Inspection Reports for
Family Of Caring At Teaneck Llc

1104 Teaneck Road, Teaneck, NJ, 07666

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Deficiencies (last 4 years)

Deficiencies (over 4 years) 9 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

73% worse than New Jersey average
New Jersey average: 5.2 deficiencies/year

Deficiencies per year

24 18 12 6 0
2021
2022
2024
2025

Occupancy

Latest occupancy rate 91% occupied

Based on a August 2024 inspection.

This facility has shown a steady increase in demand based on occupancy rates.

Occupancy rate over time

64% 72% 80% 88% 96% 104% Feb 2021 Dec 2021 Feb 2022 Feb 2024 Aug 2024

Inspection Report

Complaint Investigation
Deficiencies: 2 Date: Dec 2, 2025

Visit Reason
The inspection was conducted based on Complaint #2666131 to investigate a reported incident involving Resident #97 where hot tea was spilled on the resident's left arm and abdomen during breakfast, to assess compliance with treatment and documentation standards.

Complaint Details
Complaint #2666131 involved a hot tea spill incident on 11/9/25 affecting Resident #97. The complaint was substantiated with findings of delayed documentation and treatment order transcription failures.
Findings
The facility failed to timely transcribe physician orders and document the incident in the resident's electronic health record for Resident #97. The incident involved a hot tea spill causing skin redness and blisters, with delayed and incomplete documentation of treatment and incident reporting.

Deficiencies (2)
Failure to transcribe physician orders timely to ensure treatment and care according to professional standards and facility policies.
Failure to document the incident report timely in the resident's electronic health record.
Report Facts
Residents affected: 1 Incident date: Nov 9, 2025 Reddened area measurements: 4.5 Reddened area measurements: 1 Reddened area measurements: 8 Reddened area measurements: 2.5 BIMS score: 15

Employees mentioned
NameTitleContext
Licensed Practical NurseLPNInvolved in setting up breakfast, witnessed incident, delayed documentation and treatment transcription
Certified Nursing AssistantCNAAssisted Resident #97 during breakfast, heated tea in microwave, witnessed incident
Director of NursingDONProvided in-service about incident, confirmed documentation failures
Licensed Nursing Home AdministratorLNHAProvided accident and investigation reports to surveyor

Inspection Report

Routine
Deficiencies: 9 Date: Dec 2, 2025

Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements related to resident care, safety, and facility operations.

Findings
The facility was found deficient in multiple areas including failure to provide meals in a dignified manner, incomplete bed hold policy notifications, unclear physician orders and incomplete tuberculosis testing documentation, failure to transcribe physician orders and timely document incident reports, inadequate wound care and assessment, improper enteral feeding documentation, improper food storage and labeling, failure to follow infection control practices including hand hygiene and PPE use, and failure to maintain a clean and safe environment in shower rooms and eyewash stations.

Deficiencies (9)
Failure to ensure meals were consistently provided in a dignified and homelike manner for residents.
Failure to provide complete bed hold policy notification including reserve bed payment information for residents during hospitalizations.
Failure to clarify physician orders and follow tuberculosis testing and documentation protocols.
Failure to transcribe physician orders and timely document incident reports for a resident burn injury.
Failure to provide appropriate pressure ulcer care including clarifying orders, following weekly skin assessments, and proper wound documentation.
Failure to provide appropriate treatment and services for a resident receiving enteral tube feedings including inaccurate documentation of water flushes.
Failure to store food in a consistent manner to prevent foodborne illness including expired and unlabeled food items and unclean refrigerators.
Failure to follow appropriate hand hygiene and PPE practices for staff, risking potential spread of infection.
Failure to maintain a clean, safe, and sanitary environment in shower rooms and eyewash stations including broken fixtures, dirt accumulation, and inadequate lighting.
Report Facts
Deficiencies cited: 9 Resident count in findings: 21

