Cycle 1
Health 2025-07-24 · Fire 2025-07-24
8 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Englewood, NJ
Actors Fund Home, The
5-star overall rating with 4-star inspections with 8 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
175 West Hudson Ave, Englewood, NJ
(201) 871-8882
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
107
Certified beds
Average residents
93
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1998-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.86
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.83
Licensed practical nurse staffing · state 0.94 · national 0.87
Aide hours / resident day
3.22
Nurse aide staffing · state 2.23 · national 2.35
Total nurse hours
4.92
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.69
RN + LPN hours · state 1.62 · national 1.54
Weekend hours
4.46
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.68
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.88
CMS adjusted RN staffing hours
Adjusted total hours
5.01
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
12%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
22%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,854
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
42.42
Composite VBP score used to determine payment impact.
Payment multiplier
0.9953
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.36% · Performance 24.60% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 6.32% · Performance 9.20% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
8.97
Performance 27.00% · Measure score 8.97 · Achievement 8.97 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
7.99
Baseline 4.02 hours · Performance 5.35 hours · Measure score 7.99 · Achievement 7.99 · Improvement 7.06
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.1% |
10.72%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 339 · Observed rate 10.91% · Lower 95% interval 9.03% |
| Discharge to community | 54.07% |
50.57%
3.5 pts better
|
No Different than the National Rate · Eligible stays 342 · Observed rate 50% · Lower 95% interval 48.95% |
| Medicare spending per beneficiary | 1.05 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 260 · Denominator 260 |
| Falls with major injury | 1.54% |
0.77%
0.8 pts worse
|
Numerator 4 · Denominator 260 |
| Discharge self-care score | 53.16% |
53.69%
0.5 pts worse
|
Numerator 101 · Denominator 190 |
| Discharge mobility score | 46.84% |
50.94%
4.1 pts worse
|
Numerator 89 · Denominator 190 |
| Pressure ulcers or injuries, new or worsened | 2.69% |
2.29%
0.4 pts worse
|
Numerator 7 · Denominator 260 · Adjusted rate 3.06% |
| Healthcare-associated infections requiring hospitalization | 9.2% |
7.12%
2.1 pts worse
|
No Different than the National Rate · Eligible stays 239 · Observed rate 9.62% · Lower 95% interval 6.57% |
| Staff COVID-19 vaccination coverage | 20.21% |
8.2%
12 pts better
|
Numerator 38 · Denominator 188 |
| Staff flu vaccination coverage | 97.61% |
42%
55.6 pts better
|
Numerator 286 · Denominator 293 |
| Discharge function score | 64.74% |
56.45%
8.3 pts better
|
Numerator 123 · Denominator 190 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 63 · Denominator 63 |
| Transfer of health information to patient | 97.69% |
96.28%
1.4 pts better
|
Numerator 169 · Denominator 173 |
| Resident COVID-19 vaccinations up to date | 29.92% |
25.2%
4.7 pts better
|
Numerator 38 · Denominator 127 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.0 |
2.1
0.9 pts worse
|
1.9
1.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.0 · Observed 2.2 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.1 |
1.1
1 pts worse
|
1.8
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 1.7 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 81.1% |
93.0%
11.9 pts worse
|
93.4%
12.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 83.3% · Q2 78.4% · Q3 78.9% · Q4 84.1% · 4Q avg 81.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.0% |
97.2%
1.2 pts worse
|
95.5%
0.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.7% |
2.4%
5.3 pts worse
|
3.3%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 8.1% · Q3 8.5% · Q4 11.6% · 4Q avg 7.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.8% |
11.4%
7.6 pts better
|
11.4%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 2.9% · Q3 4.7% · Q4 4.6% · 4Q avg 3.8% |
| Percentage of long-stay residents who lose too much weight | 6.9% |
4.6%
2.3 pts worse
|
5.4%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 6.8% · Q3 8.8% · Q4 5.6% · 4Q avg 6.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.8% |
19.0%
8.8 pts worse
|
19.6%
8.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.7% · Q2 25.8% · Q3 27.1% · Q4 30.6% · 4Q avg 27.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 23.7% |
13.5%
10.2 pts worse
|
16.7%
7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 22.8% · Q3 22.4% · Q4 30.0% · 4Q avg 23.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 6.6% |
9.8%
3.2 pts better
|
16.3%
9.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 6.1% · Q3 6.0% · Q4 16.6% · 4Q avg 6.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.3% |
9.7%
1.6 pts worse
|
14.9%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 5.2% · Q3 7.0% · Q4 30.9% · 4Q avg 11.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
0.7%
0.2 pts worse
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.2% · Q4 2.5% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 8.1% |
0.8%
7.3 pts worse
|
1.7%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 12.7% · Q3 5.8% · Q4 8.2% · 4Q avg 8.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 11.9% |
15.9%
4 pts better
|
19.8%
7.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 10.2% · Q3 8.9% · Q4 25.2% · 4Q avg 11.9% |
| Percentage of long-stay residents with pressure ulcers | 6.0% |
6.0%
About the same
|
