Cycle 1
Health 2024-11-07 · Fire 2024-11-07
15 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
17 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Norwood, NJ
Buckingham At Norwood, The
1-star overall rating with 1-star inspections with Special Focus status with $101,674 in total fines with 15 recent health deficiencies with 17 fire-safety deficiencies in the latest cycle
100 Mcclellan Street, Norwood, NJ
(201) 768-6222
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
240
Certified beds
Average residents
169
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Excelcare
Operator or chain grouping
Approved since
1990-02-16
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
9 facilities
Chain averages 2 overall / 2 health / 3 staffing / 4 quality stars
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
0.66
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.71
Licensed practical nurse staffing · state 0.94 · national 0.87
Aide hours / resident day
1.92
Nurse aide staffing · state 2.23 · national 2.35
Total nurse hours
3.29
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.37
RN + LPN hours · state 1.62 · national 1.54
Weekend hours
2.99
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.46
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
0.62
CMS adjusted RN staffing hours
Adjusted total hours
3.09
CMS adjusted total nurse staffing hours
Case-mix index
1.46
Higher values indicate more complex resident acuity
RN turnover
45%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
27%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,280
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
27.28
Composite VBP score used to determine payment impact.
Payment multiplier
0.9845
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.17
Baseline 18.50% · Performance 19.96% · Measure score 3.17 · Achievement 3.17 · Improvement 0
Healthcare-associated infections
5.01
Baseline 5.77% · Performance 6.34% · Measure score 5.01 · Achievement 5.01 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
0
Baseline 2.81 hours · Performance 2.81 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.09% |
10.72%
1.6 pts better
|
No Different than the National Rate · Eligible stays 273 · Observed rate 6.59% · Lower 95% interval 6.42% |
| Discharge to community | 54.19% |
50.57%
3.6 pts better
|
No Different than the National Rate · Eligible stays 291 · Observed rate 48.8% · Lower 95% interval 47.88% |
| Medicare spending per beneficiary | 1.02 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 99.04% |
95.27%
3.8 pts better
|
Numerator 206 · Denominator 208 |
| Falls with major injury | 0.96% |
0.77%
0.2 pts worse
|
Numerator 2 · Denominator 208 |
| Discharge self-care score | 49.56% |
53.69%
4.1 pts worse
|
Numerator 56 · Denominator 113 |
| Discharge mobility score | 48.67% |
50.94%
2.3 pts worse
|
Numerator 55 · Denominator 113 |
| Pressure ulcers or injuries, new or worsened | 2.4% |
2.29%
0.1 pts worse
|
Numerator 5 · Denominator 208 · Adjusted rate 2.76% |
| Healthcare-associated infections requiring hospitalization | 6.34% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 173 · Observed rate 5.2% · Lower 95% interval 3.67% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 200 |
| Staff flu vaccination coverage | 98% |
42%
56 pts better
|
Numerator 196 · Denominator 200 |
| Discharge function score | 44.25% |
56.45%
12.2 pts worse
|
Numerator 50 · Denominator 113 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 96 · Denominator 96 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 90 · Denominator 90 |
| Resident COVID-19 vaccinations up to date | 2.31% |
25.2%
22.9 pts worse
|
Numerator 3 · Denominator 130 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
2.1
0.9 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.2 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.9 |
1.1
0.8 pts worse
|
1.8
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.5 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.1% |
93.0%
5.1 pts better
|
93.4%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 94.6% · Q2 98.4% · Q3 99.3% · Q4 100.0% · 4Q avg 98.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.3% |
97.2%
2.1 pts better
|
95.5%
3.8 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.4% |
2.4%
1 pts worse
|
3.3%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 3.9% · Q3 3.7% · Q4 3.6% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 17.0% |
11.4%
5.6 pts worse
|
11.4%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.9% · Q2 36.8% · Q3 6.8% · Q4 4.9% · 4Q avg 17.0% |
| Percentage of long-stay residents who lose too much weight | 3.7% |
4.6%
0.9 pts better
|
5.4%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 4.1% · Q3 3.3% · Q4 3.9% · 4Q avg 3.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.8% |
19.0%
1.2 pts better
|
19.6%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.4% · Q2 19.7% · Q3 14.6% · Q4 19.4% · 4Q avg 17.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.9% |
13.5%
6.4 pts worse
|
16.7%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.4% · Q2 20.0% · Q3 20.8% · Q4 22.9% · 4Q avg 19.9% · 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 | 6.3% |
9.8%
3.5 pts better
|
16.3%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 7.5% · Q3 11.2% · Q4 3.0% · 4Q avg 6.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.8% |
9.7%
2.9 pts better
|
14.9%
8.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 9.5% · Q3 12.5% · Q4 0.0% · 4Q avg 6.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.1% |
0.7%
0.6 pts better
|
1.0%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.6% · Q4 0.0% · 4Q avg 0.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.9% |
0.8%
0.1 pts worse
|
1.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.0% · Q3 2.3% · Q4 0.7% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 6.0% |
15.9%
9.9 pts better
|
19.8%
13.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 2.8% · Q3 8.5% · Q4 3.7% · 4Q avg 6.0% |
| Percentage of long-stay residents with pressure ulcers | 7.0% |
6.0%
1 pts worse
|
5.1%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 7.2% · Q3 10.6% · Q4 4.6% · 4Q avg 7.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 88.0% |
78.7%
9.3 pts better
|
81.7%
6.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 66.5% · Q2 91.2% · Q3 98.8% · Q4 100.0% · 4Q avg 88.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.7% |
8.2%
0.5 pts worse
|
12.0%
3.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.7% · Observed 7.7% · Expected 10.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.2% |
1.2%
1 pts worse
|
1.6%
