Inspection Reports for
Excel Care At Egg Harbor
6818 Delilah Road, Egg Harbor Township, NJ, 08234
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
5.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
6% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
98% occupied
Based on a January 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Notice
Deficiencies: 0
Date: Nov 19, 2025
Visit Reason
This document serves to inform recipients about the privacy practices of NJDHSS, including how personal health information is used, disclosed, and protected, as well as the rights of individuals regarding their health 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 | NJDHSS Privacy Officer named as contact for privacy practices |
Inspection Report
Routine
Census: 118
Capacity: 120
Deficiencies: 8
Date: Jan 31, 2025
Visit Reason
A routine standard survey was conducted from 01/27/2025 through 01/31/2025 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities.
Findings
The facility was found to have multiple deficiencies including an Immediate Jeopardy (IJ) related to failure to ensure adequate supervision of a resident at risk, failure to maintain resident dignity during dining, failure to issue required beneficiary notices, failure to maintain adequate staffing ratios, and several life safety code violations. Corrective actions and plans of correction were implemented and verified.
Deficiencies (8)
Failure to ensure adequate supervision of a resident at risk resulting in Immediate Jeopardy.
Failure to maintain resident dignity during dining including exposure to profanity on television and improper staff behavior.
Failure to issue required beneficiary notices to residents.
Failure to maintain required minimum direct care staffing ratios.
Failure to maintain a safe environment including delayed egress locking system not activating audible alarm.
Failure to maintain electrical systems including uncovered electrical junction boxes and missing electrical receptacle covers.
Failure to maintain food safety including improper refrigeration temperature monitoring and food storage.
Failure to follow infection prevention and control practices including hand hygiene during medication pass and meal service.
Report Facts
Census: 118
Total Capacity: 120
Sample Size: 32
Deficiencies cited: 8
Staffing Deficiency: 15
Staffing Ratios: 8
Staffing Ratios: 10
Staffing Ratios: 14
Immediate Jeopardy duration: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Documented resident medication administration and involved in Immediate Jeopardy incident. |
| CNA #3 | Certified Nursing Assistant | Observed resident not eating dinner and initiated search for missing resident. |
| LPN #1 | Licensed Practical Nurse/Unit Manager | Interviewed regarding lab order process and medication transcription. |
| Surveyor #1 | State Surveyor | Conducted observations and interviews during the survey. |
| Director of Nursing | Director of Nursing | Involved in education and monitoring of corrective actions. |
| Maintenance Director | Maintenance Director | Adjusted egress plunger to correct delayed egress locking system deficiency. |
| Licensed Practical Nurse (LPN) #4 | Licensed Practical Nurse | Observed not performing hand hygiene during medication pass. |
| Certified Nursing Assistant (CNA) #1 | Certified Nursing Assistant | Observed assisting resident during lunch and hand hygiene practices. |
Inspection Report
Abbreviated Survey
Census: 115
Deficiencies: 0
Date: Feb 14, 2024
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted on behalf of 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 the CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample Size: 5
Inspection Report
Complaint Investigation
Census: 114
Deficiencies: 1
Date: Jan 11, 2024
Visit Reason
A complaint survey was conducted on behalf of the New Jersey Department of Health due to multiple complaint numbers listed, to investigate staffing ratio compliance and other regulatory standards.
Complaint Details
The complaint investigation involved multiple complaint numbers and found the facility failed to meet minimum staffing ratios on 35 of 49 day shifts and 1 of 49 overnight shifts, potentially affecting all residents. The facility was required to submit a plan of correction.
Findings
The facility was found not in compliance with New Jersey Administrative Code staffing ratio requirements, failing to maintain minimum staff-to-resident ratios on multiple day and overnight shifts across several weeks. The facility was in substantial compliance with federal long term care requirements but deficient in state staffing standards.
Deficiencies (1)
Failure to ensure staffing ratios were met to maintain the required minimum staff-to-resident ratios as mandated by the state of New Jersey for multiple day and overnight shifts.
Report Facts
Survey Census: 114
Sample Size: 15
Deficient staffing shifts: 35
Deficient staffing shifts: 1
Date of correction completion: Mar 11, 2024
Inspection Report
Complaint Investigation
Census: 112
Deficiencies: 0
Date: Sep 27, 2023
Visit Reason
The inspection was conducted as a complaint survey (Complaint #: NJ156308) to assess compliance with 42 CFR Part 483, Subpart B, for Long Term Care Facilities.
