Inspection Reports for Family Of Caring Healthcare At Ridgewood
304 S. Van Dien Ave, NJ, 07450
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
8.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
69% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
92% occupied
Based on a March 2023 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
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
Deficiencies: 6
May 5, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to the facility's environment, medication management, physician oversight, medication labeling, and medical record accuracy.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment, proper medication order clarification and monitoring, accurate physician documentation, proper medication labeling, and accurate medical record keeping. Specific issues included dirty resident rooms and activity areas, unclear medication orders, lack of behavior monitoring for antipsychotic medication, medication administration errors, incomplete physician documentation, improperly labeled medication, and incomplete documentation of skin impairments.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to provide a safe, clean, and comfortable homelike environment in 1 of 4 units, including dirty toilets, fan coils with blackish substances, broken window glass, and dirty windowsills. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to clarify physicians' orders for PRN pain medications for 2 residents and failed to adequately monitor behavior related to antipsychotic medication for 1 resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to follow physician orders during medication administration for 1 resident (administered capsules instead of tablets). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure the resident's doctor reviews care, writes, signs, and dates progress notes and orders accurately for 2 residents, including inaccurate medication documentation and diagnoses. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to properly label medication in 1 of 4 medication carts; an inhaler was stored in a plastic bag without proper pharmacy labeling. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain accurate medical records for 1 resident, including incomplete documentation of skin impairment and inaccurate transfer form information. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Fan-coil filter cleaning frequency: 4
Residents in rooms with environmental deficiencies: 3
Residents in activity room with environmental deficiencies: 2
Residents reviewed for medication issues: 21
Residents affected by medication deficiencies: 5
Residents affected by medical record deficiencies: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Acknowledged need to clarify PRN acetaminophen and morphine orders. |
| Director of Nursing | Director of Nursing | Acknowledged medication order clarification issues and discussed behavior monitoring updates. |
| Maintenance and Environmental Services Director | Maintenance and Environmental Services Director | Discussed fan coil cleaning schedule and acknowledged environmental concerns. |
| Licensed Nursing Home Administrator | Licensed Nursing Home Administrator | Participated in exit conferences and discussed facility responses to deficiencies. |
| Consultant Pharmacist | Consultant Pharmacist | Confirmed medication labeling requirements and nursing staff expectations. |
| Registered Nurse #2 | Registered Nurse | Observed administering incorrect medication form and acknowledged order should be followed. |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Confirmed lack of specific behavior monitoring order for antipsychotic medication. |
| Registered Nurse/Unit Manager | Registered Nurse/Unit Manager | Discussed behavior monitoring expectations and skin impairment documentation. |
| Assistant Administrator | Assistant Administrator | Participated in meetings regarding environmental and medication concerns. |
| Director of Rehabilitation/Occupational Therapist | Director of Rehabilitation/Occupational Therapist | Observed environmental deficiencies and did not respond to surveyor inquiries. |
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
Routine
Census: 88
Deficiencies: 10
Feb 16, 2023
Visit Reason
Routine inspection of Family of Caring Healthcare at Ridgewood nursing home to assess compliance with regulatory requirements including resident assessments, discharge procedures, respiratory care, staffing, medication administration, infection control, and infection preventionist qualifications.
Findings
The facility failed to accurately code resident assessments for dental status, failed to obtain and document discharge orders and summaries, failed to maintain proper respiratory care and equipment hygiene, inaccurately posted nurse staffing information, failed to ensure medication administration according to physician orders including vital sign monitoring, failed to notify physicians of abnormal test results, failed to ensure proper infection control practices including hand hygiene and PPE use, and failed to designate a qualified infection preventionist meeting regulatory requirements.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 10
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to accurately code the Minimum Data Set (MDS) for dental status for one resident over eight quarters. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to obtain an order for discharge and document a discharge summary for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide safe and appropriate respiratory care including proper storage and timely changing of nebulizer equipment for two residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure nurse aides were properly certified or enrolled in training before providing direct care. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to accurately post nurse staffing information accessible to residents and visitors. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to administer medication (Midodrine) according to physician's order including monitoring and documenting blood pressure prior to administration. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to notify physician or practitioner of abnormal chest x-ray results for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to perform hand hygiene appropriately and properly use PPE by staff including Recreation Assistant and Licensed Practical Nurse. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to follow proper wound care procedures including hand hygiene and glove changes during wound treatment. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to designate a qualified infection preventionist who completed required training, met part-time position requirements, and had appropriate professional training. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Staff affected: 1
Resident census: 88
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse | LPN | Named in wound care and infection control deficiencies |
| Recreation Assistant | RA | Named in infection control PPE and hand hygiene deficiency |
| Director of Nursing | DON | Interviewed regarding multiple deficiencies and facility practices |
| Regional Director of Nursing | RDON | Interviewed regarding infection preventionist and staffing deficiencies |
| Administrator In Training | AIT | Interviewed regarding staffing and infection preventionist deficiencies |
| Consultant Pharmacist | CP | Interviewed regarding medication administration deficiency |
| Human Resources Director | HRD | Interviewed regarding nurse aide certification 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
Routine
Deficiencies: 2
Mar 4, 2021
Visit Reason
The inspection was conducted to evaluate compliance with professional standards of quality, infection prevention and control, and proper documentation of physician orders in a nursing facility.
Findings
The facility failed to document the amount of supplement intake for one resident over three months, did not ensure proper use of personal protective equipment (PPE) and hand hygiene among staff, and failed to ensure workers were knowledgeable about cleaning chemicals and processes according to CDC guidelines.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to follow a physician's order and document the amount of a supplement intake for 1 of 18 residents for three months. | Level of Harm - Minimal harm or potential for actual harm |
| 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 process used in the workplace for 1 of 3 staff in accordance with CDC guidelines. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 1
Supplement intake frequency: 5
Brief Interview for Mental Status (BIMS) score: 9
Weight gain: 1.4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeper #1 | Observed not wearing N95 mask and eye protection inside PUI room | |
| Housekeeper #2 | Observed cleaning with unlabeled disinfectant and not following contact time | |
| Certified Nursing Aide (CNA) | Forgot to wear face shield entering PUI room | |
| Optometrist | Did not wear N95 mask inside PUI room and did not perform hand hygiene after glove removal | |
| Licensed Practical Nurse (LPN) | Informed surveyor about supplement intake documentation issue | |
| Director of Nursing (DON) | Director of Nursing | Acknowledged documentation failure and educated staff on PPE use |
| Licensed Nursing Home Administrator (LNHA) | Licensed Nursing Home Administrator | Provided information on vendor protocols and PPE use |
| Director of Maintenance and Environmental Services (DMES) | Director of Maintenance and Environmental Services | Informed surveyors about labeling requirements for disinfectants |
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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