Inspection Reports for
Excel Care At Egg Harbor

Complaint investigation based on complaints 2601823, 421288, and 2646782. The deficiencies were substantiated as the facility failed to document ADLs for 5 residents, confirmed by interviews and record reviews.

The facility failed to consistently document ADL care for 5 of 5 residents reviewed, with multiple instances of blank documentation spaces indicating tasks such as bladder elimination, bowel elimination, eating, and amount eaten were not completed or recorded. Interviews with staff confirmed that undocumented ADLs were considered not done, and the facility failed to follow its ADL policy.

The complaint investigation was substantiated. The facility failed to report a resident elopement within the required timeframe and failed to provide adequate supervision, resulting in immediate jeopardy. The resident was found outside the facility with hypothermia and elevated white blood cells and was hospitalized. The facility submitted a removal plan and corrected the deficiencies by 12/30/2024.

The facility failed to timely report and submit an investigation of a resident elopement to the New Jersey Department of Health within 5 days, and failed to provide adequate supervision to prevent the elopement of a cognitively impaired resident, resulting in immediate jeopardy. Additionally, the facility failed to ensure medications were administered according to physician orders, including failure to obtain a urine culture and transcription errors in medication orders for multiple residents.

The facility was found deficient in multiple areas including failure to maintain resident dignity during leisure and dining activities, failure to issue required Medicare beneficiary notices, failure to maintain a homelike dining environment, failure to timely report an elopement incident, medication administration errors, inadequate supervision leading to resident elopement, improper food handling and storage, and lapses in infection prevention and control practices.

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.

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.

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.

The facility failed to maintain a complete medical record for 1 of 28 sampled residents, specifically Resident #138, whose weight and ADL sheets were missing from the medical record. Interviews with staff confirmed incomplete documentation and inconsistent recording of resident weights.

The facility was found deficient in multiple areas including failure to provide required Medicare beneficiary notices, incomplete care plans for residents with oxygen and diabetes, medication administration errors including failure to notify physicians of missed medications and administering medication outside prescribed parameters, unsafe environmental conditions in smoking and garbage areas, failure to maintain resident dignity with catheter care, inadequate narcotic reconciliation, failure to provide ordered nutritional supplements, and improper food handling and sanitation practices.

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.

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.

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.

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.

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.

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.

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.

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.

The facility was found deficient in handling potentially hazardous foods and maintaining kitchen sanitation, including improper storage and labeling of frozen foods. Additionally, staff failed to properly use personal protective equipment (PPE) on the COVID-19 Persons Under Investigation unit, wearing gowns across multiple rooms and not wearing gloves when entering rooms.

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.

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.

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.