Employees mentioned
NameTitleContext
Licensed Practical Nurse #1Licensed Practical NurseMentioned in relation to failure to perform hand hygiene and improper food storage.
Licensed Practical Nurse #2Licensed Practical NurseMentioned in relation to failure to perform hand hygiene and improper food storage.
Certified Nursing AssistantCertified Nursing AssistantMentioned in relation to improper PPE use and failure to follow infection control practices.
Licensed Practical Nurse/Wound NurseLicensed Practical Nurse/Wound NurseMentioned in relation to wound care deficiencies and shower room observations.
Director of NursingDirector of NursingInterviewed regarding multiple deficiencies including meal service, bed hold policy, wound care, enteral feeding, infection control, and environmental concerns.
Licensed Nursing Home AdministratorLicensed Nursing Home AdministratorInterviewed regarding multiple deficiencies and facility responses.
Licensed Practical Nurse Unit ManagerLicensed Practical Nurse Unit ManagerInterviewed regarding tuberculosis testing protocol and documentation.
Regional Director of Nursing #1Regional Director of NursingInfection Preventionist who addressed PPE concerns and infection control practices.
Licensed Practical Nurse SupervisorLicensed Practical Nurse SupervisorObserved with gloves in hallway and improper hand hygiene.
Registered NurseRegistered NurseInterviewed regarding enteral feeding documentation.

Notice

Deficiencies: 0 Date: Nov 19, 2025

Visit Reason
This document serves to inform individuals about the privacy practices of NJDHSS, including how their medical information may be used and disclosed, and their rights related to this information.

Findings
The notice details the types of information covered, reasons for use and disclosure of health information, legal duties of NJDHSS, and the rights of individuals to access, amend, and restrict their health information.

Report Facts
Effective date: 2011

Employees mentioned
NameTitleContext
Devon L. GrafDirector, Office of Legal and Regulatory ComplianceListed as NJDHSS Privacy Officer contact for questions about the notice

Inspection Report

Annual Inspection
Deficiencies: 0 Date: Aug 23, 2024

Visit Reason
The inspection was conducted as an annual survey to assess compliance with health and safety regulations at the facility.

Findings
No health deficiencies were found during the inspection.

Inspection Report

Routine
Census: 97 Deficiencies: 0 Date: Aug 23, 2024

Visit Reason
A COVID-19 Focused Infection Control Survey was conducted on behalf of the New Jersey Department of Health to assess compliance with infection control regulations.

Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented CMS and CDC recommended practices to prepare for COVID-19.

Report Facts
Sample Size: 5

Inspection Report

Routine
Deficiencies: 1 Date: May 16, 2024

Visit Reason
The inspection was conducted to assess compliance with regulations regarding the use of bed rails, including proper assessment, alternative measures, and informed consent for residents using side rails.

Findings
The facility failed to ensure that alternative measures were used prior to installation of side rails, assessments for risk of entrapment were completed, and informed consent was obtained for one resident reviewed. Interviews with staff confirmed lack of documented assessments, alternatives, and consents related to side rail use.

Deficiencies (1)
Failure to ensure residents received alternative measures prior to installation of side rails, complete assessments for risk of entrapment, and obtain informed consent for side rail use for one resident.
Report Facts
Residents affected: 1

Employees mentioned
NameTitleContext
Regional Registered Nurse (RRN)Interviewed regarding lack of side rail consents
Director of Nursing (DON)Interviewed regarding side rail assessments, alternatives, and consents

Inspection Report

Routine
Deficiencies: 1 Date: May 16, 2024

Visit Reason
The inspection was conducted to evaluate compliance with regulations regarding the use of bed rails in the facility, specifically assessing whether alternative measures were used prior to installation, risk assessments were completed, and informed consent was obtained.

Findings
The facility failed to ensure that alternative measures were used before installing side rails, did not complete risk assessments for entrapment, and did not obtain informed consent for side rail use for one resident reviewed. Interviews with staff confirmed the lack of documented assessments, alternatives, and consents related to side rails used for positioning.

Deficiencies (1)
Failure to ensure residents received alternative measures prior to installation of side rails, completion of risk assessments for entrapment, and obtaining informed consent for side rail use.
Report Facts
Residents sampled: 29 Residents affected: 1

Employees mentioned
NameTitleContext
Regional Registered NurseRegional Registered Nurse (RRN)Interviewed regarding lack of side rail consents
Director of NursingDirector of Nursing (DON)Interviewed regarding side rail assessments, alternatives, and consents

Inspection Report

Deficiencies: 0 Date: Feb 10, 2024

Visit Reason
The document is a statement of deficiencies and plan of correction related to a regulatory inspection of the nursing home facility.

Findings
No health deficiencies were found during the inspection.