Complaint Details
Complaint #: NJ156308. The facility was found to be in compliance with all requirements based on this complaint investigation.
Findings
The facility was found to be in compliance with the applicable requirements based on this complaint survey. Additionally, a COVID-19 Focused Infection Control Survey found the facility in compliance with infection control regulations and CDC recommended practices.
Report Facts
Sample Size: 11
Inspection Report
Census: 106
Deficiencies: 18
Date: Apr 3, 2023
Visit Reason
The facility was surveyed for a standard survey including complaint investigations related to multiple complaint numbers. The purpose was to assess compliance with 42 CFR Part 483, Subpart B, for Long Term Care Facilities.
Complaint Details
The survey was complaint-related, triggered by multiple complaint numbers NJ00150227, NJ00152333, NJ00152627, NJ00153588, NJ00154954. The facility was found not in substantial compliance with federal regulations.
Findings
The facility was found not in substantial compliance with federal regulations. Deficiencies were cited related to Medicaid/Medicare coverage notices, comprehensive care plans, professional standards in medication administration, accident hazards, bowel/bladder incontinence care, pharmacy services, menu adequacy, food safety, garbage disposal, resident records, and multiple life safety code violations including egress door locking, exit discharge, illumination, emergency lighting, HVAC maintenance, and electrical safety.
Deficiencies (18)
Facility failed to issue required beneficiary notice for 1 of 3 residents reviewed for Beneficiary Protection Notification.
Facility failed to develop a comprehensive, person-centered care plan for 3 of 28 sampled residents.
Facility failed to maintain professional standards by not following physician's order for medication parameters and not notifying physician when medication was not administered as ordered for 1 of 28 residents.
Facility failed to identify and eliminate accident hazard by leaving an open lid garbage receptacle in the outside smoking area.
Facility failed to maintain resident dignity by allowing an indwelling catheter drainage bag to be visible and uncovered for 1 of 2 residents reviewed.
Facility failed to consistently provide a physician ordered nutritional supplement (Health Shake) at mealtimes for 1 of 2 residents reviewed for food.
Facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner, evidenced by wet nesting of kitchen pans and uncovered meat slicer.
Facility failed to provide a sanitary environment by failing to have a cover over the opening of 1 of 2 garbage dumpsters.
Facility failed to maintain a complete medical record for 1 of 28 sampled residents.
Facility failed to maintain required minimum direct care staff to resident ratios as mandated by the state of New Jersey for 9 of 14 day shifts and 1 of 14 overnight shifts.
Facility failed to ensure that 2 of 5 newly hired employees had completed a health history and received an examination within two weeks prior to or upon employment.
Facility failed to ensure that 1 of 5 newly hired employees received the Mantoux tuberculin test upon hire as required.
Facility failed to provide 1 of 9 exit discharge doors in the means of egress readily accessible and free of obstructions, specifically a thumb turn lock and fastening device on the main sliding doors.
Facility failed to provide a suitable leveled concrete surface for evacuation at 1 of 9 designated exit discharges leading from a fenced resident smoking patio to the fire road.
Facility failed to ensure continuous illumination for 2 of 9 designated exit discharges.
Facility failed to provide a battery backup emergency light above 1 of 2 emergency generator transfer switches.
Facility failed to ensure that ventilation systems were properly maintained for 5 of 10 resident bathroom exhaust systems.
Facility failed to ensure that 1 of 24 electrical outlets located next to a water source was equipped with safe and secured Ground-Fault Circuit Interrupter (GFCI) protection.
