Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Actors Fund Home during CMS and state inspections, most recent first.
Food storage and sanitation practices were not maintained consistently. A milk chest and walk-in ref were observed above safe temp ranges, the stove top had crusted debris, uncovered bread was stored in a box, and wet pans were stacked while still damp. In a nutrition ref, the temp log was incomplete and several resident food items were unlabeled or undated, including an expired soup and other unidentified desserts.
Missed Quarterly MDS Assessments: A resident’s MDS record showed an Entry assessment, an Admission-5 day assessment, and a Not OBRA assessment, but no subsequent quarterly assessments were completed within the required timeframe. The DON stated the resident was changed from skilled to nonskilled, but the new eMR did not switch the resident to the OBRA schedule, and the vendor said the facility’s finance department should have made the change. The facility’s policy required the RAI coordinator and DON/MDS Coordinator to ensure MDS assessments were completed and submitted on time.
A resident with HTN, CKD, and schizoaffective bipolar disorder had an order for olanzapine, but the CCP and CPR did not reflect the antipsychotic use or related diagnosis. The psychiatrist consult noted Zyprexa as an adjunct for anti-depressant, yet the care plan was not updated to match the resident’s current meds and condition. The NS could not locate the CCP, and the DON acknowledged the antipsychotic information should have been included.
A resident with intact cognition, recent knee prosthesis explantation, infection, and muscle weakness had a physician order for zinc oxide to the sacral/buttocks area TID. The ointment was observed on the nightstand, and staff stated the CNA applied it while the nurse signed the eTAR. The resident’s skin documentation was also inconsistent, with an admission assessment noting erythema and rash but lacking detail, while later notes described redness in the buttocks and other areas without clear location or characterization. The DON acknowledged the discrepancy and stated the skin assessment should have specified the type and location of the redness.
A CP failed to identify medication irregularities during the monthly drug regimen review for a resident receiving IV ABT, pain meds, and other therapies after knee surgery complications. The eMAR showed two oxycodone PRN orders were given closer together than ordered, but the EPIC review did not document these irregularities. The DON acknowledged the issues should have been identified, and facility policy required the CP to review the MAR, orders, and report any irregularities.
A resident with an infected surgical knee site, intact cognition, IV ABT, and pain management needs had PRN oxycodone administered outside the ordered intervals. The eMAR showed a 5 mg dose given 4 hours apart and a 10 mg dose given 1 hour apart, while the CDAR did not match the eMAR and no CDAR existed for the 5 mg order. The CP review did not identify the irregularities, and the DON stated the issue was not reported until surveyor inquiry.
Incomplete documentation of a resident’s fall, pain management, and physician notifications was identified. A resident with severe cognitive impairment, a recent hip fracture history, and fall risk was found on the floor with left hip pain after a fall, and the record showed a STAT hip x-ray order and ongoing pain assessments. However, nursing notes did not consistently document physician notification about continued pain and delayed x-ray completion, PRN Tylenol was reportedly given but not signed in the eMAR, and key discussions with the RR and MD were recorded on the 24-hour report instead of the resident’s chart.
Improper Disposal and Maintenance of Recycling Dumpster Area: Surveyors observed the fenced recycling dumpster area with both dumpster lids open and debris scattered around the enclosure, including plastic items, a metal can, a milk crate, paper, and mop/broom sticks. The KS/C was unsure who was responsible for cleaning the area, while the FSD and HD later stated that dietary and housekeeping staff shared responsibility for keeping the area clean. The facility policy required daily checks and that the container lid remain closed when not in use.
