccination was offered, given, or refused for the most recent influenza season. The IPN stated the vaccine was offered through a mass email system to representatives, and a copy of a mass email to the resident’s representative was provided, but the record still lacked documentation of offer, refusal, or education in the resident’s medical record.
PRN Lorazepam Order Exceeded 14-Day Limit Without Documented Rationale
Penalty
Summary
The facility failed to ensure that an as-needed psychotropic medication order was limited to 14 days unless the attending physician or prescribing practitioner documented a rationale to extend it for Resident #75. Resident #75 was admitted with diagnoses including anorexia and dementia, and the most recent sMDS showed a BIMS score of 00 out of 15, indicating severe cognitive impairment. During review of the April 2026 eMAR/eTAR, the resident had an order for lorazepam oral concentrate 2 mg/ml, give 0.25 ml by mouth every 4 hours as needed for anxiety, with an order date of 3/18/26, and the order was not limited to 14 days. The surveyor observed Resident #75 asleep in bed and later interviewed facility staff about the order. The LPN stated the PRN lorazepam was ordered for 14 days and then reevaluated by the physician, the RN/UM stated it was initially ordered for 14 days and then, if still needed, would be ordered for 30 days, and the DON stated it was initially ordered for 14 days and then renewed. When the concern was brought to the LNHA and DON, the LNHA stated staff were educated on the 14 days. The facility’s Psychotropic Drug Use Policy stated that PRN anxiolytics are for 14 days and the MD will review when the medication is still needed.
Missing Bed Hold Notice Information
Penalty
Summary
The facility failed to provide residents or their resident representatives with a written notification of the facility’s bed hold policy that included reserve payment information for two residents who had hospital transfers. For one resident, the record showed multiple unplanned hospital transfers, and the electronic medical record contained bed hold policy notifications dated for some transfers, but the documents did not include reserve payment information and the responses in the notification form were blank. Facility staff also confirmed that some of the bed hold notices reviewed were for another resident and that there were no bed hold notices for certain transfer dates. For the other resident, the record showed an unplanned hospital transfer and an electronic bed hold notification dated for the transfer. That notification also did not include reserve payment information, and the facility’s bed hold policy provided by the LNHA likewise did not include reserve payment information. The surveyor also reviewed a document labeled Bed Hold Policy related to the emergency transfer, which did not include reserve payment information. During interviews, the AD stated that when a resident was transferred to the hospital, nurses gave the resident or resident representative a bed hold paper and that the amount was $420 per night, but the printed notices reviewed by surveyors did not contain that information. The RN/UM stated that the nurse would document the bed hold notice in the assessment tab and print it with discharge papers, but she could not recall seeing reserve payment information in the notice. The LNHA acknowledged that reserve payment should be included in the bed hold notices.
Late MDS Completion and Transmission
Penalty
Summary
The facility failed to complete and transmit the Minimum Data Set (MDS) assessment within the required timeframes for Resident #120. During record review, the surveyor found that the resident’s comprehensive MDS had an ARD of 12/12/25 with an admission date of 12/1/25, but the assessment was completed on 12/15/25, the care plan was completed on 12/15/25, and the assessment was locked/accepted on 12/16/25. The report states these dates were late because the comprehensive MDS, CAA completion, and care plan completion were required no later than the 14th calendar day of admission. The surveyor also found that Resident #120’s DRNA MDS with an ARD of 2/17/26 was completed on 2/23/26 and not transmitted until 4/15/26. The report states this transmission was late because the DRNA MDS was required to be transmitted within 14 calendar days of completion. The MDS entries for the late comprehensive assessment and the late DRNA transmission were shown in red in the electronic record, and the RMDSC confirmed that red entries indicate lateness and that the facility follows the RAI Manual timeframes.