Inspection Report

Routine
Census: 97 Deficiencies: 0 Date: Feb 10, 2024

Visit Reason
A COVID-19 Focused Infection Control Survey was conducted on behalf of the New Jersey Department of Health to assess compliance with infection control regulations.

Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices to prepare for COVID-19.

Report Facts
Sample Size: 9

Inspection Report

Complaint Investigation
Census: 80 Deficiencies: 1 Date: Feb 23, 2022

Visit Reason
The inspection was conducted in response to complaint NJ152584 regarding staffing ratios at the facility.

Complaint Details
Complaint NJ152584 was substantiated based on facility document review and interviews indicating deficient staffing ratios during specified weeks.
Findings
The facility failed to maintain the required minimum staff-to-resident ratios as mandated by the State of New Jersey for multiple day and overnight shifts, affecting all residents. Deficiencies in Certified Nursing Assistant (CNA) staffing were noted for 14 of 14 day shifts and 7 of 14 overnight shifts reviewed.

Deficiencies (1)
Failure to ensure staffing ratios were met to maintain the required minimum staff-to-resident ratios as mandated by the State of New Jersey for 14 of 14-day shifts and 7 of 14 overnight shifts reviewed.
Report Facts
Census: 80 Deficient day shifts: 14 Deficient overnight shifts: 7 Required CNAs on 2/06/22 day shift: 10 Actual CNAs on 2/06/22 day shift: 5 Required total staff on 2/06/22 overnight shift: 6 Actual total staff on 2/06/22 overnight shift: 5

Inspection Report

Routine
Deficiencies: 8 Date: Dec 16, 2021

Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, medication management, infection control, and facility environment.

Findings
The facility was found deficient in multiple areas including incomplete incident investigations and notifications, failure to ensure residents at risk for elopement wore wander guards, failure to follow through with restorative nursing programs, improper medication storage and labeling, unsanitary kitchen and laundry conditions, incomplete medical records, inadequate dialysis communication documentation, and failure to perform proper hand hygiene by staff.

Deficiencies (8)
Failed to complete thorough investigation and notification for fall incidents for residents.
Failed to ensure residents identified as elopement risks wore physician-ordered wander guards and lacked required elopement risk assessments.
Failed to follow through with residents' Restorative Nursing Program for range of motion and splint use.
Failed to properly label, store, and dispose of medications; medication refrigerators not maintained at proper temperatures.
Failed to properly date, store, and dispose of food; kitchen environment and equipment not maintained in sanitary condition.
Failed to maintain complete, accurate, and readily accessible medical records including smoking assessments, elopement assessments, and dialysis communication logs.
Failed to perform hand hygiene appropriately after wound treatment and garbage disposal by staff.
Laundry area was not maintained in a safe, sanitary, and comfortable condition with dust, lint, debris, and used gloves improperly stored.
Report Facts
Incident Reports not completed appropriately: 2 Residents identified with elopement risk without wander guards: 3 Dialysis treatments with incomplete communication logs: 9 Temperature of medication refrigerator: 26 BIMS scores: 7 BIMS scores: 15

Employees mentioned
NameTitleContext
Licensed Nursing Home Administrator (LNHA)Acknowledged incomplete incident reports and lack of elopement assessments.
Director of Nursing (DON)Acknowledged incomplete incident reports, lack of elopement assessments, and hand hygiene concerns.
Licensed Practical Nurse (LPN) #1Observed failing to perform hand hygiene properly after wound treatment.
Housekeeper (HK)Observed failing to perform hand hygiene before and after glove use during garbage disposal.
Regional Registered Nurse (RRN) #1Acknowledged lack of elopement assessments and hand hygiene concerns.
Physical Therapist/Rehab Director (PT/RD)Provided information on restorative nursing program and communication failures.
Food Service Director (FSD)Acknowledged unsanitary kitchen conditions and food storage issues.
Maintenance Director (MD)Acknowledged unsanitary laundry conditions and lack of cleaning.

Inspection Report

Annual Inspection
Census: 88 Deficiencies: 12 Date: Dec 16, 2021

Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.

