Cycle 1
Health 2025-01-22 · Fire 2025-01-22
17 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Wayne, NJ
Preakness Healthcare Center
2-star overall rating with 2-star inspections with $15,646 in total fines with 17 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
305 Oldham Road, Wayne, NJ
(973) 585-2132
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
406
Certified beds
Average residents
282
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1996-12-01
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
1.10
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.41
Licensed practical nurse staffing · state 0.94 · national 0.87
Aide hours / resident day
2.68
Nurse aide staffing · state 2.23 · national 2.35
Total nurse hours
4.19
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.51
RN + LPN hours · state 1.62 · national 1.54
Weekend hours
3.87
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.90
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
1.09
CMS adjusted RN staffing hours
Adjusted total hours
4.16
CMS adjusted total nurse staffing hours
Case-mix index
1.38
Higher values indicate more complex resident acuity
RN turnover
37%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
40%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,092
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
46.07
Composite VBP score used to determine payment impact.
Payment multiplier
0.9994
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.32
Baseline 22.66% · Performance 20.51% · Measure score 3.32 · Achievement 1.98 · Improvement 3.32
Healthcare-associated infections
1.96
Baseline 5.71% · Performance 7.25% · Measure score 1.96 · Achievement 1.96 · Improvement 0
Total nurse turnover
10
Baseline 30.00% · Performance 15.65% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
3.15
Baseline 4.01 hours · Performance 3.98 hours · Measure score 3.15 · Achievement 3.15 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.73% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 179 · Observed rate 12.29% · Lower 95% interval 7.81% |
| Discharge to community | 41.69% |
50.57%
8.9 pts worse
|
No Different than the National Rate · Eligible stays 88 · Observed rate 30.68% · Lower 95% interval 32.62% |
| Medicare spending per beneficiary | 0.75 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 90.91% |
95.27%
4.4 pts worse
|
Numerator 110 · Denominator 121 |
| Falls with major injury | 1.65% |
0.77%
0.9 pts worse
|
Numerator 2 · Denominator 121 |
| Discharge self-care score | 35.53% |
53.69%
18.2 pts worse
|
Numerator 27 · Denominator 76 |
| Discharge mobility score | 36.84% |
50.94%
14.1 pts worse
|
Numerator 28 · Denominator 76 |
| Pressure ulcers or injuries, new or worsened | 4.96% |
2.29%
2.7 pts worse
|
Numerator 6 · Denominator 121 · Adjusted rate 3.37% |
| Healthcare-associated infections requiring hospitalization | 7.25% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 99 · Observed rate 9.09% · Lower 95% interval 4.74% |
| Staff COVID-19 vaccination coverage | 0.23% |
8.2%
8 pts worse
|
Numerator 1 · Denominator 444 |
| Staff flu vaccination coverage | 96.32% |
42%
54.3 pts better
|
Numerator 419 · Denominator 435 |
| Discharge function score | 39.47% |
56.45%
17 pts worse
|
Numerator 30 · Denominator 76 |
| Transfer of health information to provider | 92.59% |
95.95%
3.4 pts worse
|
Numerator 25 · Denominator 27 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 41.54% |
25.2%
16.3 pts better
|
Numerator 27 · Denominator 65 |
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 1.9 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.8 |
1.1
0.7 pts worse
|
1.8
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.5 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.5% |
93.0%
4.5 pts better
|
93.4%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 99.6% · Q2 98.9% · Q3 97.0% · Q4 94.6% · 4Q avg 97.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.5% |
97.2%
5.7 pts worse
|
95.5%
4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 91.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.8% |
2.4%
0.4 pts worse
|
3.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 3.0% · Q3 3.7% · Q4 2.5% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.0% |
11.4%
10.4 pts better
|
11.4%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.4% · Q2 1.7% · Q3 0.8% · Q4 1.2% · 4Q avg 1.0% |
| Percentage of long-stay residents who lose too much weight | 7.1% |
4.6%
2.5 pts worse
|
5.4%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 9.2% · Q3 6.7% · Q4 5.1% · 4Q avg 7.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.4% |
19.0%
0.6 pts better
|
19.6%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.5% · Q2 18.5% · Q3 17.6% · Q4 18.0% · 4Q avg 18.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.9% |
13.5%
2.4 pts worse
|
16.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.0% · Q2 16.5% · Q3 15.5% · Q4 14.9% · 4Q avg 15.9% · 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 7.6% · Q2 5.7% · Q3 5.2% · Q4 7.8% · 4Q avg 6.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.9% |
9.7%
0.8 pts better
|
14.9%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 13.7% · Q3 5.8% · Q4 9.3% · 4Q avg 8.9% · 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 0.4% · Q2 0.9% · Q3 1.0% · Q4 1.1% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.4% |
0.8%
0.6 pts worse
|
1.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.5% · Q3 0.8% · Q4 1.9% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 4.3% |
15.9%
11.6 pts better
|
19.8%
15.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 2.8% · Q3 4.9% · Q4 6.0% · 4Q avg 4.3% |
| Percentage of long-stay residents with pressure ulcers | 9.7% |
6.0%
3.7 pts worse
|
5.1%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 11.0% · Q3 11.5% · Q4 8.5% · 4Q avg 9.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 83.3% |
78.7%
4.6 pts better
|
81.7%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 82.8% · Q2 82.5% · Q3 79.4% · Q4 89.1% · 4Q avg 83.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.8% |
8.2%
7.6 pts worse
|
12.0%
3.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.8% · Observed 14.9% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
1.2%
0.3 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.2% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.9% |
80.1%
10.8 pts better
|
79.7%
11.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.0% |
25.4%
3.4 pts better
|
23.9%
