Dellridge Health & Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to maintain residents' environment in a safe, clean, comfortable, and homelike surrounding. This deficient practice was identified for 3 of 3 shower rooms in the long term care units. The deficient practice was evidenced by the following: On 4/16/26 at 9:32 AM, Surveyor #1 (S #1) toured the A side nursing unit shower room that was near the nursing station, and observed in the middle cubicle a shower chair with ripped back cover, below was two broken floor tiles, and the heater grills with heavy accumulation of brownish, rusty like substances. [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent facility provided documentation, it was determined that the facility failed to a.) follow the physicians' orders with regard to behavior and side effects monitoring for 5 of 5 residents (Residents #3, #7, #8, #9, and #89) reviewed for unnecessary medications and b.) clarify the physician's order according to the standard of clinical practice and facility's policies. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to ensure that the resident's medical record included documentation that indicated, at a minimum, that the resident or resident's representative was provided education regarding the benefits and potential side effects of the influenza and pneumococcal immunization for 3 of 5 residents reviewed for immunizations (Residents #6, #7, and #89). This deficient practice was evidenced by the following: 1. On 4/16/26 at 10:46 AM, Surveyor #1 (S #1) reviewed the medical record for Resident #6. A review of the admission Record (AR) or face sheet (an admission summary) for Resident #6, revealed diagnoses which included, but were not limited to; multiple sclerosis, sepsis, extended spectrum beta-lactamase resistance, acute kidney failure, and depression. [...]

Inspectors wroteBased on observation, interview, review of the medical record, and review of other facility documentation, it was determined that the facility failed to ensure an as needed psychotropic (affecting the brain and nervous system, altering mood, thoughts, perception, and behavior) medication ordered was limited to 14 days, unless the attending physician/prescribing practitioner documents a rationale to extend the medication for 1 of 2 residents reviewed for hospice (Residents #75). This deficient practice was evidenced by the following: On 4/15/26 at 10:20 AM, the surveyor observed Resident #75 asleep in bed. On 4/16/26 at 11:51 AM, the surveyor reviewed Resident #75's medical record. [...]

Inspectors wroteBased on the interview, review of the medical record, and review of other pertinent facility documentation, it was determined that the facility failed to provide the Resident or Resident Representative with a written notification of the facility's bed hold policy that included the reserve payment information for 2 of 2 residents (Residents #1 and #14) reviewed for hospitalizations. This deficient practice was evidenced by the following: 1. On 4/17/26 at 9:44 AM, Surveyor #1 (S #1) interviewed the Licensed Practical Nurse (LPN) who stated that he was the assigned nurse of Resident #14. The LPN informed S #1 that the resident was cognitively impaired, required total assistance with care, with pressure ulcer (PU), and had been in and out of the hospital where PU worsened. S #1 reviewed the medical records of Resident #14, and revealed the following: [...]

Inspectors wroteBased on interviews and record review, it was determined that the facility failed to complete and transmit the Minimum Data Set Assessment (MDS), an assessment tool used to facilitate the management of care, within 14 days as required, for 1 of 2 residents, (Resident #120), reviewed for facility task-resident assessment, in accordance with federal guidelines. This deficient practice was evidenced by the following:According to the Resident Assessment Instrument (RAI) Manual, dated October 2025, RAI-required Assessment Summary:-The admission (Comprehensive) assessment, the MDS completion date no later than 14th calendar day of the resident's admission (admission date + 13 calendar days). The CAA(s) (Care Area Assessment) Completion date no later than 14th calendar day of the resident's admission (admission date + 13 calendar days). [...]

Inspectors wroteBased on interview and record review it was determined that the facility failed to accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, in accordance with federal guidelines for 5 of 27 residents, (Residents #7, #8, #13, #14, and #89), reviewed for accuracy for MDS coding. This deficient practice was evidenced by the following: 1. On 4/17/26 at 9:00 AM, Surveyor #1 (S #1) reviewed the electronic medical record (eMR) of Resident #7 and revealed: A review of the immunization record reflected that there was no documentation for offered, administered or refusal of flu and pneumonia vaccines. A review of the MDS revealed under section O0250, that C. If influenza vaccine not received, state reason: the code entered in the assessment was 1. Resident not in this facility during this year's influenza vaccination season. [...]

