Cycle 1
Health 2025-06-11 · Fire 2025-06-11
12 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
5 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Tenafly, NJ
Family Of Caring Healthcare At Tenafly, LLC
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
133 County Road, Tenafly, NJ
(201) 567-7800
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
69
Certified beds
Average residents
64
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Family Of Caring Healthcare
Operator or chain grouping
Approved since
1977-08-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
8 facilities
Chain averages 4 overall / 3 health / 4 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.88
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.89
Licensed practical nurse staffing · state 0.94 · national 0.87
Aide hours / resident day
2.09
Nurse aide staffing · state 2.23 · national 2.35
Total nurse hours
3.86
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.77
RN + LPN hours · state 1.62 · national 1.54
Weekend hours
3.48
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.76
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.81
CMS adjusted RN staffing hours
Adjusted total hours
3.58
CMS adjusted total nurse staffing hours
Case-mix index
1.48
Higher values indicate more complex resident acuity
RN turnover
27%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
28%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,494
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
11.97
Composite VBP score used to determine payment impact.
Payment multiplier
0.9811
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.96% · Performance 23.32% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 8.58% · Performance 8.49% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
2.91
Baseline 24.49% · Performance 51.77% · Measure score 2.91 · Achievement 2.91 · Improvement 0
Adjusted total nurse staffing
1.87
Baseline 3.47 hours · Performance 3.61 hours · Measure score 1.87 · Achievement 1.87 · Improvement 0.13
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.82% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 232 · Observed rate 9.05% · Lower 95% interval 7.83% |
| Discharge to community | 54.21% |
50.57%
3.6 pts better
|
No Different than the National Rate · Eligible stays 272 · Observed rate 47.79% · Lower 95% interval 47.56% |
| Medicare spending per beneficiary | 1.17 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 154 · Denominator 154 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 154 |
| Discharge self-care score | 62.62% |
53.69%
8.9 pts better
|
Numerator 67 · Denominator 107 |
| Discharge mobility score | 64.49% |
50.94%
13.5 pts better
|
Numerator 69 · Denominator 107 |
| Pressure ulcers or injuries, new or worsened | 1.95% |
2.29%
0.3 pts better
|
Numerator 3 · Denominator 154 · Adjusted rate 1.97% |
| Healthcare-associated infections requiring hospitalization | 8.49% |
7.12%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 163 · Observed rate 9.2% · Lower 95% interval 5.6% |
| Staff COVID-19 vaccination coverage | 5.71% |
8.2%
2.5 pts worse
|
Numerator 8 · Denominator 140 |
| Staff flu vaccination coverage | 87.84% |
42%
45.8 pts better
|
Numerator 130 · Denominator 148 |
| Discharge function score | 65.42% |
56.45%
9 pts better
|
Numerator 70 · Denominator 107 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 45 · Denominator 45 |
| Transfer of health information to patient | 98.81% |
96.28%
2.5 pts better
|
Numerator 83 · Denominator 84 |
| Resident COVID-19 vaccinations up to date | 22.97% |
25.2%
2.2 pts worse
|
Numerator 17 · Denominator 74 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.4 |
2.1
0.3 pts worse
|
1.9
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 1.8 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.1
0.3 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.6 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.5% |
93.0%
3.5 pts better
|
93.4%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 92.3% · Q2 100.0% · Q3 98.0% · Q4 95.7% · 4Q avg 96.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.1% |
97.2%
0.9 pts better
|
95.5%
2.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.0% |
2.4%
4.6 pts worse
|
3.3%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 8.0% · Q3 7.8% · Q4 4.3% · 4Q avg 7.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 8.9% |
11.4%
2.5 pts better
|
11.4%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 11.6% · Q3 4.7% · Q4 9.8% · 4Q avg 8.9% |
| Percentage of long-stay residents who lose too much weight | 3.5% |
4.6%
1.1 pts better
|
5.4%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 2.4% · Q3 2.2% · Q4 2.4% · 4Q avg 3.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.6% |
19.0%
4.6 pts worse
|
19.6%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.4% · Q2 26.7% · Q3 19.1% · Q4 18.2% · 4Q avg 23.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.6% |
13.5%
7.1 pts worse
|
16.7%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.9% · Q2 18.8% · Q3 17.6% · Q4 23.3% · 4Q avg 20.6% · 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 | 18.8% |
9.8%
9 pts worse
|
16.3%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.8% · Q2 14.3% · Q3 18.2% · Q4 23.7% · 4Q avg 18.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.8% |
9.7%
0.1 pts worse
|
14.9%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.0% · Q2 4.7% · Q3 11.1% · Q4 9.5% · 4Q avg 9.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