Inaccurate MDS Coding for Immunizations, Therapy, and Wound Status
Penalty
Summary
The facility failed to accurately code the MDS for multiple residents after surveyors compared the assessments with the medical record, immunization records, therapy documentation, wound documentation, and staff interviews. The report identified inaccurate MDS coding for 5 of 27 residents reviewed for accuracy, involving immunization status, therapy services, and skin/wound conditions. The facility’s MDS Accuracy Policy stated that assessments were to be completed in accordance with the RAI and CMS guidelines, and the MDS Error Correction Policy stated that significant errors inaccurately reflect the resident’s clinical status and/or may result in an inappropriate plan of care. For one resident, the immunization record did not document offered, administered, or refusal status for flu and pneumonia vaccines, yet the MDS initially coded influenza and pneumococcal items in a way that did not match the record. For another resident, the quarterly MDS did not reflect physical therapy services during the 7-day look-back period even though therapy notes, physician orders, and staff interviews showed the resident had been receiving rehab services and was discharged only after reaching highest potential. The MDS coordinator acknowledged the therapy was not captured in the assessment. A third resident’s MDS coded influenza, pneumococcal, and COVID-19 vaccination items without supporting documentation in the immunization tab, and the record did not show that the resident was offered and declined pneumococcal or COVID-19 vaccines or that COVID-19 history had been obtained in the admission assessment. For another resident with pressure injuries and skin issues, the record contained documentation of sacral stage 4 wounds, right buttock DTI, and MASD in nursing and physician notes, but the comprehensive MDS did not capture the MASD findings. A fifth resident’s MDS coded influenza vaccination as received in the facility for the current season even though the documented vaccine date was outside the current season and there was no documented evidence that the vaccine had been offered, given, or refused for the most recent season.
Failure to document consent for video monitoring and clarify hospice medication orders
Penalty
Summary
The facility failed to ensure that video monitoring for a resident with a recent fall and severe cognitive impairment was carried out in accordance with its own policy and documented consent requirements. Resident #16 had diagnoses including hemiplegia/hemiparesis following cerebral infarction and encephalopathy, a BIMS score of 3, and a recent fall with major injury. The care plan and eTAR included video monitoring at all times for safety, and a camera was observed in the room. However, there was no signage on the room door or inside the room indicating video monitoring was in use, and the record did not contain a written consent from the resident representative. Staff stated that verbal consent had been obtained, but this was not documented in the record. The surveyor reviewed the resident’s record, progress notes, and facility policy, which required a sign at the room entrance and signed consent from the resident or legal representative before video monitoring started. Interviews with LPNs and the DON confirmed that the room had no signage and that a written consent was not present. The DON stated that verbal consent would be expected to be documented and acknowledged that signage should be considered. The facility’s documentation did not show that the resident representative had been notified or had given permission in writing for the monitoring. The facility also failed to clarify hospice medication recommendations for a resident receiving hospice services who had severe cognitive impairment and repeatedly refused medications. Resident #75 had diagnoses including anorexia and dementia, a BIMS score of 0, and hospice recommendations to discontinue multiple medications and supplements. The physician note clearly discontinued Eliquis, but the rest of the hospice-recommended discontinuations were not clearly addressed in the note, and several medications continued to appear on the eMAR despite repeated refusals by the resident. Nursing notes documented multiple refusals and agitation during attempts to administer the medications, yet the record did not show timely clarification of which hospice recommendations were to be followed until after surveyor inquiry.
Pressure Ulcer Care and Medication Documentation Deficiencies
Penalty
Summary
The facility failed to ensure that a resident with a facility-acquired Stage 3 pressure ulcer received care consistent with the resident’s weight and that the resident’s IV antibiotic administration was documented in accordance with nursing standards. The resident had diagnoses that included cerebral infarction and moderate protein-calorie malnutrition, and the most recent quarterly MDS showed a BIMS score of 14 out of 15, indicating intact cognition. The resident also had one Stage 3 pressure ulcer that was not present on admission. During observation, the resident was seen in bed and later received wound treatment from two LPNs. After the treatment, the resident’s air mattress was observed set at 260, even though the resident’s documented weight was 126 pounds. Both LPNs confirmed the setting. The resident’s mattress order required it to be checked for placement and functioning every shift, and the facility’s mattress instructions stated that the control knob should be set to the patient’s weight. Review of the April 2026 eMAR showed an order for IV Vancomycin for wound infection with blanks on two dates; the medication was neither marked as administered nor held. The RN/UM stated there should not be blanks and that if a medication was not administered, documentation should explain why. The DON stated that unless there was a hold, there should not be blanks, and that there should be a code for a hold. The facility policy also stated that if a drug is withheld, refused, or given at a time other than scheduled, the nurse must document using the appropriate key guide in the eMAR.