Report Facts
Census: 106
Deficient CNA staffing day shifts: 9
Deficient total staff overnight shifts: 1
Residents sampled for care plan deficiency: 28
Residents with care plan deficiency: 3
Residents sampled for medication administration: 28
Residents with medication administration deficiency: 1
Residents sampled for incontinence care: 2
Residents with incontinence dignity deficiency: 1
Residents sampled for nutritional supplement: 2
Residents with nutritional supplement deficiency: 1
Newly hired employee files reviewed: 5
New employees without timely physical: 2
New employees without Mantoux test: 1
Deficient exit discharge doors: 1
Deficient exit discharge surface: 1
Deficient exit discharge illumination: 2
Deficient emergency lighting: 1
Resident bathrooms with ventilation failure: 5
Electrical outlets without GFCI protection: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker | Facility Social Worker | Interviewed regarding Medicare Part A discharge beneficiary notices |
| Unit Manager/Registered Nurse | Unit Manager/Registered Nurse (UM/RN #1) | Interviewed regarding care plan development and medication administration |
| Vice President of Clinical Services | Vice President of Clinical Services (VPCS) | Interviewed regarding care plan development, medication administration, and medical records |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding care plan expectations and medical record completeness |
| Licensed Practical Nurse | LPN #1 | Interviewed regarding medication administration and health shake provision |
| Licensed Practical Nurse | LPN #2 | Interviewed regarding medication administration and physician notification |
| Director of Dietary | Director of Dietary (DOD) | Interviewed regarding garbage disposal and kitchen sanitation |
| Administrator | Facility Administrator | Interviewed regarding staffing ratios and employee physicals |
| Human Resources Director | Human Resources Director (HRD) | Interviewed regarding new employee physicals and Mantoux testing |
| Maintenance Director | Maintenance Director | Interviewed regarding life safety code deficiencies and corrective actions |
Inspection Report
Routine
Census: 84
Deficiencies: 0
Date: Jul 21, 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 related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 5
Inspection Report
Routine
Census: 58
Deficiencies: 0
Date: Dec 15, 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 related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 5
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 1
Date: Nov 27, 2021
Visit Reason
The inspection was a complaint survey triggered by complaints NJ149579, NJ149504, and NJ149151 to investigate compliance with New Jersey Administrative Code 8:39, Standards for Licensure of Long-Term Care Facilities.
Complaint Details
Complaint #: NJ149579, NJ149504, NJ149151. The facility was found deficient in staffing ratios based on complaint intake and review of facility documents and NJDOH memo dated 01/28/2021. The deficient practice had the potential to affect all residents.
Findings
The facility was found not in substantial compliance due to failure to meet minimum staffing ratios for certified nursing assistants (CNAs) on multiple day and evening shifts, affecting all residents. The facility submitted a plan of correction to address staffing deficiencies.
Deficiencies (1)
Failure to ensure staffing ratios were met, deficient in CNA staffing for residents on 7 of 14 day shifts and deficient in CNAs to total staff on 1 of 14 evening shifts.
Report Facts
Census: 68
Deficient CNA staffing days: 7
Deficient CNA staffing evenings: 1
Required CNAs on 11/07/2021 day shift: 10
Actual CNAs on 11/07/2021 day shift: 9
Required CNAs on 11/08/2021 day shift: 10
Actual CNAs on 11/08/2021 day shift: 8
Required CNAs on 11/09/2021 evening shift: 5
Actual CNAs on 11/09/2021 evening shift: 4
Required CNAs on 11/11/2021 day shift: 10
Actual CNAs on 11/11/2021 day shift: 9
Required CNAs on 11/14/2021 day shift: 9
Actual CNAs on 11/14/2021 day shift: 8
Required CNAs on 11/16/2021 day shift: 10
Actual CNAs on 11/16/2021 day shift: 9
Required CNAs on 11/19/2021 day shift: 10
Actual CNAs on 11/19/2021 day shift: 9
Required CNAs on 11/20/2021 day shift: 10
Actual CNAs on 11/20/2021 day shift: 9
CNA wage: 18
Number of staffing agencies contracted: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator | Interviewed on 11/27/2021 regarding CNA staffing ratios and recruitment efforts |
Inspection Report
Complaint Investigation
Census: 71
Deficiencies: 1
Date: Sep 3, 2021
Visit Reason
The inspection was conducted based on complaint NJ146328 to investigate concerns regarding the facility's compliance with requirements for long term care facilities.
Complaint Details
Complaint NJ146328 was substantiated as the facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, based on the complaint visit.
Findings
The facility was found not in substantial compliance due to failure to maintain accurate medical records including care conference notes and Activities of Daily Living (ADL) sheets for three residents. The facility also failed to follow its policies on interdisciplinary team care conferences and charting/documentation.
Deficiencies (1)
Failure to maintain accurate medical records including care conference notes and ADL sheets for 3 residents.