Food Storage, Temperature, and Sanitation Lapses
Penalty
Summary
The facility failed to maintain sanitation in a safe and consistent manner to prevent food borne illness. During an initial kitchen tour, the surveyor observed a milk chest holding beverages at 49 degrees and a walk-in refrigerator at 52 degrees. The kitchen supervisor/cook stated the temperatures should have been below 41 degrees and below 40 degrees, respectively, and attributed the higher readings to staff entering the refrigerators, doors being left open, and the kitchen being warm. The stove top was also observed with three of twelve burners in use and multiple areas of dry, crusted debris, while the kitchen supervisor stated the stove was cleaned after every use. The surveyor also observed an open cardboard box on top of a freezer chest containing two exposed loaves of bread, while other bread items in the box were secured in a plastic bag. The kitchen supervisor stated the uncovered bread had been received that way from the vendor and acknowledged the loaves should have been covered for proper storage. In addition, two half pans on a drying rack were observed wet inside, and the kitchen supervisor stated washed items should be stacked only when completely dry to prevent wet nesting. On a later inspection of a nutrition refrigerator near the East unit, the surveyor observed a blank and unsigned temperature log for two shifts, an unlabeled container of ice cream, an unlabeled container of tomato feta soup with a manufacturer use-by date of 4/15/24, and an unlabeled dessert container with a sticker dated 7/14. The RN could not identify the owners of the items and removed the expired soup and dessert for disposal. The FSD stated outside food items should be labeled with the resident's name, room number, date brought in, and date placed in the refrigerator, and that items would be discarded after 48 hours.
Missed Quarterly MDS Assessments
Penalty
Summary
The facility failed to complete the Quarterly MDS within the required timeframe for one resident whose assessments were reviewed. Resident #74 had MDS transmissions showing an Entry assessment with ARD 11/29/24, an Admission-5 day assessment with ARD 12/6/24, and a Not OBRA assessment with ARD 3/6/25, but no further MDS assessments were completed after that. The surveyor reviewed the resident’s record and found there was no quarterly assessment for March 2025 and no quarterly assessment for June 2025, despite the requirement that the Quarterly MDS be completed within the specified timing window. During interview, the DON stated the resident had been admitted on skilled services and later changed from skilled to nonskilled, but the facility’s new eMR program did not switch the resident to the OBRA schedule. The DON explained that after the surveyor’s inquiry, she contacted the outside vendor and was told someone from the facility’s finance department should have switched the skilled to nonskilled residents. The facility’s MDS policy stated that the RAI coordinator would ensure MDS assessments were completed and submitted within regulation guidelines, and that the DON/MDS Coordinator would obtain weekly MDS missing reports monthly to ensure all MDS were completed and submitted.
Care Plan Not Updated for Antipsychotic Use
Penalty
Summary
The facility failed to update and revise the comprehensive care plan for a resident with hypertension, chronic kidney disease, and schizoaffective disorder bipolar. The resident’s cMDS showed that the BIMS could not be completed and that the resident was rarely or never understood. The medication record showed an order for olanzapine 2.5 mg daily, an antipsychotic medication, with a diagnosis of schizo-affective bipolar disorder. A psychiatrist consult also documented a plan to continue Zyprexa as an adjunct for anti-depressant, but did not reflect a diagnosis of schizoaffective or bipolar disorder. The resident’s comprehensive care plan, last revised on the date noted in the report, did not mention antipsychotic medication use or olanzapine for schizoaffective, bipolar, or any other diagnosis. The current Care Plan Report also did not reflect olanzapine or any antipsychotic use, although it did reflect antidepressant medications. During interview, the Nursing Supervisor stated the MDS Coordinator was primarily responsible for updating the care plan, and that in the coordinator’s absence the DON, 3 to 11 shift NS, and nursing staff would work on it; the supervisor could not locate the resident’s care plan. The DON stated antipsychotic medication use should be included in the care plan and acknowledged that the resident’s olanzapine and related diagnosis should have been updated, noting it would be addressed at the next quarterly MDS and should be updated as needed.