Inspectors wroteBased on interviews and record review and review of pertinent facility documentation, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice that meet each resident's physical, mental and psychosocial needs, specifically a.) ensuring a consent was obtained and signage posted for video monitoring for 1 of 2 residents reviewed for falls (Resident #16) and b.) ensuring hospice recommendations that were not followed were clarified with the physician and medications discontinued that a hospice resident was refusing to take for 1 of 2 residents reviewed for hospice (Resident #75). This deficient practice was evidenced by the following:Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure a.) an air mattress was set according to the resident's weight and b.) the medication administration record was signed in accordance with professional standards of nursing practice for 1 of 2 residents reviewed for pressure ulcer (PU) (Resident #11). This deficient practice was evidenced by the following:Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wroteBased on observations, interviews, record review, and review of other pertinent facility documentation, it was determined that the facility failed to ensure the necessary respiratory care and services of resident that was receiving oxygen according to the standard of clinical practice and the facility's policy and procedure. This deficient practice was identified for 1 of 1 resident, Resident #8, reviewed for respiratory care, and was evidenced by the following:Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wroteBased on interviews and review of other facility documentation, the facility failed to ensure that the physician must include 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. The primary physician's history and physical and succeeding visit notes did not reflect resident's skin impairment and pressure ulcer. This deficient practice was identified for 1 of 27 residents, (Resident #14), reviewed for physician services. This deficient practice was evidenced by the following: On 4/17/26 at 8:34 AM, the surveyor reviewed the medical records of Resident #14, and revealed the following: The admission Record or face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnosis that included but were not limited to; [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to a.) ensure the consultant pharmacist identified and reported irregularities in the medication regimen, b.) ensure duplicate and conflicting physician orders were clarified, and c.) ensure that as needed and routine orders were not duplicative or clinically appropriate. This deficient practice was identified for 1 of 27 residents (Resident #6) reviewed for orders. The deficient practice was evidenced by the following: On 4/16/26 at 10:10 AM, the surveyor observed Resident #6 in the resident's room lying in bed. The resident was alert and oriented, with the call bell within reach. The surveyor reviewed the medical record for Resident #6. [...]

Inspectors wroteREPEAT DEFICIENCYBased on observation, interview, and review of other pertinent facility documentation, it was determined that the facility failed to; a.) follow appropriate hand hygiene, use of personal protective equipment (PPE), and disinfect equipment for 1 of 4 nurses during medication pass observation, b.) perform hand hygiene and follow enhanced barrier precautions (EBP) for 1 of 1 staff (Housekeeper), and c.) track the extent to which staff were following the facility's policy and procedures to control infections and communicable diseases for all residents with regard to vaccinations, failed to follow appropriate infection control practices to prevent the spread of infection in accordance with the Center for Disease Control and Prevention (CDC) guidelines, standards of clinical practice, and the facility's policy. This deficient practice was evidenced by the following: [...]

Inspectors wroteBased on interview, record review, and review of other pertinent facility documents, it was determined that the facility failed to ensure all residents and/or resident representatives must be educated on the COVID-19 vaccine the facility offered, in a manner they could understand for 2 of 5 residents reviewed for immunizations (Residents #6 and #7). This deficient practice was evidenced by the following: 1. On 4/16/26 at 10:46 AM, Surveyor #1 (S #1) reviewed the medical record for Resident #6. A review of the admission Record (AR) or face sheet (an admission summary) for Resident #6, revealed diagnoses which included, but were not limited to; multiple sclerosis, sepsis, extended spectrum beta-lactamase resistance, acute kidney failure, and depression. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents it was determined that the facility failed to maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 12/15/24 at 9:28 AM, the surveyor, in the presence of the Food Service Director (FSD) and Regional FSD (RFSD), observed the following during the kitchen tour: 1. In the juice dispenser area, there were three 5-gallon beverage boxes that were past their best used by date. A thickened water (nectar consistency) 5-gallon box had a best if used by date of 9/11/24. A thickened water (honey consistency) 5-gallon box had a best if used by date of 7/31/24. A diet lemonade 5-gallon box had a best if used by date of 10/3/23. The FSD stated that the beverage boxes were good for 6 months after their best if used by date. [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent facility provided documentation, the facility failed to adhere to professional standards of clinical practice by failing to: a.) follow the residents' meal tickets for 2 of 2 meal observations for Residents #41, #43, and #44; b.) clarify the physician's order with regard to supplement for 1 of 24 residents, Resident #41; and c.) ensure medication was administered in accordance with the manufacturer's specifications, and d.) ensure proper disposal of excess medication in a safe and approved manner for 2 of 6 residents, Residents #45 and #339, reviewed during the medication pass observation. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wroteREPEAT DEFICIENCY Based on observation, interview, review of medical records, and other pertinent facility documentation, it was determined that the facility failed to a.) follow appropriate hand hygiene and use of personal protective equipment (PPE) practices for 5 of 11 staff (1 Housekeeper,1 Recreation Aide, 2 Dietary Staff, and 1 Physician), b.) disinfect the examination area after use, and follow appropriate infection control practices during meal observation, environment tour, and kitchen tour, to prevent the potential spread of infection in accordance with the Center for Disease Control and Prevention (CDC) guidelines, standards of clinical practice, and facility's policy. This deficient practice was evidenced by the following: According to the CDC Clinical Safety: Hand Hygiene for Healthcare Workers dated 2/27/24 revealed: [...]