Failure to Follow PRN Oxygen Order and Document Respiratory Care
Penalty
Summary
The facility failed to ensure necessary respiratory care and services for a resident who was receiving oxygen. The resident was admitted with diagnoses including a displaced trimalleolar fracture of the right lower leg, atrial fibrillation, chronic kidney disease stage 4, and muscle weakness. The resident’s MDS showed a BIMS score of 15 out of 15 and indicated that oxygen was being used. The physician’s orders included checking oxygen saturation every shift and administering oxygen at 3 L/min via nasal cannula as needed for shortness of breath or oxygen saturation below 90%. Surveyor observations and record review showed that the resident was observed in the room with oxygen in use, but the chart did not consistently document oxygen saturation checks or administration of oxygen as ordered. One shift lacked documentation of oxygen saturation and nurse initials, and there was no documentation that the PRN oxygen order was carried out when the resident was observed with oxygen in use. A progress note documented the resident as anxious and complaining of shortness of breath, but there was no documentation that the ordered PRN oxygen was administered at that time. During interviews, an LPN stated the resident was on continuous oxygen at 3 L/min and that the resident had already been on oxygen when the shift began, although the order was PRN rather than continuous. The RN/UM confirmed that the oxygen eMAR and eTAR should have been signed, and another LPN stated the resident was on continuous oxygen and that the records should have reflected administration. The facility policy required obtaining an order for the rate of flow and route of oxygen administration, and the report concluded that the PRN oxygen order was not followed and the required documentation was not completed.
Physician Notes Did Not Reflect Resident’s Pressure Ulcers
Penalty
Summary
The facility failed to ensure that the resident’s physician included an evaluation of the resident’s condition and total program of care, and a decision about the continued appropriateness of the resident’s current medical regimen, during required visits. The deficiency involved one resident who was admitted with diagnoses including a stage 4 sacral pressure ulcer, generalized muscle weakness, difficulty walking, and unspecified protein-calorie malnutrition. The resident’s MDS assessments and care plan documented pressure injuries, including a stage 4 sacral pressure ulcer, a right buttock deep tissue injury, and later unstageable and other skin impairments. Facility nursing documentation also reflected ongoing skin problems. The assessment tab showed skin evaluations on admission and readmission that identified sacral and buttock wounds, and a weekly skin condition note documented stage 4 sacral and bilateral buttocks mycosis. Nursing progress notes described sacral wounds, peri-buttocks MASD, right buttock DTI, and bilateral thigh wounds, with no signs or symptoms of infection noted. A transfer form dated 12/9/25 documented transfer to the hospital for failure to thrive, malnutrition, and an unstageable sacral wound. The resident’s primary physician’s handwritten H&P and subsequent visit notes did not reflect the resident’s skin impairment or pressure ulcers. The H&P documented skin as having no lesions, and multiple follow-up notes stated pressure ulcers were absent and skin had no rashes, lesions, or ulcers, despite the resident’s documented wounds in the facility record. During interview, the assigned LPN confirmed that the physician did not identify any skin impairment or pressure ulcer in the visit notes, and the RN/UM stated she did not know why the physician did not document the wounds and that it was expected for physician notes to include wound information.