Ointment Administration and Skin Assessment Documentation Deficiency
Penalty
Summary
The facility failed to follow a physician order for zinc oxide ointment and failed to ensure the resident’s skin assessment was accurate and completed in accordance with professional standards of practice and the facility’s policy for one resident. The resident was admitted with diagnoses including aftercare following explantation of a knee prosthesis with spacer, infection following a procedure, osteoarthritis, hypertension, and muscle weakness. The resident’s MDS reflected intact cognition with a BIMS score of 15, and the resident was observed seated in a wheelchair with a leg rest and left leg immobilizer in use. During the initial tour, the surveyor observed a tube of zinc oxide ointment on the nightstand, and the resident stated it was being applied to the sacral area for rashes and redness. The resident’s record showed physician orders for zinc oxide 20% topical ointment to the sacral/buttocks area three times daily and klayesta powder to skin folds three times daily, both transcribed to the eTAR and signed off as administered each shift. The care plan included interventions for urinary incontinence and risk for impaired skin integrity, including applying zinc oxide as ordered, but the disciplines tab was blank for the incontinence interventions. The admission nursing assessment documented a surgical wound and “erythema and rash” under skin, but there was no further description of the redness or rash in the comments section. The surveyor also reviewed progress notes and found a discrepancy between the admission skin assessment and later documentation describing redness in the buttocks and other areas. During interviews, the assigned LPN stated the CNA applied the zinc oxide and the nurse was responsible for making sure it was done and then signing the eTAR, and acknowledged the ointment should have been stored properly. The CNA stated she applied zinc oxide during continence care as prevention and that the nurse signed the record after it was applied. The DON stated that if an ointment order was in the eTAR, the nurse should administer it unless it was standard care, and also stated that the skin assessment should identify what kind of redness was present and whether it was a pressure wound, MASD, or stage 1 pressure injury. The DON confirmed there was a discrepancy between the skin assessment and progress notes and stated the assessment should have specified the location of redness and rash.
Consultant Pharmacist Failed to Identify Oxycodone PRN Irregularities
Penalty
Summary
The facility's Consultant Pharmacist failed to identify medication irregularities during the monthly drug regimen review for one resident. The resident was admitted with diagnoses including aftercare following explantation of a knee joint prosthesis with cement spacer placement, infection following a surgical procedure, osteoarthritis, hypertension, and muscle weakness. The resident had intact cognition with a BIMS score of 15, reported pain, and was receiving medications that included an IV antibiotic, a diuretic, an opioid, and anticonvulsant medication. Review of the June 2025 eMAR showed two oxycodone PRN orders that were not followed as written. One order for oxycodone 5 mg every 8 hours as needed for moderate pain was administered at 9:06 AM and again at 1:49 PM on the same day, which was 4 hours apart. Another order for oxycodone 10 mg every 8 hours as needed for severe pain was administered at 1:51 PM and again at 3:00 PM on the same day, which was 1 hour apart. The surveyor reviewed the Consultant Pharmacist's EPIC review dated 6/24/25 and found no documented evidence that these oxycodone irregularities were identified. Interviews with the DON, the Consultant Pharmacist, and facility leadership confirmed that the pharmacist was responsible for reviewing the eMAR, medication orders, and related records and reporting irregularities. The DON acknowledged that the oxycodone irregularities should have been identified by the Consultant Pharmacist. Facility policy stated that the Consultant Pharmacist would perform a drug regimen review using the available orders and medication records and report any drug regimen irregularities.
PRN oxycodone administered outside ordered intervals
Penalty
Summary
The facility failed to ensure that medications were administered in accordance with the physician’s orders, facility policy, and accepted professional standards of practice for one resident reviewed for medications. The deficiency involved a resident admitted with diagnoses including aftercare following explantation of a knee joint prosthesis, infection following a surgical procedure, osteoarthritis, hypertension, and muscle weakness. The resident had intact cognition with a BIMS score of 15/15, was receiving IV antibiotics for an infected left surgical site, and was on rehab with pain management needs. Review of the June 2025 eMAR showed two active oxycodone PRN orders: oxycodone 5 mg every 8 hours as needed for moderate pain, and oxycodone 10 mg every 8 hours as needed for severe pain. The record showed the 5 mg order was administered at 9:06 AM and again at 1:49 PM on the same day, which was 4 hours apart. The 10 mg order was administered at 1:51 PM and again at 3:00 PM on the same day, which was 1 hour apart. The controlled drug administration record also showed documentation for oxycodone 10 mg doses, including entries that did not match the eMAR, and there were no controlled drug administration records for the 5 mg oxycodone order. The consultant pharmacist’s monthly review did not identify the irregularities with the PRN oxycodone administration. The DON stated she was unaware of the medication error until the surveyor’s inquiry and that no reports had been received from nursing staff or the subacute unit regarding discrepancies with the PRN oxycodone. The resident stated that the oxycodone had been given before the ordered interval because of severe pain and that the order was later changed to every 4 hours PRN. A facility policy provided during the survey stated that medication errors must be immediately reported to the resident’s physician and that a Medication Error Form must be initiated by the nurse discovering the error.