1.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.0% · Observed 25.6% · Expected 27.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-08 · Fire 2023-09-08
15 health deficiencies
Top issue: Resident Rights (4 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2021-07-14 · Fire 2021-07-14
3 health deficiencies
Top issue: Nursing and Physician Services (2 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-22
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2025-02-28
F · Potential for more than minimal harm
2025-01-22
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2025-02-14
F · Potential for more than minimal harm
2025-01-22
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-02-14
F · Potential for more than minimal harm
2025-01-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-28
F · Potential for more than minimal harm
2025-01-22
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-02-14
F · Potential for more than minimal harm
2025-01-22
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-02-21
F · Potential for more than minimal harm
2025-01-22
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-02-28
F · Potential for more than minimal harm
2025-01-22
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-02-21
F · Potential for more than minimal harm
2025-01-22
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2025-02-28
F · Potential for more than minimal harm
2023-09-08
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2023-10-27
F · Potential for more than minimal harm
2023-09-08
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-09-27
F · Potential for more than minimal harm
2023-09-08
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-10-27
E · Potential for more than minimal harm
2021-07-14
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2021-07-30
E · Potential for more than minimal harm
2021-07-14
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2021-07-30
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-08
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.
Not marked corrected
D · Potential for more than minimal harm
2025-05-02
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-06-13
F · Potential for more than minimal harm
2025-01-22
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 2025-02-28
E · Potential for more than minimal harm
2025-01-22
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-02-21
E · Potential for more than minimal harm
2025-01-22
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 2025-02-10
E · Potential for more than minimal harm
2025-01-22
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-01-22
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-01-22
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-01-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-01-22
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 2025-02-28
D · Potential for more than minimal harm
2025-01-22
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-02-14
D · Potential for more than minimal harm
2025-01-22
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-01-22
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 2025-02-28
D · Potential for more than minimal harm
2025-01-22
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 2025-02-21
D · Potential for more than minimal harm
2025-01-22
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-01-22
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 2025-02-28
C · Minimal harm
2025-01-22
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-01-14
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 2025-02-14
J · Immediate jeopardy
2024-11-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-21
D · Potential for more than minimal harm
2024-03-01
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 2024-04-05
E · Potential for more than minimal harm
2023-09-08
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 2023-10-06
E · Potential for more than minimal harm
2023-09-08
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-10-27
E · Potential for more than minimal harm
2023-09-08
F909 · Environmental Deficiencies
Health
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected 2023-10-06
E · Potential for more than minimal harm
2023-09-08
F949 · Administration Deficiencies
Health
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected 2023-10-27
D · Potential for more than minimal harm
2023-09-08
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-10-06
D · Potential for more than minimal harm
2023-09-08
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-10-06
D · Potential for more than minimal harm
2023-09-08
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-10-20
D · Potential for more than minimal harm
2023-09-08
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 2023-10-20
D · Potential for more than minimal harm
2023-09-08
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2023-10-20
D · Potential for more than minimal harm
2023-09-08
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2023-10-27
D · Potential for more than minimal harm
2023-09-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-27
C · Minimal harm
2023-09-08
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-10-13
D · Potential for more than minimal harm
2021-07-14
F711 · Nursing and Physician Services Deficiencies
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected 2021-07-30
D · Potential for more than minimal harm
2021-07-14
F712 · Nursing and Physician Services Deficiencies
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2021-07-30
D · Potential for more than minimal harm
2021-07-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-08-06
Penalties and ownership
What sits behind the stars
$15,646
2024-11-26
Fine
Fine · fine $15,646
Fine
Ownership
County Of Passaic Department Of Finance
5% Or Greater Direct Ownership Interest · Organization
Corrado, Lucinda
Operational/Managerial Control · Individual
Williamson, Thomas
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Excel Care At Wayne
Wayne, NJ
4-star overall rating with 5-star inspections with 5 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#2
Doctors Subacute Healthcare, LLC
Paterson, NJ
4-star overall rating with 4-star inspections with 6 recent health deficiencies
#3
Alps at Wayne Rehab & Care Center
Wayne, NJ
3-star overall rating with 3-star inspections with $14,507 in total fines with 8 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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