Wyckoff, NJ

Christian Health Care Center

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

Compare this facility

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

Facility snapshot

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

Hours and turnover

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

Value-based purchasing

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

How the VBP score is built

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

Medicare quality reporting measures

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

Resident outcomes and process scores

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

Recent inspection cycles

Cycle 1 Health 2024-10-08 · Fire 2024-10-08

16 health deficiencies

Top issue: Quality of Life and Care (6 deficiencies)

8 fire-safety deficiencies

Top issue: Smoke (6 deficiencies)

Cycle 2 Health 2023-06-14 · Fire 2023-06-14

8 health deficiencies

Top issue: Resident Assessment and Care Planning (3 deficiencies)

4 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 3 Health 2021-10-18 · Fire 2021-10-18

19 health 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 citations

F · Potential for more than minimal harm 2024-10-08

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 2024-11-05

F · Potential for more than minimal harm 2024-10-08

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 2024-11-05

F · Potential for more than minimal harm 2024-10-08

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-11-05

F · Potential for more than minimal harm 2024-10-08

K341 · Smoke Deficiencies

Fire Safety

Install a fire alarm system that can be heard throughout the facility.

Corrected 2024-11-05

F · Potential for more than minimal harm 2024-10-08

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2024-11-05

F · Potential for more than minimal harm 2024-10-08

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-11-05

F · Potential for more than minimal harm 2024-10-08

K362 · Smoke Deficiencies

Fire Safety

Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.

Corrected 2024-11-05

F · Potential for more than minimal harm 2024-10-08

K741 · Miscellaneous Deficiencies

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

E · Potential for more than minimal harm 2023-06-14

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2023-06-15

E · Potential for more than minimal harm 2023-06-14

K341 · Smoke Deficiencies

Fire Safety

Install a fire alarm system that can be heard throughout the facility.

Corrected 2023-06-16

E · Potential for more than minimal harm 2023-06-14

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2023-06-15

D · Potential for more than minimal harm 2023-06-14

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2023-06-16

Inspection history

Recent health citations

F · Potential for more than minimal harm 2024-10-08

F838 · Administration Deficiencies

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

E · Potential for more than minimal harm 2024-10-08

F565 · Resident Rights Deficiencies

Health

Honor the resident's right to organize and participate in resident/family groups in the facility.

Corrected 2024-10-17

E · Potential for more than minimal harm 2024-10-08

F576 · Resident Rights Deficiencies

Health

Ensure residents have reasonable access to and privacy in their use of communication methods.

Corrected 2024-10-18

E · Potential for more than minimal harm 2024-10-08

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2024-10-31

D · Potential for more than minimal harm 2024-10-08

F578 · Resident Rights Deficiencies

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

D · Potential for more than minimal harm 2024-10-08

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2024-10-31

D · Potential for more than minimal harm 2024-10-08

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2024-10-09

D · Potential for more than minimal harm 2024-10-08

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2024-10-11

D · Potential for more than minimal harm 2024-10-08

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2024-10-11

D · Potential for more than minimal harm 2024-10-08

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 2024-10-11

D · Potential for more than minimal harm 2024-10-08

F697 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate pain management for a resident who requires such services.

Corrected 2024-11-05

D · Potential for more than minimal harm 2024-10-08

F698 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected 2024-10-12

D · Potential for more than minimal harm 2024-10-08

F725 · Nursing and Physician Services Deficiencies

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

D · Potential for more than minimal harm 2024-10-08

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 2024-10-31

D · Potential for more than minimal harm 2024-10-08

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2024-10-09

D · Potential for more than minimal harm 2024-10-08

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-10-09

J · Immediate jeopardy 2023-06-14

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2023-04-07

D · Potential for more than minimal harm 2023-06-14

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 2023-06-26

D · Potential for more than minimal harm 2023-06-14

F656 · Resident Assessment and Care Planning Deficiencies

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

D · Potential for more than minimal harm 2023-06-14

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2023-07-28

D · Potential for more than minimal harm 2023-06-14

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2023-07-28

D · Potential for more than minimal harm 2023-06-14

F698 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected 2023-07-24

D · Potential for more than minimal harm 2023-06-14

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 2023-07-24

D · Potential for more than minimal harm 2023-06-14

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 2023-06-15

D · Potential for more than minimal harm 2023-06-14

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-06-15

L · Immediate jeopardy 2021-10-18

F835 · Administration Deficiencies

Health

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Corrected 2021-11-18

K · Immediate jeopardy 2021-10-18

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

K · Immediate jeopardy 2021-10-18

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected 2021-11-18

G · Actual harm 2021-10-18

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 2021-12-17

G · Actual harm 2021-10-18

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2021-12-17

F · Potential for more than minimal harm 2021-10-18

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 2021-11-18

E · Potential for more than minimal harm 2021-10-18

F565 · Resident Rights Deficiencies

Health

Honor the resident's right to organize and participate in resident/family groups in the facility.

Corrected 2021-11-24

E · Potential for more than minimal harm 2021-10-18

F656 · Resident Assessment and Care Planning Deficiencies

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

E · Potential for more than minimal harm 2021-10-18

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2021-12-17

D · Potential for more than minimal harm 2021-10-18

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2021-11-26

D · Potential for more than minimal harm 2021-10-18

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2021-12-08

D · Potential for more than minimal harm 2021-10-18

F679 · Quality of Life and Care Deficiencies

Health

Provide activities to meet all resident's needs.

Corrected 2021-11-30

D · Potential for more than minimal harm 2021-10-18

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2021-12-17

D · Potential for more than minimal harm 2021-10-18

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 2021-12-01

D · Potential for more than minimal harm 2021-10-18

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2021-11-30

D · Potential for more than minimal harm 2021-10-18

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 2021-12-17

D · Potential for more than minimal harm 2021-10-18

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2021-12-17

B · Minimal harm 2021-10-18

F577 · Resident Rights Deficiencies

Health

Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

Corrected 2021-11-19

Penalties and ownership

What sits behind the stars

$15,593 2023-06-14

Fine

Fine · fine $15,593

Fine

Ownership

Christian Health Care Center

5% Or Greater Direct Ownership Interest · Organization

0% 2 facilities 1997-12-01
Christian Health Care Center

Operational/Managerial Control · Organization

0% 2 facilities 1997-12-01
Dumke, Stephen

Operational/Managerial Control · Individual

0% 2 facilities 2025-01-01
Dumke, Stephen

Corporate Officer · Individual

0% 2 facilities 2025-01-01
Gomez, Myrna

Corporate Director · Individual

0% 1 facilities 2022-07-05
Stagg, Kevin

Corporate Officer · Individual

0% 1 facilities 1997-12-01
Svensson, Erik

Corporate Director · Individual

0% 1 facilities 2024-11-01

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