Incomplete Documentation of Fall, Pain, and Physician Notifications
Penalty
Summary
The facility failed to maintain complete, accurate, and readily accessible medical records for a resident with a history of left femur fracture, dementia, macular degeneration, falls, muscle weakness, and difficulty walking. The resident had a BIMS score of 6 out of 15, indicating severely impaired cognition, and had a care plan focused on pain related to a recent fall and left hip fracture with ORIF. After the resident was found on the floor with left hip pain, the record showed a physician order for a STAT left hip x-ray and pain assessment documentation, but the documentation in the eMR was inconsistent and incomplete. Following the fall, nursing notes documented that the resident was guarding the left hip, complained of pain, and had a left knee abrasion treated with dressing. The record also showed repeated references to the resident waiting for the x-ray to be completed, but one nurse note did not document that the physician was notified of the continued pain or the delay in obtaining the STAT x-ray. Pain scores were documented in the vitals section at different times, including a score of 3 and later 5, but the record did not show documented administration of pain medication corresponding to all of the pain assessments that were recorded. The surveyor also found that the eMAR did not contain documentation of PRN Tylenol administration that nurses stated had been given on two shifts, and the nurses acknowledged they did not sign the eMAR when the medication was administered. In addition, discussions with the resident’s representative and physician about the delayed x-ray and the resident’s condition were documented on the 24-hour report rather than in the resident’s medical record, and the DON stated that the 24-hour report was legal facility documentation but not part of the resident’s medical record. The facility policy required documentation of physician notification and change of treatment in electronic charting, and the pain management policy required documentation of date and time of physician notification and change of treatment.
Improper Disposal and Maintenance of Recycling Dumpster Area
Penalty
Summary
The facility failed to dispose of garbage and refuse properly in the designated recycling dumpster area outside the building. During observation with the Kitchen Supervisor/Cook, the surveyor saw an enclosed white privacy fence around the cardboard recycling dumpster, and when the fence was opened, one dumpster was observed with both lids open and debris scattered on the ground around it, including plastic bottles, plastic bags, gloves, a #10 metal can, an empty plastic milk crate, a few paper items, and four mop/broom sticks beside the dumpster. The Kitchen Supervisor/Cook was unsure who was responsible for cleaning the area and believed it was maintenance. On the following day, the surveyor returned to the garbage disposal area with the Food Service Director and observed the dumpster area clean, with no debris on the floor and the lids closed. The Food Service Director stated it had been cleaned by staff the day before, and both the Food Service Director and Housekeeping Director stated that housekeeping and dietary staff were responsible for keeping the area clean. The facility’s Cardboard Recycling Policy required dietary and housekeeping staff to thoroughly check the fenced enclosure after pickup, perform a daily check for debris, and keep the container lid closed when not in use.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Englewood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Family Of Caring Healthcare At Tenafly, Llc | 1.5 mi | ★★★★★ | 1 | 0 |
| Family Of Caring At Teaneck Llc | 1.9 mi | ★★★★★ | 17 | 0 |
| Complete Care At Inglemoor, Llc | 2 mi | ★★★★★ | 3 | 0 |
| Careone At Cresskill | 2.4 mi | ★★★★★ | 18 | 0 |
| Careone At New Milford | 2.9 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.