Average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Family Of Caring Healthcare At Tenafly, Llc during CMS and state inspections, most recent first.
A resident with type 2 DM and multiple comorbidities had several insulin orders, including Lantus and lispro sliding scale, that were not consistently or accurately documented across the OSR, MAR, and PNs. Nursing staff recorded code 9 entries on the MAR for a bedtime Lantus dose and documented awaiting pharmacy delivery, but did not fully document MD notification or the resulting one-time short-acting insulin order. One-time Admelog doses and coverage doses were administered and charted on the MAR or in PNs without corresponding entries on the OSR, and some PNs omitted the insulin type. Additional changes to Lantus dosing and lispro sliding scale, as well as an MD order for an 8-unit coverage dose, were documented in PNs without matching physician orders or timely MAR entries. Interviews with an LPN, the RN supervisor, the DON, and the MD confirmed that insulin orders and administrations were not completely or accurately recorded, contrary to the facility’s charting and documentation policy.
The facility failed to provide pharmaceutical services and timely medication administration, resulting in a resident not receiving a prescribed medication for over a month, five residents receiving medications late, and inaccurate documentation of PRN medication administration.
The facility failed to provide proper indwelling urinary catheter care for a resident with a history of UTI, as observed by an uncapped urinary drainage bag stored improperly. The CNA and LPN confirmed the issue, and the facility's policy for maintaining a closed drainage system was not followed.
The facility failed to ensure proper medication administration, resulting in a 7.1% error rate. An LPN administered an incorrect multivitamin and failed to provide a prescribed iron supplement to a resident with anemia and a femur fracture. The errors were due to inadequate medication availability and insufficient staff orientation.
The facility failed to ensure medications were stored and labeled appropriately, as observed during an inspection of two medication carts. Items such as Ultra Track test strips, Ipratropium/Albuterol, and Budesonide nebulizer solutions were found without dates indicating when they were opened. Staff confirmed the absence of dates and acknowledged the oversight.
The facility failed to offer the pneumonia (PNA) vaccination to two residents, as identified during a survey. Both residents had no evidence in their medical records that they had been offered or administered the PNA vaccination. Interviews with staff confirmed the lack of documentation, despite the facility's policy requiring all residents to be offered the vaccine.
Incomplete and Inaccurate Insulin Order and MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to completely and accurately document physician insulin orders and insulin administration for one resident in accordance with accepted professional standards and the facility’s own documentation policy. The resident was admitted with multiple diagnoses, including a right femur fracture, muscle weakness, type 2 DM with diabetic chronic kidney disease, heart failure, hypertension, and repeated falls, and was assessed as alert and oriented times three. The Order Summary Report (OSR) as of 07/23/2025 showed multiple insulin orders: Admelog sliding scale before meals, Humalog sliding scale before meals and at bedtime, and three separate Lantus bedtime dose orders (16 units, then 22 units, then 10 units), but no further insulin orders beyond these. The facility’s policy required that all medications administered and services performed be documented in the clinical record. Review of the Medication Administration Record (MAR) for July 2025 revealed inconsistencies and missing documentation relative to the OSR and progress notes (PN). For Lantus 16 units at bedtime, the MAR showed a code 9 entry on 07/22/2025, with the chart code indicating “Other/See Progress Notes,” and the PN documented that the nurse was awaiting pharmacy delivery; however, there was no PN entry indicating that the medication was not received or that the MD was notified, despite LPN #1 later stating that the RN supervisor called the MD and obtained a one-time short-acting insulin order. The MAR also showed a one-time Admelog 4-unit dose on 07/22/2025 at 10:03 PM and a one-time Admelog 7-unit dose on 07/23/2025 at 2:47 AM, but these one-time orders were not reflected on the OSR. A PN at 2:10 AM on 07/23/2025 documented a phone order for 7 units x1 dose but did not