5.1%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.2% · Q2 6.4% · Q3 8.5% · Q4 1.3% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 21.2% |
78.7%
57.5 pts worse
|
81.7%
60.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 28.5% · Q2 20.3% · Q3 11.7% · Q4 24.1% · 4Q avg 21.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.9% |
8.2%
4.7 pts worse
|
12.0%
0.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.9% · Observed 12.2% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.7% |
1.2%
3.5 pts worse
|
1.6%
3.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 4.5% · Q3 4.8% · Q4 4.0% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 30.3% |
80.1%
49.8 pts worse
|
79.7%
49.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 30.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.7% |
25.4%
2.3 pts worse
|
23.9%
3.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.7% · Observed 24.4% · Expected 21.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-05 · Fire 2024-02-05
4 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2021-10-28 · Fire 2021-10-28
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
6 fire-safety deficiencies
Top issue: Services (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-24
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-07-25
F · Potential for more than minimal harm
2025-07-24
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-08-08
F · Potential for more than minimal harm
2025-07-24
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2025-08-11
F · Potential for more than minimal harm
2025-07-24
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-07-25
F · Potential for more than minimal harm
2025-07-24
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-08-05
F · Potential for more than minimal harm
2025-07-24
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-08-29
F · Potential for more than minimal harm
2025-07-24
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-08-18
F · Potential for more than minimal harm
2025-07-24
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-07-25
F · Potential for more than minimal harm
2025-07-24
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-08-27
F · Potential for more than minimal harm
2025-07-24
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2025-08-08
F · Potential for more than minimal harm
2024-02-05
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-02-06
F · Potential for more than minimal harm
2024-02-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-02-14
E · Potential for more than minimal harm
2024-02-05
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-02-07
E · Potential for more than minimal harm
2024-02-05
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2024-02-16
F · Potential for more than minimal harm
2021-10-28
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2021-12-02
E · Potential for more than minimal harm
2021-10-28
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2021-11-10
E · Potential for more than minimal harm
2021-10-28
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2021-11-18
D · Potential for more than minimal harm
2021-10-28
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2021-11-01
D · Potential for more than minimal harm
2021-10-28
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2021-11-01
D · Potential for more than minimal harm
2021-10-28
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-11-01
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-07-24
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-08-01
D · Potential for more than minimal harm
2025-07-24
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2025-07-25
D · Potential for more than minimal harm
2025-07-24
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-07-25
D · Potential for more than minimal harm
2025-07-24
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-07-30
D · Potential for more than minimal harm
2025-07-24
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-07-30
D · Potential for more than minimal harm
2025-07-24
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-08-01
D · Potential for more than minimal harm
2025-07-24
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2025-07-25
D · Potential for more than minimal harm
2025-07-24
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-08-01
D · Potential for more than minimal harm
2024-02-05
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-02-06
D · Potential for more than minimal harm
2024-02-05
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-02-06
B · Minimal harm
2024-02-05
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-02-08
B · Minimal harm
2024-02-05
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2024-02-06
D · Potential for more than minimal harm
2021-10-28
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2021-11-01
D · Potential for more than minimal harm
2021-10-28
F808 · Nutrition and Dietary Deficiencies
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2021-11-01
B · Minimal harm
2021-10-28
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2021-11-01
Penalties and ownership
What sits behind the stars
Ownership
Actors Fund Of America
5% Or Greater Direct Ownership Interest · Organization
Eng, Kim
W-2 Managing Employee · Individual
Strohl, Jordan
Corporate Director · Individual
Strohl, Jordan
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Family Of Caring Healthcare At Tenafly, LLC
Tenafly, NJ
3-star overall rating with 3-star inspections with $4,938 in total fines with 12 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Family Of Caring At Teaneck LLC
Teaneck, NJ
4-star overall rating with 4-star inspections with 9 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Complete Care At Inglemoor, LLC
Englewood, NJ
2-star overall rating with 2-star inspections with 19 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
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