Inspectors wroteBased on observation, interview, and review of facility-provided documents, it was determined that the facility failed to ensure that a) meals were consistently provided in a dignified and homelike manner and b) resident meal assistance was provided in a dignified manner. The deficient practice was observed in the recreation dining room for 2 of 6 residents (Residents #15 & #44). The deficient practice was evidenced by the following: On 12/15/24 at 11:46 AM, the surveyor observed the Kitchen Staff (KS) deliver the food truck to the recreation room, there were 6 residents, 4 residents at one table, 1 resident at one table, and another resident at one table, there were 2 Recreation Aides (RA) inside the dining area and later Registered Nurse Supervisor (RNS) came and assisted in distributing lunch trays. [...]

Inspectors wroteBased on observation, interview, record review, and review of other facility documentation, it was determined the facility failed to ensure accurate documentation of a resident's advance directives for 1 of 7 residents (Resident #10) reviewed. This deficient practice was evidenced by the following: The surveyor reviewed the hybrid (electronic and paper) medical records of Resident #10 which revealed: The admission Record (a summary of important information about the resident) revealed that the resident was admitted with diagnoses that included but were not limited to, chronic respiratory failure (a chronic condition when the airways in the lungs become damaged and narrow), anxiety disorder, and type 2 diabetes mellitus. [...]

Inspectors wroteCOMPLAINT NJ#169518 Based on interviews, review of medical records, and pertinent facility documentation, it was determined that the facility failed to notify the Resident's Representative (RR) of a change in condition for 1 of 24 sampled residents (Resident # 239). This deficient practice was evidenced by the following: The surveyor reviewed Resident #239's closed hybrid (paper and electronic) medical record. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to maintain residents' environment in a safe, clean, comfortable, and homelike surrounding. This deficient practice was identified for 3 of 21 residents reviewed, Resident #48, #71 and #47. The deficient practice was evidenced by the following: 1. During the initial tour of the facility on 12/15/24 at 11:35 AM, the surveyor observed room [ROOM NUMBER]-LW and Resident #48 was not in the room. The surveyor observed dressers on both sides of the bed. Some areas of the wood on the left dresser and the edges of the right dresser were peeled, exposing the underlying particle board which created a rough surface and edges on the dressers. The heater unit in room [ROOM NUMBER]-LW was observed without the front grill cover. The front grill cover was observed laying against the wall. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide the necessary service to maintain good personal grooming for a resident who was unable to carry out activities of daily living (ADL). This deficient practice was identified for 1 of 21 residents reviewed for care, Resident #71. The deficient practice was evidenced by the following: On 12/15/24 at 11:12 AM, the surveyor observed Resident #71 lying on an air mattress inside their room. The resident waved to the surveyor but was unable to answer questions at that time. The surveyor observed Resident #71 unshaven, with hair stubbles on both cheeks, and beard on chin. On 12/16/24 at 11:28 AM, the surveyor observed the Resident #71 sitting on the wheelchair (w/c) inside their room, unshaven, and Certified Nursing Assistant #1 (CNA#1) was combing the resident's hair. [...]

Inspectors wroteREPEAT DEFICIENCY Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice and facility policies and procedures for 1 of 24 residents, Resident #86, reviewed for quality of care. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to ensure the necessary respiratory care and services of residents that were receiving oxygen, according to the standard of clinical practice and the facility's policy and procedure, specifically, administer oxygen therapy according to the physician's order by documenting the date and time the oxygen tubing was changed for 1 of 1 resident, Resident #10. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent documents, it was determined that the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice for 1 of 1 resident (Resident #25), reviewed for dialysis services. The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure that the 24-hour staffing report posted was accurate and in a prominent place within the facility readily accessible to the residents and the visitors. This deficient practice was evidenced by the following: On 12/15/24 at 8:56 AM, the survey team entered the facility. The surveyor did not observe a 24-hour staffing report in the initial hallway leading to the nursing station or at the nursing station. The surveyor then turned right and proceeded down a different hallway, which contained the lower odd numbered resident rooms and observed a staffing report sheet that was posted on the right wall next to the menu. [...]