Report Facts
Sample size: 3
Plan of Correction Completion Date: Oct 15, 2021
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 1
Date: Aug 21, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ146046, NJ145548, and NJ145439 regarding alleged violations at the facility.
Complaint Details
Complaint Intake NJ146046 involved failure to report an injury of unknown origin for Resident #3. The facility did not notify the State Survey Agency as required. The deficiency was substantiated and corrective actions were implemented, including notification of the SSA by the new Director of Nursing and monitoring of incident reports.
Findings
The facility was found not in compliance with 42 CFR Part 483, Subpart B, specifically failing to report an injury of unknown origin for Resident #3 to the State Survey Agency within the required timeframe. The investigation revealed the resident had a fall with unknown origin, and the facility did not report it as required, although corrective actions were later taken.
Deficiencies (1)
Failure to report an injury of unknown origin to the State Survey Agency for Resident #3 within the required timeframe.
Report Facts
Census: 65
Sample Size: 9
Plan of Correction Completion Date: Sep 17, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse RN #1 | Registered Nurse | Charted progress note regarding Resident #3's condition |
| Nurse LPN #2 | Licensed Practical Nurse | Notified RN #1 about Resident #3's condition |
| Certified Nurse Aide CNA #3 | Certified Nurse Aide | Last observed Resident #3 sleeping and notified LPN #2 |
| Director of Nursing (DON) | Director of Nursing | Acknowledged failure to report injury and described corrective actions |
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 0
Date: May 31, 2021
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaint numbers NJ143302, NJ141445, NJ142703, NJ137505, and NJ142330.
Complaint Details
Complaint numbers NJ143302, NJ141445, NJ142703, NJ137505, and NJ142330 were 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 B for Long Term Care Facilities based on this complaint survey.
Report Facts
Sample Size: 7
Inspection Report
Annual Inspection
Census: 122
Deficiencies: 2
Date: Apr 21, 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 food procurement and sanitation practices, and infection prevention and control, including improper handling of potentially hazardous foods and failure to properly use personal protective equipment (PPE) on the Persons Under Investigation unit.
Deficiencies (2)
Facility failed to handle potentially hazardous foods and maintain kitchen sanitation in a safe consistent manner designed to prevent food borne illness.
Facility failed to establish and maintain an infection prevention and control program, including failure to remove PPE gowns when exiting resident rooms and failure to wear gloves when entering resident rooms on the PUI unit.
Report Facts
Census: 122
Sample size: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Named in infection prevention deficiency related to improper PPE use |
| CNA #2 | Certified Nurse Aide | Named in infection prevention deficiency related to improper PPE use |
| Food Service Director | Named in food procurement and sanitation deficiency related to improper food handling and labeling | |
| Director of Nursing | Interviewed regarding infection prevention practices and PPE use |
Inspection Report
Routine
Census: 69
Deficiencies: 0
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 related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 3
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 1
Date: Jan 11, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ00138097 and NJ00139426 regarding the facility's compliance with 42 CFR Part 483, Subpart B for Long Term Care Facilities.
Complaint Details
Complaint # NJ00138097, NJ00139426. The facility was found non-compliant for failing to notify the responsible party of a change in condition for one of three residents reviewed for pressure ulcers.
Findings
The facility failed to notify the responsible party of a change in condition for one resident (Resident #2) related to pressure ulcers. Documentation and interviews revealed that notifications to the responsible party were not made despite changes in the resident's skin condition and treatments.
Deficiencies (1)
Failure to notify the responsible party of a change in condition for one resident with pressure ulcers.
Report Facts
Census: 73
Sample size: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed on 01/11/2021 confirming that the responsible party should have been notified of changes in the resident's skin and treatments. |
Inspection Report
Routine
Census: 69
Deficiencies: 0
Date: Jan 7, 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 and recommended COVID-19 practices.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 5
Inspection Report
Complaint Investigation
Census: 75
Deficiencies: 0
Date: Dec 30, 2020
Visit Reason
The inspection was conducted in response to complaints #NJ 141824 and 142025 to investigate alleged issues at the facility.
Complaint Details
Complaint numbers NJ 141824 and 142025 were investigated and the facility was found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR Part 483, Subpart B, for long term care facilities based on this complaint visit.
Report Facts
Sample size: 4
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