0.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 2.5% · Q3 2.9% · Q4 1.4% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.8% |
80.1%
13.7 pts better
|
79.7%
14.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 31.4% |
25.4%
6 pts worse
|
23.9%
7.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.4% · Observed 30.9% · Expected 23.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-07-14 · Fire 2023-07-14
4 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2021-04-23 · Fire 2021-04-23
3 health deficiencies
Top issue: Infection Control (1 deficiency)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-11-07
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2024-11-11
F · Potential for more than minimal harm
2024-11-07
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2024-11-22
F · Potential for more than minimal harm
2024-11-07
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-11-11
F · Potential for more than minimal harm
2024-11-07
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 2024-11-11
F · Potential for more than minimal harm
2024-11-07
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 2024-11-11
F · Potential for more than minimal harm
2024-11-07
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-11-07
F · Potential for more than minimal harm
2024-11-07
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 2024-11-07
F · Potential for more than minimal harm
2024-11-07
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-01-07
F · Potential for more than minimal harm
2024-11-07
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-01-07
F · Potential for more than minimal harm
2024-11-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-18
F · Potential for more than minimal harm
2024-11-07
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-11-07
F · Potential for more than minimal harm
2024-11-07
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-11-16
F · Potential for more than minimal harm
2024-11-07
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-01-07
F · Potential for more than minimal harm
2024-11-07
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2025-01-07
F · Potential for more than minimal harm
2024-11-07
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 2025-01-02
F · Potential for more than minimal harm
2024-11-07
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-01-07
F · Potential for more than minimal harm
2024-11-07
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-01-07
F · Potential for more than minimal harm
2023-07-14
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-08-28
F · Potential for more than minimal harm
2023-07-14
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-08-28
F · Potential for more than minimal harm
2023-07-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-08-28
D · Potential for more than minimal harm
2021-04-23
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 2021-05-07
D · Potential for more than minimal harm
2021-04-23
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2021-05-25
D · Potential for more than minimal harm
2021-04-23
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-05-07
D · Potential for more than minimal harm
2021-04-23
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-05-19
Inspection history
Recent health citations
L · Immediate jeopardy
2024-11-07
F728 · Nursing and Physician Services Deficiencies
Health
Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
Corrected 2024-12-06
F · Potential for more than minimal harm
2024-11-07
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2024-12-06
E · Potential for more than minimal harm
2024-11-07
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-12-06
E · Potential for more than minimal harm
2024-11-07
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-12-06
E · Potential for more than minimal harm
2024-11-07
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 2024-12-06
D · Potential for more than minimal harm
2024-11-07
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 2024-12-01
D · Potential for more than minimal harm
2024-11-07
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 2024-12-06
D · Potential for more than minimal harm
2024-11-07
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-12-06
D · Potential for more than minimal harm
2024-11-07
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 2024-12-01
D · Potential for more than minimal harm
2024-11-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-06
D · Potential for more than minimal harm
2024-11-07
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-12-01
D · Potential for more than minimal harm
2024-11-07
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 2024-12-01
D · Potential for more than minimal harm
2024-11-07
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-12-01
D · Potential for more than minimal harm
2024-11-07
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 2024-12-01
D · Potential for more than minimal harm
2024-11-07
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-12-06
J · Immediate jeopardy
2023-07-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-10
D · Potential for more than minimal harm
2023-07-14
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-07-31
D · Potential for more than minimal harm
2023-07-14
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 2023-07-31
D · Potential for more than minimal harm
2023-07-14
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-07-31
E · Potential for more than minimal harm
2021-04-23
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2021-05-31
E · Potential for more than minimal harm
2021-04-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-06-11
D · Potential for more than minimal harm
2021-04-23
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2021-05-31
Penalties and ownership
What sits behind the stars
$76,226
2024-11-07
Fine
Fine · fine $76,226
Fine
$25,448
2023-07-14
Fine
Fine · fine $25,448
Fine
Ownership
Jacobs, Hyman
5% Or Greater Direct Ownership Interest · Individual
Jacobs, Livia
5% Or Greater Direct Ownership Interest · Individual
Dublin, Trevor
W-2 Managing Employee · Individual
Metternich, Christopher
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Jewish Home At Rockleigh
Rockleigh, NJ
4-star overall rating with 3-star inspections with 15 recent health deficiencies with 17 fire-safety deficiencies in the latest cycle
#2
Careone At Valley
Westwood, NJ
5-star overall rating with 5-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Emerson Health Care Center
Emerson, NJ
5-star overall rating with 5-star inspections with 7 fire-safety deficiencies in the latest cycle
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