Family of Caring at Teaneck LLC

Inspectors wroteBased on interview, record review, and review of facility provided documents, it was determined that the facility failed to ensure a.) the bed hold-policy that was provided to the Resident or Resident's Representative (RR) included information about the reserve bed payment policy plan for 2 of 2 residents (Residents #3 and #113) reviewed for hospitalizations and b) completion of a physician's discharge summary for 1 of 1 residents (Resident #115) reviewed for discharge to the community. The deficient practice was evidenced by the following: 1. Surveyor #1 (S #1) reviewed the electronic medical record (EMR) for Resident #3 for hospitalization and revealed: A review of the admission Record (AR; [...]

Inspectors wroteBased on observation, interview, and review of facility-provided documents, it was determined that the facility failed to ensure that meals were consistently provided in a dignified and homelike manner. The deficient practice was observed in the recreation dining area for 2 of 2 residents (Residents #87 and #91). The deficient practice was evidenced by the following:On 11/21/2025 at 12:09 PM, the surveyor observed the lunch meal service in the dining room, Residents #87 and #91 were seated at table #9. Resident #91 had been served a tray of food and was independently eating. Resident #87, seated across from Resident #91 was not served a tray. The surveyor observed staff in the room that included but were not limited to the Director of Activities (DA) and Certified Nurse Aides (CNAs) that distributed meal trays and assisted residents to eat. [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent facility provided documentation, it was determined that the facility failed to; a.) clarify the physicians' orders for 1 of 5 residents, (Resident #23), observed during medication administration, according to the standard of clinical practice and facility policy and b) follow appropriate tuberculosis (TB) testing and documentation according to standards of clinical practice and facility protocol for 1 of 5 residents (Resident #30) reviewed for unnecessary medications. 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 wroteComplaint #2666131Based on observation, interview, and record review, it was determined that the facility failed to: a.) transcribed a physician order to ensure that a resident receive treatment and care in accordance with professional standards of practice and facility policies and procedures and b.) ensure that an incident report was documented in the resident's electronic health record (EHR) timely for 1 of 21 residents (Resident #97) reviewed. 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, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that a resident received care consistent with professional standards of practice by failing to; a.) clarify the physician order for sacrum wound, b.) follow the physician order and care plan for weekly skin assessment, and c.) properly assess and document wound assessments for 1 of 2 residents, (Resident #14), reviewed for facility acquired pressure injury. The evidence was as follows: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 record review, it was determined that the facility failed to provide appropriate treatment and services for a resident receiving enteral (tube) feedings. This deficient practice was identified for 1 of 2 residents (Residents #81), reviewed for enteral tube feeding. This deficient practice was evidenced by the following: On 11/19/25 at 10:03 AM, the surveyor observed Resident #81 lying in bed with their head of the bed elevated. The resident was alert and verbally responsive. Resident #81 stated they had a tube feeding (TF; delivery of nutrients through a feeding tube directly into the stomach), received enteral feedings, and recently started a diet to eat food by mouth. On 11/20/25 at 10:20 AM, the surveyor reviewed the electronic medical record (EMR) of Resident #81. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents it was determined that the facility failed to store food in a consistent manner to prevent foodborne illness for 2 of 10 refrigerators and freezers reviewed. This deficient practice was evidenced by the following: On 11/20/25 at 1:47 PM, the surveyor interviewed Licensed Practical Nurse #1 (LPN #1), who stated the refrigerator (ref) to store resident food items for the entire floor was on the central nurses' station. The ref had signage which indicated food items should be labeled, dated, and kept in the ref for no more than three days. The surveyor with LPN #1 checked the nutrition ref and observed the following:1. A ricotta cheese manufacturer container which had a written date of 11/2/25 and a room number. The manufacturer expiration date of the container was in January 2026. [...]

Inspectors wroteBased on observation, interview, review of medical records, and other pertinent facility documentation, it was determined that the facility failed to follow appropriate hand hygiene and use of personal protective equipment (PPE) practices for 5 of 8 staff (1 Certified Nursing Aide, 3 Licensed Practical Nurses, and 1 non-licensed staff) and follow appropriate infection control practices to prevent the potential 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: According to the CDC Clinical Safety: Hand Hygiene for Healthcare Workers dated 2/27/24 revealed. [...]

Inspectors wroteBased on observation, interview, and review of pertinent documents, it was determined that the facility failed to maintain a clean, safe, and sanitary environment for: a.) 1 of 2 shower rooms and b.) 1 of 2 eyewash stations. This deficient practice was evidenced by the following: Onn 11/20/25 at 10:40 AM, the surveyor asked the Licensed Practical Nurse/Wound Nurse (LPN/WN) where the shower rooms of the residents were, and he accompanied the surveyor to the south shower room. Both the surveyor and the LPN/WN observed a plastic cover in the south shower room. He stated that he just came back from vacation, and the room was on renovation. The LPN/WN then asked the Director of Nursing (DON), who informed the surveyor that the south shower room was on renovation, and the north unit shower room was being used by the residents. [...]

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure residents received alternative measures prior to installation of side rails, assessments were completed for the risk of entrapment prior to installation, and informed consent with explained risks and benefits was obtained prior to installation for one of one resident reviewed for side rails (Resident (R) 13) of 29 sampled residents. The lack of alternate side rail measures and proper assessment/consent could lead to potential restraint or side rail entrapment.