Failure to Identify Duplicate and Conflicting Medication Orders
Penalty
Summary
The facility failed to ensure that the consultant pharmacist identified and reported irregularities during the monthly drug regimen review for one resident. Resident #6 was admitted with diagnoses including multiple sclerosis, sepsis, extended spectrum beta-lactamase resistance, acute kidney failure, and depression. The resident’s MDS assessment dated 4/2/26 showed a BIMS score of 15 out of 15, indicating intact cognition. Review of the care plan showed no interventions addressing duplicate or conflicting physician orders related to skin treatments or medication monitoring. Review of the order summary revealed duplicate and overlapping orders for skin care and wound treatment, including cornstarch orders for multiple overlapping body areas and multiple orders for the intergluteal cleft involving cleansing with NS, Silvadene 1% cream, and alginate. The orders also included routine and PRN directions for the same treatments without clear differentiation. There was no documented evidence that these duplicate or conflicting orders were clarified, and the monthly medication regimen review dated 3/12/26 did not identify or report these irregularities.
Infection Control and Immunization Tracking Failures
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program by not following hand hygiene, PPE, equipment disinfection, and vaccination tracking practices described in its policies and CDC guidance. During observation, a housekeeper was seen inside a resident room with gloves on while picking up garbage, then leaving the room, walking in the hallway, discarding the garbage and used gloves, and entering another resident room with an EBP sign without performing hand hygiene. The housekeeper acknowledged leaving the room without removing the used gloves and without performing hand hygiene before going to the next room. During medication administration observation, an LPN entered a resident’s room and administered medications and used a stethoscope and pulse oximeter without performing hand hygiene before entry. The LPN also did not sanitize the stethoscope or pulse oximeter before or after use. After leaving the room, the LPN washed hands for 14 seconds and used the same paper towel to turn off the faucet that had been used to dry the hands. The resident involved had COPD, was cognitively intact, and was receiving Allegra and nebulized ipratropium-albuterol. The facility also did not track resident immunizations as described by staff and documentation review. For one resident, the record showed influenza vaccine received outside the facility, pneumococcal vaccine offered and declined, and COVID-19 vaccinations not up to date, but the immunization tab was blank and there was no documented evidence that the resident or resident representative was offered the COVID-19 vaccine in writing. Paper consent forms were absent, and the IPN stated that the resident had been missed in her tracking notebooks. Staff gave inconsistent responses about who was responsible for tracking immunizations and where the tracking was documented.
Incomplete COVID-19 Vaccine Education and Documentation
Penalty
Summary
The facility failed to ensure that residents and/or resident representatives were educated on the COVID-19 vaccine in a manner they could understand and that vaccination status was properly documented for 2 of 5 residents reviewed for immunizations. For one resident, the medical record showed diagnoses including multiple sclerosis, sepsis, extended spectrum beta-lactamase resistance, acute kidney failure, and depression, and a BIMS score of 15 out of 15 indicating intact cognition. The immunization record showed the last documented COVID-19 vaccine was given on 10/5/23, but there was no documented evidence that the vaccine was offered, accepted, refused, or that education was provided after that date. Surveyor interviews with the IPN, DON, and LNHA showed the facility relied on Care Feed notifications and general postings as evidence that the vaccine was offered, but the resident’s medical record did not contain documentation of the resident’s response or education. The facility’s Resident Vaccination for COVID-19 Protocol stated that the resident’s medical record should include documentation of consent for each COVID-19 vaccine and/or booster, the date of each dose administered, and education regarding the benefits, risks, and potential side effects associated with the vaccine or booster. For another resident, the record showed diagnoses including dementia, psychosis, depression, and anxiety disorder, with a quarterly MDS BIMS score of 0 out of 15 indicating severe cognitive impairment. The immunization record showed COVID-19 booster history of administration on 10/21/21, but there was no recent documentation of vaccine offer, administration, or refusal, and no documented evidence that the resident representative was educated regarding the benefits and potential side effects of COVID-19 immunizations. The IPN stated there was no tracking system in place for resident immunization status and could not provide documentation of education to the resident representative.
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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What surveyors actually found near you
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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.
Illustrative
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Illustrative
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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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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.