Inspectors wroteComplaint NJ#169518 Based on observation, interview, record review, and review of other pertinent documents, it was determined that the facility failed to maintain complete and readily accessible medical records. This deficient practice was identified for 1 of 24 residents reviewed (Resident #239). This deficient practice was evidenced by the following: On 12/18/24 at 9:01 AM, the surveyor reviewed Resident #239's closed hybrid (paper and electronic) medical record. [...]

Inspectors wroteREPEAT DEFICIENCY Based on interview and record review it was determined that the facility failed to accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, in accordance with federal guidelines for 1 of 24 residents, (Residents #88), reviewed for accuracy for MDS coding. This deficient practice was evidenced by the following: The surveyor reviewed the medical records of Resident #88 and revealed: [...]

Inspectors wroteComplaint #NJ00154277 Based on the interview, review of the facility closed record, and the review of facility provided documents, it was determined that the facility failed to: a) document the skin impairment of the resident, b) provide scheduled showers, c) administer medications according to the order of the physician, and d) notify the physician of late administration of prescribed medications in accordance with the resident's preferences, goals for care and professional standards of clinical practice for one (1) of 19 residents, (Resident#127) reviewed for quality of care and was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wroteBased on observation, interview, record review, and review of the facility provided documents, it was determined that the facility failed to ensure a) proper storage of medication (med) for one (1) of 19 residents, Resident #32 observed during the first day of tour; b) med was available for one (1) of four (4) residents, Resident#45 during med administration observation; c) proper disposal of med for one (1) of three (3) nurses observed during med administration; d) med was administered according to the order of the physician for one (1) of 19 residents, Resident#129 observed during med cart inspection according to the standards of clinical practice and facility policies. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to thoroughly investigate a fracture of unknown origin on 3/02/23 of Resident#10. This deficient practice was identified for one (1) of three (3) residents reviewed for incident/accident and was evidenced by the following: On 7/06/23 at 10:59 AM, the surveyor observed Resident #10 seated in a wheelchair inside their room, with one floor mat to the left side of the bed. The resident stated to the surveyor that he/she had a fall incident last night while in the bathroom. At the same time, Certified Nursing Aide#1 (CNA#1) who was also inside the room informed the surveyor that she was the aide of the resident. The CNA stated that the fall incident happened not on her shift. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility provided documents, it was determined that the facility failed to ensure that a Significant Change in Status Assessment (SCSA) was completed for Resident #10. This deficient practice was identified for one (1) of 19 residents reviewed, and was evidenced by the following: According to the MDS (minimum data set) 3.0 RAI (Resident Assessment Instrument) Manual October 2019 page 2-22 (pages 44-49) included that the SCSA is a comprehensive assessment for a resident must be completed when the IDT (interdisciplinary team) has determined that a resident meets the significant change guidelines for either major improvement or decline. A significant change is a major decline or improvement in a resident's status that: 1. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, for 3 (three) of 19 residents, (Residents #10, #11 and #54) reviewed, and was evidenced by the following: 1. On 7/06/23 at 10:59 AM, the surveyor observed Resident #10 seated in a wheelchair inside their room with the Certified Nursing Aide (CNA) with one floor mat to the left side of the bed and informed the surveyor that she was the aide of the resident. The resident stated to the surveyor that he/she had a fall incident last night while in the bathroom. The CNA stated that the fall incident happened not on her shift. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility provided documents, it was determined that the facility failed to follow and revised the diet slip of one (1) of 19 residents, Resident #32 observed during breakfast observation according to the standards of clinical practice. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to assess for risk for pressure ulcer quarterly and accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, for one (1) of three (3) residents reviewed for pressure ulcer/injury (Resident #40). The deficient practice was evidenced by the following: On 7/06/23 at 10:48 AM, the surveyor observed Resident #40 lying in bed with an air mattress. The surveyor reviewed the medical records of Resident #40 which revealed the following: The admission Record (or face sheet; [...]

Inspectors wroteBased on observation, interview, and review of the facility provided documents, it was determined that the facility failed to: a) label and properly store the nebulizer (neb) mask for one (1) of two (2) residents, (Resident#126) reviewed for respiratory care and b) perform hand hygiene appropriately for one (1) (Licensed Practical Nurse) of three (3) staff observed during medication (med) administration in accordance with the Centers for Disease Control and Prevention (CDC) guidelines and facility policy. This deficient practice was evidenced by the following: According to the U.S. [...]