Inspection Reports for
Family Of Caring Healthcare At Tenafly, Llc
133 County Road, Tenafly, NJ, 07670
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
6.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
25% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
80% occupied
Based on a November 2023 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
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, 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: 12
Date: Jun 11, 2025
Visit Reason
Routine inspection of Family of Caring Healthcare at Tenafly, LLC to assess compliance with healthcare regulations including resident care, medication administration, infection control, and documentation.
Findings
The facility was found deficient in multiple areas including inaccurate Minimum Data Set coding, incomplete care plan updates, improper pain assessment and medication administration, failure to follow wound care consultant recommendations, unclear enteral feeding orders, incomplete physician visits documentation, medication administration errors, incomplete medical records, inadequate infection control practices, failure to offer influenza vaccination, and insufficient nurse aide annual training.
Deficiencies (12)
Failed to accurately code the Minimum Data Set (MDS) for Resident #21.
Failed to update and revise comprehensive care plans for Residents #3 and #37.
Failed to follow physician's order for appropriate pain assessment and PRN medication administration for Resident #17.
Failed to follow wound care consultant's recommendations for Resident #21's pressure ulcers.
Failed to clarify enteral feeding orders and documentation for Resident #56.
Failed to maintain respiratory care and monitor pulse oximetry as ordered for Resident #47.
Failed to ensure attending physician documented required alternating monthly visits with Nurse Practitioner for Residents #21 and #33.
Failed to maintain accurate, complete, and accessible medical records for Residents #16, #21, and #38.
Medication administration error rate of 6.45% observed during medication pass for Residents #17 and #50, including improper administration of Vitamin D and Glycolax.
Failed to ensure infection prevention and control program compliance including specimen refrigerator temperature monitoring, cleanliness of eyewash station and biohazard disposal, and resident environment cleanliness.
Failed to offer influenza vaccine to Resident #16 for the 2024-2025 flu season.
Failed to ensure Certified Nurse Aide #1 completed required 12 hours of annual in-service education.
Report Facts
Medication administration opportunities: 31
Medication administration errors: 2
Medication administration error rate: 6.45
Vitamin D dosage: 1000
Glycolax dosage: 17
Enteral feeding rate: 40
Enteral feeding total volume: 840
Pulse oximetry monitoring frequency: 3
BIMS score: 14
BIMS score: 10
BIMS score: 9
BIMS score: 12
CNA annual in-service hours completed: 5.75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Named in medication administration errors and pain assessment findings |
| Licensed Practical Nurse #2 | LPN | Named in medication administration errors and medication disposal |
| Director of Nursing | DON | Named in multiple findings including wound care, medication administration, infection control, and physician visit concerns |
| Licensed Nursing Home Administrator | LNHA | Named in multiple findings and exit conferences |
| Regional Director of Nursing #1 | RDON | Named in wound care and medication administration interviews |
| Regional Director of Nursing #2 | RDON | Named in medication administration and infection control interviews |
| Licensed Practical Nurse/Unit Manager #1 | LPN/UM | Named in infection control and medication administration observations |
| Licensed Practical Nurse/Unit Manager #2 | LPN/UM | Named in infection control observations |
| Psychiatric Advanced Practice Nurse | PAPN | Named in medical record and medication regimen discrepancy |
| Licensed Practical Nurse #1 | LPN | Named in Resident #38 interview |
| Staffing Coordinator | SC | Named in infection control observations |
| Housekeeping Director | HD | Named in infection control interview |
Inspection Report
Annual Inspection
Census: 55
Capacity: 69
Deficiencies: 7
Date: Nov 22, 2023
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long-Term Care Facilities. Complaint investigations were also completed during this survey.
Complaint Details
Complaint # NJ00168846 was investigated during the survey. The complaint involved infection control and medication administration issues, which were substantiated as deficiencies.
Findings
The facility was found to be in substantial compliance with emergency preparedness but had deficiencies related to bowel/bladder incontinence care, pharmacy services, medication administration errors, life safety code violations including egress doors and electrical systems, and immunization documentation. Plans of correction were submitted and approved for all cited deficiencies.
Deficiencies (7)
Facility failed to provide appropriate care to prevent spread of infection related to bowel/bladder incontinence and catheter care.
Facility failed to provide pharmaceutical services in accordance with professional standards including accurate medication administration and documentation.
Medication error rate exceeded 5%, with errors in administration and documentation.
Facility failed to ensure exit doors were readily accessible and free of obstructions or impediments to full instant use in case of emergency.
Facility failed to ensure corridor doors resist passage of smoke in accordance with NFPA requirements.
Facility failed to certify emergency electrical generator transfer times within required 10-second timeframe.
Facility failed to offer pneumococcal and influenza immunizations to residents as required.
