Inspection Reports for Family Of Caring Healthcare At Ridgewood
304 S. Van Dien Ave, NJ, 07450
Back to Facility ProfileDeficiencies per Year
16
12
8
4
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Notice
Deficiencies: 0
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, individuals' rights to access and control their information, and the legal duties of NJDHSS to protect privacy.
Report Facts
Effective date: 2011
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer contact for questions about the notice |
Inspection Report
Routine
Census: 88
Capacity: 96
Deficiencies: 14
Mar 2, 2023
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
Deficiencies were cited related to accuracy of assessments, discharge summary documentation, respiratory care, nurse aide staffing and qualifications, nurse staffing information posting, pharmacy services, radiology result notifications, infection prevention and control, life safety code compliance including egress doors, exit signage, smoke barriers, electrical systems, and oxygen cylinder safety.
Severity Breakdown
Level E: 6
Level D: 6
Level F: 1
Deficiencies (14)
| Description | Severity |
|---|---|
| Facility failed to accurately code the Minimum Data Set (MDS) for one resident over eight quarters. | Level E |
| Facility failed to obtain and document a discharge summary including physician order for discharge for one resident. | Level D |
| Facility failed to maintain respiratory care equipment properly and failed to follow infection control procedures for oxygen and nebulizer treatments for two residents. | Level D |
| Facility used a Hospitality Aide to provide direct resident care without proper CNA certification. | Level D |
| Facility failed to accurately post nurse staffing information reflecting actual CNAs and hours worked. | Level D |
| Facility failed to ensure licensed nurses documented vital sign parameters prior to medication administration as ordered for one resident. | Level D |
| Facility failed to notify physician or nurse practitioner of abnormal radiology results for one resident. | Level D |
| Facility staff failed to perform proper hand hygiene and PPE use in isolation room. | Level D |
| Facility failed to ensure designated Infection Preventionist met training, professional qualifications, and part-time work requirements. | Level D |
| Delayed-egress locking arrangement did not release within 15 seconds upon force application. | Level E |
| Facility failed to post illuminated exit or directional exit signs where egress path was not obvious. | Level E |
| Smoke barriers were not continuous from floor to floor in one area above ceiling tiles. | Level E |
| Diesel-powered emergency power supply system was not exercised annually with required supplemental loads and duration. | Level F |
| Freestanding compressed oxygen cylinders were not properly chained or supported in a proper cylinder stand or cart. | Level E |
Report Facts
CNA staffing deficiency: 6
Resident census: 88
Total licensed beds: 96
Delayed egress door release time: 15
Emergency power supply test duration: 1.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Named in medication administration and wound care deficiency. |
| RN #2 | Registered Nurse | Named in hand hygiene and infection control deficiency. |
| LPN | Licensed Practical Nurse | Named in wound care and infection control deficiency. |
| RDON | Regional Director of Nursing | Named in multiple interviews and findings related to staffing and infection control. |
| DON | Director of Nursing | Named in multiple interviews and findings related to staffing, infection control, and medication administration. |
| AIT | Administrator In Training | Named in staffing and infection preventionist role deficiency. |
| Maintenance Director | Named in deficiencies related to door locking, smoke barriers, emergency power, and oxygen cylinder safety. | |
| IPN | Infection Preventionist Nurse | Named in infection control deficiencies. |
| COO | Chief Operating Officer | Named in staffing and infection preventionist role deficiency. |
Inspection Report
Annual Inspection
Census: 76
Deficiencies: 2
Mar 4, 2021
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities, including a COVID-19 Focused Infection Control Survey conducted in conjunction with the recertification survey.
Findings
The facility was found not in compliance with infection control regulations related to COVID-19 and failed to follow a physician's order and document supplement intake for one resident. Deficiencies included failure to properly use PPE, perform hand hygiene, and label cleaning chemicals, among others.
Severity Breakdown
SS=E: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to follow a physician's order and document the amount of supplement intake for 1 of 18 residents for three months. | SS=E |
| Failed to ensure proper use of personal protective equipment (PPE) for 3 of 7 staff, perform handwashing appropriately for 1 of 8 staff, and ensure workers were knowledgeable of cleaning chemicals and processes for 1 of 3 staff. | SS=E |
Report Facts
Census: 76
Sample size: 18
Deficiency completion date: Mar 18, 2021
Deficiency completion date: Apr 13, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Aide (CNA) | Mentioned in relation to failure to wear eye protection entering PUI room and supplement intake observation | |
| Licensed Practical Nurse (LPN) | Provided information about resident's appetite and supplement intake documentation | |
| Dietician | Monitored resident's weight and supplement intake documentation | |
| Director of Nursing (DON) | Involved in re-education and audit plans related to deficiencies | |
| Licensed Nursing Home Administrator (LNHA) | Provided explanations regarding documentation and vendor protocols | |
| HK#1 | Housekeeper | Failed to wear N95 mask and eye protection in PUI room |
| HK#2 | Housekeeper | Failed to check cleaning chemicals and contact times |
Inspection Report
Life Safety
Deficiencies: 0
Mar 4, 2021
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code 101:2012 and emergency preparedness requirements for long term care facilities.
Findings
The facility was found to be in substantial compliance with Appendix Z-Emergency Preparedness and in compliance with the minimum Life Safety Code requirements as surveyed using CMS-2786R.
Inspection Report
Abbreviated Survey
Deficiencies: 1
Dec 29, 2020
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 in compliance with infection control regulations, specifically failing to ensure proper use of Personal Protective Equipment (PPE) by staff on the COVID-19 Positive Unit. One Licensed Practical Nurse (LPN) was observed not wearing required PPE and was removed from the unit and sent home to quarantine.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure implementation of infection control practices and precautions on the proper use of Personal Protective Equipment (PPE) by one of three employees observed on the COVID-19 Positive Unit. | SS=D |
Report Facts
Deficiency count: 1
Quarantine duration: 14
Performance improvement program duration: 30
Monitoring frequency: 2
Monitoring duration: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Observed not wearing required PPE on COVID-19 Positive Unit and removed from unit. | |
| Assistant Licensed Nursing Home Administrator (A. LNHA) | Interviewed and confirmed PPE requirements and actions taken regarding the LPN. | |
| Staffing Coordinator (SC) / Certified Nursing Assistant | Interviewed and confirmed PPE requirements and actions taken regarding the LPN. | |
| Infection Control Preventionist | Interviewed and confirmed PPE requirements on COVID-19 Positive Unit. | |
| Nursing Supervisor | Assigned as replacement nurse on COVID Unit after LPN removal. | |
| Unit Manager | Observed in compliance with PPE requirements on COVID Unit. |
Inspection Report
Routine
Census: 74
Deficiencies: 0
Dec 9, 2020
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 and recommended COVID-19 practices.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 3
Inspection Report
Routine
Census: 74
Deficiencies: 0
Nov 20, 2020
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 to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
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