16 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Wyckoff, NJ
3-star overall rating with 2-star inspections with $15,593 in total fines with 16 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
301 Sicomac Ave, Wyckoff, NJ
(201) 848-5200
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
304
Certified beds
Average residents
277
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1997-10-01
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
RN hours / resident day
0.82
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.66
Licensed practical nurse staffing · state 0.94 · national 0.87
Aide hours / resident day
2.53
Nurse aide staffing · state 2.23 · national 2.35
Total nurse hours
4.01
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.48
RN + LPN hours · state 1.62 · national 1.54
Weekend hours
3.71
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.56
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.18
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.86
CMS adjusted RN staffing hours
Adjusted total hours
4.18
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
96%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
94%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Program rank
2,990
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
46.55
Composite VBP score used to determine payment impact.
Payment multiplier
0.9999
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
3.01
Baseline 21.15% · Performance 20.04% · Measure score 3.01 · Achievement 3.01 · Improvement 2.19
Healthcare-associated infections
3.86
Baseline 5.93% · Performance 6.68% · Measure score 3.86 · Achievement 3.86 · Improvement 0
Total nurse turnover
10
Baseline 22.68% · Performance 18.83% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
1.75
Baseline 3.56 hours · Performance 3.58 hours · Measure score 1.75 · Achievement 1.75 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.21% |
10.72%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 1254 · Observed rate 9.73% · Lower 95% interval 9.76% |
| Discharge to community | 65.72% |
50.57%
15.1 pts better
|
Better than the National Rate · Eligible stays 1343 · Observed rate 59.72% · Lower 95% interval 62.57% |
| Medicare spending per beneficiary | 0.98 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 97.78% |
95.27%
2.5 pts better
|
Numerator 793 · Denominator 811 |
| Falls with major injury | 0.25% |
0.77%
0.5 pts better
|
Numerator 2 · Denominator 811 |
| Discharge self-care score | 31% |
53.69%
22.7 pts worse
|
Numerator 208 · Denominator 671 |
| Discharge mobility score | 38.45% |
50.94%
12.5 pts worse
|
Numerator 258 · Denominator 671 |
| Pressure ulcers or injuries, new or worsened | 1.11% |
2.29%
1.2 pts better
|
Numerator 9 · Denominator 811 · Adjusted rate 1.28% |
| Healthcare-associated infections requiring hospitalization | 6.68% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 798 · Observed rate 6.02% · Lower 95% interval 4.72% |
| Staff COVID-19 vaccination coverage | 3.57% |
8.2%
4.6 pts worse
|
Numerator 26 · Denominator 729 |
| Staff flu vaccination coverage | 97.27% |
42%
55.3 pts better
|
Numerator 535 · Denominator 550 |
| Discharge function score | 33.53% |
56.45%
22.9 pts worse
|
Numerator 225 · Denominator 671 |
| Transfer of health information to provider | 99.27% |
95.95%
3.3 pts better
|
Numerator 136 · Denominator 137 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 574 · Denominator 574 |
| Resident COVID-19 vaccinations up to date | 19.44% |
25.2%
5.8 pts worse
|
Numerator 77 · Denominator 396 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
2.1
0.6 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.4 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.5 |
1.1
0.6 pts better
|
1.8
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.4 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.7% |
93.0%
2.7 pts better
|
93.4%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.1% · Q2 96.6% · Q3 98.0% · Q4 90.9% · 4Q avg 95.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.2% |
97.2%
1 pts better
|
95.5%
2.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.9% |
2.4%
0.5 pts worse
|
3.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 2.4% · Q3 2.9% · Q4 4.5% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.4% |
11.4%
9 pts better
|
11.4%
9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 2.5% · Q3 2.5% · Q4 2.7% · 4Q avg 2.4% |
| Percentage of long-stay residents who lose too much weight | 4.9% |
4.6%
0.3 pts worse
|
5.4%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 7.3% · Q3 5.4% · Q4 2.7% · 4Q avg 4.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.4% |
19.0%
5.4 pts worse
|
19.6%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.1% · Q2 23.0% · Q3 24.5% · Q4 26.1% · 4Q avg 24.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 26.3% |
13.5%
12.8 pts worse
|
16.7%
9.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.3% · Q2 26.1% · Q3 27.3% · Q4 27.6% · 4Q avg 26.3% · 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 | 5.9% |
9.8%
3.9 pts better
|
16.3%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.9% · Q2 3.5% · Q3 4.6% · Q4 3.7% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.5% |
9.7%
2.2 pts better
|
14.9%
7.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.9% · Q2 7.2% · Q3 4.4% · Q4 6.3% · 4Q avg 7.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.7%
0.4 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.2% |
0.8%
1.4 pts worse
|
1.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 3.9% · Q3 1.5% · Q4 1.5% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.3% |
15.9%
2.4 pts worse
|
19.8%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 28.4% · Q2 17.6% · Q3 13.6% · Q4 13.5% · 4Q avg 18.3% |
| 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 6.5% · Q2 6.1% · Q3 6.8% · Q4 2.3% · 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 98.5% · Q3 99.0% · Q4 98.7% · 4Q avg 98.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.4% |
8.2%
1.8 pts better
|
12.0%
5.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.4% · Observed 5.6% · Expected 9.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
1.2%
0.2 pts worse
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 1.3% · Q3 1.7% · Q4 1.6% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.2% |
80.1%
14.1 pts better
|
79.7%
14.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.5% |
25.4%
2.9 pts better
|
23.9%
1.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.5% · Observed 19.0% · Expected 20.2% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (6 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Top issue: Resident Assessment and Care Planning (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Quality of Life and Care (7 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
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 2024-11-05
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 2024-11-05
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-11-05
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-11-05
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-11-05
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-05
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2024-11-05
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-11-05
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-06-15
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-06-16
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-06-15
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-06-16
Inspection history
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2024-10-09
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-10-17
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2024-10-18
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-10-31
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-10-11
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-10-31
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-10-09
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-10-11
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-10-11
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 2024-10-11
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-11-05
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-10-12
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-10-09
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 2024-10-31
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-10-09
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-09
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-04-07
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2023-06-26
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-06-15
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-07-28
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-07-28
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-07-24
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 2023-07-24
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-06-15
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-15
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2021-11-18
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2021-11-18
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2021-11-18
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 2021-12-17
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2021-12-17
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2021-11-18
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2021-11-24
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2021-12-01
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-12-17
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2021-11-26
Health
Respond appropriately to all alleged violations.
Corrected 2021-12-08
Health
Provide activities to meet all resident's needs.
Corrected 2021-11-30
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2021-12-17
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 2021-12-01
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-11-30
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 2021-12-17
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2021-12-17
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2021-11-19
Penalties and ownership
Fine · fine $15,593
Fine
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Corporate Officer · Individual
Corporate Director · Individual
Corporate Officer · Individual
Corporate Director · Individual
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5-star overall rating with 4-star inspections with 5 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
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