specify the insulin type. Further discrepancies occurred with sliding scale insulin and Lantus dose changes on 07/23/2025. The MAR documented administration of Admelog per sliding scale for a blood sugar of 341 at 11:30 AM and a code 9 entry for a blood sugar of 400 at 4:30 PM, while PNs by an LPN described blood sugars “over 400 mg/dl since last night and during lunch,” extra 2-unit Admelog doses, and communication attempts with the MD and endocrinologist. Another PN documented obtaining a new order to increase Lantus to 22 units nightly and giving another 2 units for blood sugar coverage, but the OSR and MAR did not consistently reflect all of these specific coverage doses. Later PNs documented new orders to change the lispro sliding scale and to discontinue the current Lantus and decrease it to 10 units, and a 10:20 PM PN described an MD order for 8 units of insulin prior to dinner, with Lantus and 8 units of coverage given for a blood sugar of 402 at 9:02 PM; however, there was no corresponding physician order on the OSR or order entry on the MAR for this medication. Interviews with nursing staff and the DON confirmed that some insulin doses were documented only in PNs as late entries, that the RN supervisor did not document MD communication, and that documentation on the MAR did not coincide with or timely reflect the insulin orders and administrations, contrary to the facility’s charting and documentation policy. Interviews with staff and the resident’s MD further highlighted the documentation failures. LPN #1 confirmed using code 9 on the MAR and documenting “awaiting RX delivery” in the PN for the 16-unit Lantus order and stated she did not administer the Lantus because the facility was waiting for pharmacy delivery, and that the RN supervisor notified the MD and obtained a one-time short-acting insulin order, which was not fully documented in the PNs. The RN supervisor stated she could not recall the exact blood sugar or details of the MD call and acknowledged she did not document at the time, assuming the nurse would document in the PNs. The DON acknowledged that an LPN’s late-entry documentation of insulin given did not coincide with or timely appear on the MAR. The resident’s MD stated that nurses called when the patient was admitted, that the blood sugar was over 400, and that the insulin order given was based on the hospital sliding scale, but the facility’s records did not fully or accurately capture these orders and administrations. Collectively, these findings show that the facility failed to maintain complete and accurate physician orders and medication administration records for insulin for this resident, in violation of professional standards and the facility’s own documentation policy.
Failure to Provide Pharmaceutical Services and Timely Medication Administration
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with professional standards, resulting in multiple deficiencies. One resident did not receive their prescribed Polysaccharide Iron Complex medication from 10/7/23 until 11/16/23. The medication was not available in the medication cart, and the facility did not follow up adequately to ensure its availability. The Director of Nursing (DON) acknowledged that the medication was not available and that there was no follow-up when the medication was not administered. The facility's process for handling missing medications was not clearly defined, leading to the medication being unavailable for an extended period. Additionally, the facility failed to administer medications in a timely manner to five residents. An LPN, who was an agency nurse on his first day at the facility, was observed administering medications late. The LPN did not receive proper orientation and was late starting his medication pass. The DON acknowledged that the medications were not administered within the required time frame and that the Unit Manager should have intervened to assist the LPN. The facility's policy required medications to be administered within one hour of their prescribed time, which was not adhered to in this case. Furthermore, the facility failed to accurately document the administration of an as-needed (PRN) medication for a resident. The resident reported knee pain and stated that the staff provided pain medication when needed. However, the electronic medication administration record (eMAR) did not reflect the administration of acetaminophen on two occasions, despite nurse progress notes indicating that the medication was given. The DON confirmed that the medication was administered but not documented in the eMAR, highlighting a lapse in proper documentation practices.