Findings
The facility was found deficient in multiple areas including failure to complete thorough investigations of fall incidents, failure to ensure residents at risk for elopement wore wander guards, failure to follow restorative nursing programs, improper labeling and storage of medications, unsanitary food procurement and preparation practices, incomplete and inaccurate resident medical records, inadequate infection prevention and control practices, unsafe and unsanitary laundry environment, failure to maintain required staffing ratios, and deficiencies in life safety code compliance including fire alarm system and electrical safety.

Deficiencies (12)
Failure to complete thorough investigation for fall incidents and notify physician and responsible party.
Failure to ensure residents identified as elopement risks were wearing physician ordered wander guards and lack of elopement assessments.
Failure to follow through with residents' Restorative Nursing Program and lack of appropriate orders and documentation.
Failure to properly label, store, and dispose of medications including unlocked medication refrigerators and undated insulin vial.
Failure to properly date, store, and dispose of potentially hazardous and dry foods and maintain sanitary kitchen environment.
Failure to maintain complete, accurate, and readily accessible medical records including missing smoking and elopement assessments and incomplete dialysis communication logs.
Failure to perform hand hygiene appropriately after wound treatment and garbage disposal by staff.
Failure to provide a safe, sanitary, and comfortable environment in the laundry area including soiled carts, debris, dust, and lint buildup.
Failure to maintain required minimum direct care staff to resident ratios as mandated by the State of New Jersey.
Failure to provide fire alarm notification by audible and visible signals in an enclosed courtyard.
Failure to perform and document monthly visual examination of fire extinguishers on three extinguishers.
Failure to ensure electrical outlet near water source had proper working Ground-Fault Circuit Interrupter (GFCI) protection.
Report Facts
Census: 88 Staffing Deficiencies: 14 Staffing Deficiencies: 2 Staffing Deficiencies: 12

Employees mentioned
NameTitleContext
LPN #1Licensed Practical NurseNamed in hand hygiene deficiency for failure to perform hand hygiene after wound treatment
Housekeeper (HK)Housekeeping StaffNamed in hand hygiene deficiency for failure to perform hand hygiene after garbage disposal
Director of Nursing (DON)Director of NursingInvolved in multiple interviews and acknowledged deficiencies in investigations, documentation, and infection control
Maintenance and Environmental Services Director (MEVSD)Maintenance and Environmental Services DirectorInvolved in fire alarm and fire extinguisher deficiencies and electrical outlet inspection
Staffing Coordinator (SC)Staffing CoordinatorInterviewed regarding staffing shortages and compliance with state staffing ratios

Inspection Report

Abbreviated Survey
Census: 82 Deficiencies: 2 Date: Feb 10, 2021

Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations related to COVID-19.

Findings
The facility was found not to be in compliance with 42 CFR §483.80 infection control regulations, specifically failing to ensure appropriate hand hygiene practices for 3 of 9 staff observed and inadequate staff knowledge of cleaning chemical contact times for 3 of 3 staff. The facility implemented CMS and CDC recommended practices and provided in-service training to staff.

Deficiencies (2)
Failure to practice appropriate hand hygiene for 3 of 9 staff observed, including wearing gloves in hallways and not performing hand hygiene after glove removal.
Failure to ensure workers are knowledgeable of the cleaning chemical contact time used in the workplace for 3 of 3 staff.
Report Facts
Sample size: 5 Deficiencies cited: 2

Employees mentioned
NameTitleContext
Housekeeper #1Observed not removing gloves and not performing hand hygiene after exiting resident room
Housekeeper #2Observed wearing gloves in hallway and unable to state disinfectant contact time; previously given verbal warning for glove use in hallway
Housekeeper #3Observed not performing hand hygiene between glove changes and unable to state disinfectant contact time
Licensed Practical Nurse #1Observed wearing gloves in nursing station and educated on glove use and hand hygiene
Licensed Practical Nurse #2Unable to state disinfectant contact time
Registered Nurse/SupervisorRN/SStated staff should not wear gloves in hallways and should perform hand hygiene after glove removal
Infection Preventionist NurseIPNIn-serviced staff on hand hygiene and glove use according to CDC guidelines
Licensed Nursing Home AdministratorLNHAIn-serviced staff regarding cleaning chemicals and aware of concerns
Housekeeping and Laundry DirectorHLDReported staff should not wear gloves in hallways and acknowledged lack of education on disinfectant contact time
Director of NursingDONUnaware if staff were educated about disinfectant contact time

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