Inspection Reports for Excel Care At Dover
65 North Sussex Street, Dover, NJ, 07801
Back to Facility ProfileInspection Report Summary
The most recent inspection on November 20, 2025, did not identify any deficiencies. Earlier inspections showed a pattern of deficiencies primarily related to medication administration, staffing ratios, infection control, and life safety code compliance. Complaint investigations were mostly unsubstantiated, except for one in March 2024 that cited late medication administration, unsecured medication storage, expired medications, and staffing shortages. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s inspection history shows some improvement in recent years, with the latest survey free of cited issues after prior mixed results.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
35% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
28
21
14
7
0
Census
Latest occupancy rate
143 residents
Based on a March 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Notice
Deficiencies: 0
Date: Nov 20, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of NJDHSS, including how their medical information may be used and disclosed, and their rights related to this information.
Findings
The notice details the types of information covered, reasons for use and disclosure of health information, individuals' rights to access and control their information, and the legal duties of NJDHSS to protect privacy.
Report Facts
Effective date: 2011
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer contact for questions about the notice |
Inspection Report
Complaint Investigation
Census: 143
Deficiencies: 3
Date: Mar 21, 2024
Visit Reason
Complaint investigation regarding failure to administer medications according to the acceptable standard of nursing practice and facility policy on Medication Administration and Physician Services.
Complaint Details
Complaint # NJ 00164594. The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, based on this complaint visit regarding medication administration and storage, and staffing ratios.
Findings
The facility failed to administer medications on time for 5 sampled residents, with multiple instances of late medication administration documented. Additionally, medication storage cabinets and refrigerators were found unlocked, and expired medications were present in medication carts. Staffing ratios were also found deficient on multiple day shifts.
Deficiencies (3)
Failure to administer medications according to physician orders and facility policy, resulting in late medication administration for 5 sampled residents.
Failure to ensure medication storage cabinets and refrigerator were locked and secure, with expired medications found in medication carts.
Failure to maintain required minimum staff-to-resident ratios as mandated by the state of New Jersey for 11 of 28 day shifts.
Report Facts
Census: 143
Sample Size: 5
Deficient CNA staffing days: 11
Expired medication: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Observed administering medications late and found medication cabinets unlocked during medication pass. |
Inspection Report
Abbreviated Survey
Census: 141
Deficiencies: 0
Date: Aug 3, 2023
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample Size: 8
Inspection Report
Complaint Investigation
Census: 129
Deficiencies: 0
Date: Apr 18, 2023
Visit Reason
The inspection was conducted as a complaint survey based on Complaint #163422.
Complaint Details
Complaint #163422 was investigated and found to be unsubstantiated as the facility was in compliance.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, for Long Term Care Facilities based on this complaint survey.
Report Facts
Sample Size: 3
Inspection Report
Abbreviated Survey
Census: 125
Deficiencies: 1
Date: Aug 2, 2022
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations and CMS/CDC recommended practices for COVID-19.
Findings
The facility was found to be in compliance with federal infection control regulations related to COVID-19 in one part of the report, but also found not in compliance with New Jersey Administrative Code infection control regulations due to failure to maintain required minimum direct care staff to resident ratios for 6 out of 14 shifts reviewed.
Deficiencies (1)
Failed to maintain the required minimum direct care staff to resident ratios as mandated by the State of New Jersey for 6 out of 14 shifts reviewed.
Report Facts
Census: 125
Sample size: 5
Shifts not meeting staffing ratios: 6
Staffing ratios required: 1
Staffing ratios required: 1
Staffing ratios required: 1
CNAs on 07/19/22: 14
CNAs on 07/24/22: 13
CNAs on 07/25/22: 13
CNAs on 07/26/22: 15
CNAs on 07/27/22: 15
CNAs on 07/30/22: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Informed surveyor about staffing variations and use of contracted agency staff |
Inspection Report
Annual Inspection
Census: 124
Capacity: 155
Deficiencies: 26
Date: May 2, 2022
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
Deficiencies were cited in multiple areas including diet consistency posing aspiration risk, failure to review advance directives, failure to follow physician orders, inadequate assistance with activities of daily living, medication administration errors, food safety and preparation issues, life safety code violations including fire protection and exit signage, and infection preventionist qualifications.
Deficiencies (26)
Facility failed to ensure puree consistency diet was free of large particles posing aspiration risk, resulting in Immediate Jeopardy.
Failure to review and document life-sustaining treatment wishes for residents.
Failure to follow physician orders for psychiatric consultation.
Failure to provide oral care consistent with resident needs.
Failure to ensure pureed diet free of large particles and proper preparation.
Failure to maintain food at appropriate temperatures.
Failure to use standardized recipes to conserve nutritive value and flavor.
Failure to maintain sanitary kitchen environment and separate handwashing sinks from food prep area.
Facility assessment failed to include dietary staff competencies and pureed diet competencies.
Failure to implement effective QAPI program addressing food concerns.
Failure to maintain minimum direct care staff to resident ratios as mandated by NJ law.
Infection Preventionist assigned had other responsibilities and lacked required infection control education.
Building construction failed to provide required 2-hour fire resistance rating on structural steel beams in multiple floors.
Exit doors with delayed egress devices lacked required instructional signage.
Stairwells lacked required stair tread marking stripes on steps, landings, and handrails.
Exits passed through intervening rooms instead of directly to exit stairwells.
Exit discharge paths were obstructed or had uneven surfaces and lacked handrails on steps.
Exit signage lacked directional indicators in locations where direction to nearest exit was not apparent.
Hazardous storage room door lacked self-closing device.
Fixed interior wall surfaces had carpet with flame spread rating not meeting Class A or B requirements.
Outside overhang canopy lacked fire sprinkler protection.