Report Facts
Census: 55
Total Capacity: 69
Medication Error Rate: 7.1
Medication Opportunities: 28
Medication Errors: 2
Deficiencies Cited: 7
Licensed Beds: 69
Residents with CNA staffing deficiency: 3
Certified Nurse Aides Required: 8
Certified Nurse Aides Present: 7
Certified Nurse Aides Present: 6
Certified Nurse Aides Present: 6
Inspection Report
Routine
Deficiencies: 6
Date: Nov 22, 2023
Visit Reason
The inspection was conducted to assess compliance with healthcare regulations including medication administration, catheter care, medication storage, vaccination policies, and overall resident care.
Findings
The facility was found deficient in multiple areas including improper indwelling urinary catheter care leading to infection risk, medication administration errors including missed and late doses, failure to properly document medication administration, improper medication storage and labeling, and failure to offer pneumococcal vaccination to eligible residents.
Deficiencies (6)
Failure to provide indwelling urinary catheter care to prevent infection, including uncapped urinary drainage bag.
Failure to provide pharmaceutical services including acquisition, administration, and documentation of medications, resulting in missed doses and late administration.
Medication administration error rate of 7.1% observed during medication pass, including administration of incorrect multivitamin and missed iron supplement doses.
Failure to document administration of PRN acetaminophen medication for pain relief.
Medications and biologicals not properly labeled with date opened and stored appropriately, including test strips and nebulizer solutions without dates.
Failure to offer pneumococcal vaccination to eligible residents and failure to document vaccine offer or administration.
Report Facts
Medication administration opportunities: 28
Medication administration errors: 2
Medication administration error rate: 7.1
Medications timed for 9 AM for Resident #23: 7
Medications timed for 9 AM for Resident #53: 10
Medications timed for 9 AM for Resident #1: 14
Medications timed for 9 AM for Resident #2: 7
Medications timed for 9 AM for Resident #3: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Agency Nurse | Involved in medication administration errors and late medication administration on 11/16/23 |
| Certified Nursing Assistant (CNA) | Confirmed uncapped urinary drainage bag and lack of knowledge about catheter care | |
| Licensed Practical Nurse (LPN) | Charge Nurse (CN/LPN) | Assisted in medication administration, called physician regarding missing medication, and acknowledged documentation errors |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding deficiencies, policies, and investigations |
| Consultant Pharmacist (CP) | Consultant Pharmacist | Provided medication pass in-service and information on medication errors |
| Unit Clerk (UC) | Unit Clerk | Responsible for central supply and medication ordering, unaware of need to order certain OTC medications |
| Regional Registered Nurse (RRN) | Regional Registered Nurse | Confirmed lack of documentation for pneumococcal vaccine offer |
| Infection Preventionist (IP) | Infection Preventionist | Confirmed vaccination offer and documentation requirements |
Inspection Report
Routine
Census: 67
Deficiencies: 0
Date: Feb 2, 2023
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.
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: 6
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 0
Date: Jun 29, 2022
Visit Reason
The inspection was conducted in response to complaint #NJ 151660 to assess compliance with regulatory requirements for long term care facilities.
Complaint Details
Complaint # NJ 151660 was investigated and found to be unsubstantiated as the facility was in compliance.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, based on this complaint visit.
Report Facts
Sample size: 3
Inspection Report
Deficiencies: 0
Date: Aug 13, 2021
Visit Reason
The document is a statement of deficiencies and plan of correction related to a facility survey completed on 08/13/2021.
Findings
No health deficiencies were found during the survey.
Inspection Report
Follow-Up
Census: 53
Deficiencies: 1
Date: Aug 13, 2021
Visit Reason
The visit was conducted to assess compliance with New Jersey Administrative Code standards for licensure of long term care facilities and to follow up on previously cited deficiencies related to staffing ratios.
Findings
The facility was found not in compliance with mandatory staffing ratios, failing to maintain the required minimum direct care staff-to-resident ratios for the day shift on 7 of 42 shifts reviewed. The facility submitted a plan of correction and subsequently corrected the deficiency as verified by the revisit on 10/13/2021. Additionally, a Life Safety Code survey found the facility in compliance with fire safety requirements.
Deficiencies (1)
Failed to maintain the required minimum direct care staff-to-resident ratios for the day shift as mandated by the state of New Jersey.
Report Facts
Census: 53
Deficiency shifts: 7
Staffing ratios: 8.17
Staffing ratios: 12
Staffing ratios: 9.8
Staffing ratios: 10.2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Human Resources / Staffing Coordinator | Interviewed regarding staffing ratio issues and recruitment challenges | |
| Administrator and Director of Nursing | Responsible for reviewing staffing schedules and implementing corrective actions |
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 0
Date: Jul 4, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ144839 and NJ143661.
Complaint Details
Complaint numbers NJ144839 and NJ143661 were investigated and found to be unsubstantiated as the facility was in compliance.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B for Long Term Care Facilities based on this complaint survey.
Report Facts
Sample Size: 9
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