0.7%
0.1 pts worse
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.6% · Q3 1.6% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.6% |
0.8%
0.8 pts worse
|
1.7%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 2.1% · Q3 0.0% · Q4 2.3% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.4% |
15.9%
8.5 pts worse
|
19.8%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.1% · Q2 24.7% · Q3 18.6% · Q4 27.3% · 4Q avg 24.4% |
| Percentage of long-stay residents with pressure ulcers | 5.5% |
6.0%
0.5 pts better
|
5.1%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 5.7% · Q3 5.8% · Q4 4.5% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.3% |
78.7%
19.6 pts better
|
81.7%
16.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.9% · Q2 99.2% · Q3 100.0% · Q4 97.4% · 4Q avg 98.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.7% |
8.2%
4.5 pts worse
|
12.0%
0.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.7% · Observed 10.6% · Expected 9.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.2%
0.5 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.0% · Q3 0.0% · Q4 1.6% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.0% |
80.1%
14.9 pts better
|
79.7%
15.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.0% |
25.4%
0.6 pts worse
|
23.9%
2.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.0% · Observed 22.4% · Expected 20.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-22 · Fire 2023-11-22
5 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
5 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2021-08-13 · Fire 2021-08-13
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-06-11
K252 · Egress Deficiencies
Fire Safety
Provide at least two remote exits on each floor or fire section of the building.
Corrected 2025-08-01
F · Potential for more than minimal harm
2025-06-11
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-06-23
F · Potential for more than minimal harm
2025-06-11
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-08-01
E · Potential for more than minimal harm
2025-06-11
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 2025-06-12
E · Potential for more than minimal harm
2025-06-11
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-08-01
F · Potential for more than minimal harm
2023-11-22
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 2023-12-30
F · Potential for more than minimal harm
2023-11-22
K251 · Egress Deficiencies
Fire Safety
Conform to length requirements for dead end corridors.
Corrected 2024-05-30
F · Potential for more than minimal harm
2023-11-22
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-12-30
F · Potential for more than minimal harm
2023-11-22
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-01-24
F · Potential for more than minimal harm
2023-11-22
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-12-30
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-06-11
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-07-25
D · Potential for more than minimal harm
2025-06-11
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 2025-07-15
D · Potential for more than minimal harm
2025-06-11
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
2025-06-11
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-07-11
D · Potential for more than minimal harm
2025-06-11
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2025-07-15
D · Potential for more than minimal harm
2025-06-11
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-07-15
D · Potential for more than minimal harm
2025-06-11
F712 · Nursing and Physician Services Deficiencies
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2025-07-15
D · Potential for more than minimal harm
2025-06-11
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-07-15
D · Potential for more than minimal harm
2025-06-11
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 2025-07-15
D · Potential for more than minimal harm
2025-06-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-15
D · Potential for more than minimal harm
2025-06-11
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-07-15
D · Potential for more than minimal harm
2025-06-11
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2025-07-15
E · Potential for more than minimal harm
2023-11-22
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-12-30
D · Potential for more than minimal harm
2023-11-22
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-12-30
D · Potential for more than minimal harm
2023-11-22
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-12-30
D · Potential for more than minimal harm
2023-11-22
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 2023-12-30
D · Potential for more than minimal harm
2023-11-22
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-12-30
Penalties and ownership
What sits behind the stars
$1,764
2023-10-10
Fine
Fine · fine $1,764
Fine
$3,174
2023-09-18
Fine
Fine · fine $3,174
Fine
Ownership
Friedman, Nathan
5% Or Greater Direct Ownership Interest · Individual
Friedman, Edward
Operational/Managerial Control · Individual
Friedman, Edward
Corporate Officer · Individual
Nearby options
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5-star overall rating with 4-star inspections with 8 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#3
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5-star overall rating with 5-star inspections with 3 fire-safety deficiencies in the latest cycle
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