Failure to Maintain Closed Urinary Drainage System
Penalty
Summary
The facility failed to provide proper indwelling urinary catheter care to prevent the spread of infection for a resident with a history of urinary tract infection (UTI). The deficiency was observed when the surveyor noted that the resident's small urinary drainage bag had uncapped tubing open to air, stored in a plastic bag hanging from a handrail next to the toilet. The Certified Nursing Assistant (CNA) assigned to the resident confirmed the uncapped tubing and admitted to not knowing whose drainage bag it was. The Licensed Practical Nurse (LPN) also confirmed the presence of the uncapped drainage bag and acknowledged that only the resident with the indwelling urinary catheter used the bathroom. The LPN stated that she would educate the CNA on the importance of capping the tubing to maintain a closed drainage system, as per the facility's policy for Urinary Catheter Care revised in October 2010. The resident involved was admitted to the facility with diagnoses of retention of urine and UTI. The resident's electronic medical record indicated a physician's order for the use of an indwelling urinary catheter and noted a current UTI. The facility's policy for Urinary Catheter Care included a directive to maintain a closed drainage system, which was not followed in this instance. The deficiency was discussed with the Director of Nursing (DON), the Licensed Nursing Home Administrator, and the Day to Day Manager, who were made aware of the uncapped urinary drainage bag and the need for adherence to infection control protocols.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure that all medications were administered without error, resulting in a medication administration error rate of 7.1%. During the morning medication administration, surveyors observed an LPN preparing and attempting to administer seven medications to a resident. The LPN mistakenly prepared a multivitamin without minerals instead of the prescribed multivitamin with minerals. The error was identified when the LPN and CN/LPN reviewed the medication and found that the correct multivitamin with minerals was not available in the medication cart. The CN/LPN later provided the correct medication, but the initial error had already occurred. The resident involved had a moderately impaired cognition and required an interpreter, which may have contributed to the communication challenges during medication administration. In another instance, the same LPN was unable to find the prescribed Polysaccharide Iron Complex capsule in the medication cart. Despite assistance from the CN/LPN, the medication was not located, and the LPN signed the EMAR indicating the medication was on hold. The CN/LPN later ordered the medication from the provider pharmacy, but it was not administered until the following day. The resident, who had a history of anemia and a fracture of the right femur, did not receive the prescribed iron supplement on the scheduled day, resulting in a second medication error. The facility's policies and procedures for medication administration were not adequately followed, particularly in ensuring the availability of prescribed medications and proper communication among staff. The LPN, who was an agency nurse on his first day at the facility, did not receive sufficient orientation or support to prevent these errors. The DON acknowledged that the facility's policy did not address the process for handling unavailable medications, contributing to the observed deficiencies.
Failure to Properly Label and Store Medications
Penalty
Summary
The facility failed to ensure that medications were stored and labeled appropriately, as observed during an inspection of two medication carts on two units. On South Cart 1, a vial of Ultra Track test strips and a box of Ipratropium/Albuterol nebulizer solution were found without dates indicating when they were opened. The Unit Manager confirmed the absence of dates and acknowledged uncertainty about when these items were opened. Similarly, on North Cart 1, a box of Budesonide nebulizer solution was found with an open foil packet containing vials that were not dated. The Licensed Practical Nurse confirmed that the foil package should have been dated but was not. The Consultant Pharmacist stated that she regularly inspects medication carts for expired items and proper labeling, documenting any irregularities and reporting them to the staff. The Director of Nursing confirmed that staff were previously aware of the requirement to date medications when opened but had failed to do so in these instances. A handout provided to the nurses, which included information on medications with shortened expiration dates, was reviewed and confirmed the need for dating these specific medications. Despite this, the staff did not adhere to the protocol, leading to the identified deficiencies.
Failure to Offer Pneumonia Vaccination
Penalty
Summary
The facility failed to offer the pneumonia (PNA) vaccination to two residents, as identified during a survey. Resident #16 and Resident #5, both over the age of [AGE] years, had no evidence in their medical records that they had been offered or administered the PNA vaccination. This was confirmed through a review of their immunization histories in the electronic medical records. Interviews with the Licensed Practical Nurse/Charge Nurse (LPN/CN) and other LPNs revealed that the protocol on admission includes asking residents for vaccine information and offering all vaccines, but this was not documented for these residents. The Regional Registered Nurse (RRN) confirmed the lack of documentation in the progress notes, and the Infection Preventionist (IP) stated that all vaccines, including PNA, should have been offered and documented in the resident's record. The facility's policy, adapted from the CDC and dated January 27, 2022, states that all newly admitted, readmitted, and current residents are to be offered a pneumococcal vaccine unless medically contraindicated or already immunized. Despite this policy, the surveyor found no documentation that the PNA vaccine was offered to Resident #16 and Resident #5. The issue was discussed with the RRN, interim Director of Nursing, Administrator, and Regional Administrator, but no further information was provided to address the deficiency.
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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 Tenafly
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Careone At Cresskill | 0.9 mi | ★★★★★ | 18 | 0 |
| Actors Fund Home | 1.5 mi | ★★★★★ | 0 | 0 |
| Hebrew Home For The Aged At Riverdale | 3.1 mi | ★★★★★ | 14 | 0 |
| Family Of Caring At Teaneck Llc | 3.3 mi | ★★★★★ | 17 | 0 |
| Careone At New Milford | 3.3 mi | ★★★★★ | 1 | 0 |
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