Corridor doors did not close and latch properly to resist passage of smoke.
Resident bathroom ventilation systems were not functioning and corridor vent shafts lacked smoke dampers.
Elevators lacked documented monthly Phase I and II testing and one elevator emergency alarm was not functioning.
Power strips were used improperly as substitute for fixed wiring and extension cords were used inappropriately.
Oxygen cylinders stored within 5 feet of combustible materials exceeding allowed limits.
Report Facts
Residents present: 124
Total licensed beds: 155
Medication administration error rate: 16
Number of portable oxygen cylinders: 23
Number of resident bathrooms with non-functioning ventilation: 35
Number of resident room doors with improper latching: 4
Number of stairwells without marking stripes: 3
Number of exit doors lacking instructional signage: 4
Number of hazardous storage rooms without self-closing doors: 1
Number of corridor doors not resisting smoke: 4
Number of resident room bathrooms with non-functioning ventilation: 35
Number of corridor vent shafts without smoke dampers: 4
Number of elevators lacking documented monthly Phase I and II testing: 2
Number of elevators with non-functioning emergency alarm: 1
Number of power strips improperly used: 5
Number of oxygen cylinders stored improperly: 23
Number of exit discharges with uneven surfaces or obstructions: 3
Number of exit doors lacking directional signage: 2
Number of structural steel beams unprotected: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Named in medication error finding |
| Licensed Practical Nurse #2 | LPN | Interviewed about physician visits |
| Registered Nurse #1 | RN | Interviewed about physician visits |
| Registered Nurse #2 | RN | Interviewed about physician visits |
| Licensed Nursing Home Administrator | LNHA | Acknowledged issues with advance directives and food complaints |
| Director of Nursing | DON | Acknowledged multiple deficiencies and staffing issues |
| Assistant Director of Nursing | ADON | Named as Infection Preventionist and involved in findings |
| Food Service Director | FSD | Named in food safety and preparation deficiencies |
| Consultant Certified Dietary Manager | CDM | Involved in dietary corrective actions |
| Dietitian #1 | RD | Interviewed about dietary practices |
| Dietitian #2 | RD | Interviewed about dietary practices |
| Daytime Cook | Cook | Named in food preparation deficiencies |
| Evening Cook | Cook | Named in food preparation deficiencies |
| Certified Nursing Aide #1 | CNA | Named in oral care and diet consistency findings |
| Certified Nursing Aide #2 | CNA | Named in diet consistency findings |
| Certified Nursing Aide #3 | CNA | Named in diet consistency findings |
| Social Worker | SW | Named in advance directive deficiency |
| Speech Language Pathologist | SLP | Named in diet consistency deficiency |
Inspection Report
Complaint Investigation
Census: 121
Deficiencies: 0
Date: Jul 10, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ143197 and NJ145851.
Complaint Details
Complaint #: NJ143197, NJ145851. The facility was found compliant based on this complaint survey.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, for Long Term Care Facilities based on this complaint survey.
Report Facts
Sample Size: 9
Inspection Report
Annual Inspection
Census: 112
Deficiencies: 3
Date: Apr 22, 2021
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
Deficiencies were cited related to visitation rights, resident records management, and infection prevention and control practices. The facility failed to allow easy access for family visitation, maintain complete and accurate medical records including POLST forms, and ensure proper infection control during treatment procedures.
Deficiencies (3)
Failed to allow easy access for family members to have visitation in accordance with state and federal guidelines for 2 residents.
Failed to maintain complete, accurate, and readily accessible medical records for 4 residents, including missing POLST forms in medical folders.
Failed to maintain proper infection control practices during treatment observation for 1 resident, including improper hand hygiene and handling of contaminated materials.
Report Facts
Sample Size: 27
Sample Size: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) | Observed performing treatment with improper infection control practices | |
| Director of Nursing (DON) | Provided information on visitation policy and medical records storage | |
| Licensed Nursing Home Administrator (LNHA) | Discussed visitation limitations and facility policies | |
| Receptionist | Responsible for scheduling visits and enforcing visitation time limits |
Inspection Report
Life Safety
Deficiencies: 1
Date: Apr 14, 2021
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health, Health Facility Survey and Field Operations to assess compliance with Medicare/Medicaid participation requirements related to Life Safety from Fire and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code.
Findings
The facility was found to be in noncompliance due to exits passing through intervening rooms rather than directly to exit stairways, specifically one of two exits on floors 3 through 6 passed through the Dayroom. The facility acknowledged the deficiency and proposed corrective actions including constructing walls to create separate fire corridors.
Deficiencies (1)
Facility failed to ensure that exits did not pass through an intervening room; one exit on floors 3 through 6 passed through the Dayroom instead of directly to the exit stairway.
Report Facts
Number of smoke zones: 13
Building stories: 6
Projected completion date: Nov 1, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Present during interview and observation of deficiency. | |
| Administrator | Acknowledged deficiency during tour and exit conference. |
Inspection Report
Abbreviated Survey
Census: 114
Deficiencies: 1
Date: Feb 3, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations during the COVID-19 pandemic.
Findings
The facility was found not to be in compliance with infection control regulations related to the storage of re-usable PPE gowns, which were hung outside resident rooms instead of inside, potentially risking the spread of infection. Corrective actions and staff reeducation were implemented.
Deficiencies (1)
Failure to follow proper infection control practices for storage of re-usable PPE gowns, which were hung on hooks outside resident rooms instead of inside, risking potential spread of infection.
Report Facts
Census: 114
Sample size: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding PPE gown storage and infection control practices |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding PPE gown storage and infection control practices |
| Register Nurse/Unit Manager | Register Nurse/Unit Manager | Provided information about PPE gown use and storage on the Admission Cohort unit |
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