Inspectors wroteBased on observation, interview, and review of documentation provided by the facility, it was determined that the facility failed to a.) properly date, store and dispose of potentially hazardous and dry foods in a manner to prevent food borne illness and b.) maintain the kitchen environment and equipment in a sanitary manner to prevent contamination from foreign substances and potential for the development a food borne illness. This deficient practice was observed and evidenced by the following: On 12/01/21 at 10:42 AM, during the initial tour of the kitchen in the presence of the Food Service Director (FSD), the surveyor observed the following: 1. Five broken floor tiles and a missing tile in the dish machine area. 2. A white epoxy covered chipped and rust colored wall mounted wire rack. The rack was directly over the three compartment sinks for rinsing and sanitizing. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to a.) complete a thorough investigation for a fall incident that was identified and documented on the Nurse's Notes (NN) from 9/24/21 through 9/25/21 for Resident#39 and b.) ensure that the physician and responsible party (RP) were notified and documented on 11/20/21 fall investigation for Resident#60. The deficient practice was evidenced for 2 of 3 residents reviewed for incident/accident. This deficient practice was evidenced by the following: 1. On 12/2/21 at 9:15 AM, during the tour, the surveyor observed Resident #39 sitting in a chair next to the South unit nursing station. A review of the admission Record for Resident #39 revealed that the resident was admitted to the facility with diagnoses that included, but were not limited to: [...]

Inspectors wroteBased on observation, interviews, record review, and review of other facility documents it was determined that the facility failed to a.) ensure residents identified as elopement risks were wearing a physician's ordered wander guard (a device that allows residents to have freedom within their facility while providing security by alarming to prevent the resident from exiting the building unattended) and b.) ensure that Elopement Assessment's and care plan's were done according to facility policy and procedure and standards of clinical practice. This was identified for 3 of 11 residents (Resident #51, #56, and #47). 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 other facility documents it was determined that the facility failed to follow through with the resident's Restorative Nursing Program (RNP) for 2 of 2 residents (Resident #19 and 24), according to the facility's policy and procedure and standards of clinical practice. This deficient practice was evidenced by the following: 1. On 12/1/21 at 10:56 AM, the surveyor observed Resident #19 lying on the bed eyes closed, with a right-hand limitation with no assistive device in use. A review of the Physician's Oder Form (POF) for December 2021 with a list of residents' diagnoses included Chronic obstructive pulmonary disease (COPD), cerebrovascular accident with right-sided weakness (stroke), and hypertension (elevated blood pressure). [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to properly label, store and dispose of medications in 1 of 3 medication carts and in 2 of 3 medication refrigerators inspected. This deficient practice was evidenced by the following: On 12/07/21 at 11:55 AM, the surveyor inspected the North unit medication refrigerator in the presence of a Licensed Practical Nurse (LPN) #1 which was in the North unit nursing station unlocked. The North unit medication refrigerator contained insulin, Purified Protein Derivative (PPD) and a narcotic lockbox (it was locked and affixed to the refrigerator) that contained Ativan topical gel and Ativan intramuscular vials. The surveyor interviewed LPN #1 who stated that the medication refrigerator should have been locked. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to maintain complete, accurate, and readily accessible medical records. This deficient practice was identified for 2 of 24 residents reviewed, Resident#12 and 63 and was evidenced by the following: 1. On 12/2/21 at 9:50 AM, the Director of Nursing (DON) in the presence of the Regional Registered Nurse (RRN) #1) informed the surveyor that Resident#12 was probably walking around that was why the resident was not in their room. The DON further stated that the resident had a diagnosis of Dementia. On that same date at 9:52 AM, the Certified Nursing Aide (CNA) informed the surveyor that the resident had forgetfulness, was able to walk independently without an assistive device and was on supervised smoking. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to perform hand hygiene appropriately for 2 of 7 Staff observed after wound treatment and garbage disposal in accordance with the Centers for Disease Control and Prevention guidelines for infection control. This deficient practice was evidenced by the following: According to the U.S. CDC guidelines Hand Hygiene Recommendations, Guidance for Healthcare Providers for Hand Hygiene and COVID-19, page last reviewed 1/8/2021 included, Hand Hygiene means cleaning your hands by using either handwashing (washing hands with soap and water), antiseptic handwash, antiseptic hand rub (i.e. alcohol-based hand sanitizer including foam or gel), or surgical hand antisepsis . Multiple opportunities for hand hygiene may occur during a single care episode. Following are the clinical indications for hand hygiene: [...]

Inspectors wroteBased on observation, interview, and facility-provided documents, it was determined that the facility failed to provide a safe, sanitary, and comfortable environment for residents and staff in the laundry area according to facility policy and procedure. This deficient practice was evidenced by the following: On 12/8/21 at 9:24 AM, the surveyor toured the laundry area with the Director of Environmental Services (DES) who informed the surveyor that he's in charge of the laundry and the housekeeping department. There were 4 out of 6 hanging rack carts parked in the hallway near the laundry room with clean clothes which also had soiled bottom racks and used gloves. The DES informed the surveyor that probably it was the nurse from the unit who left the used gloves there. [...]