Inspection Reports for Excel Care At The Pines
29 North Vermont Ave, NJ, 08401
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
11.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
127% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
76% occupied
Based on a November 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Notice
Deficiencies: 0
Nov 19, 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 explains the types of information covered, reasons for use and disclosure of health information, legal duties of NJDHSS, and the rights of individuals to access, amend, and restrict their health information.
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 this notice |
Inspection Report
Routine
Census: 115
Capacity: 151
Deficiencies: 16
Nov 19, 2024
Visit Reason
The inspection was a standard routine survey conducted on 11/19/2024 to assess compliance with federal and state regulations for long term care facilities.
Findings
The facility was found not in substantial compliance with several deficiencies cited related to resident rights, safe environment, comprehensive care plans, respiratory care, food safety, infection control, staffing, and life safety code violations including fire safety and electrical systems.
Severity Breakdown
Level D: 5
Level E: 3
Level F: 8
Deficiencies (16)
| Description | Severity |
|---|---|
| Failure to make State of New Jersey inspection results readily accessible to residents. | Level D |
| Facility failed to maintain a safe, clean and homelike environment including housekeeping and maintenance issues. | Level E |
| Failure to notify a physician of a resident's condition in accordance with professional standards. | Level D |
| Failure to implement proper respiratory care and tracheostomy care and suctioning. | Level D |
| Failure to meet food safety requirements including expired food and improper sanitation. | Level F |
| Failure to establish and maintain an infection prevention and control program. | Level D |
| Failure to maintain required staffing levels for certified nursing assistants (CNAs). | Level D |
| Failure to provide emergency illumination and maintain fire safety systems including smoke detectors and fire alarm sensitivity. | Level D |
| Failure to provide adequate means of egress including delayed egress door devices and illumination. | Level F |
| Failure to maintain electrical systems including guarding live parts and ensuring GFCI protection. | Level F |
| Failure to maintain policies and protocols for patient care related electrical equipment. | Level F |
| Failure to maintain smoking regulations and designated smoking areas. | Level E |
| Failure to maintain sprinkler system installation according to NFPA standards. | Level F |
| Failure to maintain electrical equipment testing and maintenance records. | Level F |
| Failure to maintain emergency power generator and temporary rental generator in compliance with NFPA standards. | Level F |
| Failure to maintain corridor walls to resist passage of smoke. | Level F |
Report Facts
Census: 115
Total Capacity: 151
Deficiencies cited: 16
Staffing ratios: 12
Staffing ratios: 15
Beds: 151
Inspection Report
Routine
Census: 112
Deficiencies: 13
Aug 22, 2023
Visit Reason
Routine inspection survey conducted to assess compliance with federal and state regulations for long term care facilities, including emergency preparedness, resident accommodations, infection control, life safety, and other regulatory requirements.
Findings
The facility was found not in substantial compliance with several regulatory requirements including emergency preparedness training, reasonable accommodations for residents, infection control, life safety code, and staffing ratios. Multiple deficiencies were cited across various areas including emergency preparedness, resident call bell accessibility, sanitation, medication management, food safety, and fire safety.
Severity Breakdown
SS=D: 7
SS=E: 5
Deficiencies (13)
| Description | Severity |
|---|---|
| Facility failed to provide emergency preparedness training to all new and existing staff annually. | SS=D |
| Facility failed to provide reasonable accommodation of resident needs by ensuring call devices were within reach of 6 residents. | SS=D |
| Facility failed to maintain a sanitary and homelike environment in multiple areas including dining rooms and resident rooms. | SS=E |
| Facility failed to ensure resident environment was free from accident hazards including unattended medications left in resident rooms. | SS=D |
| Facility failed to ensure proper infection prevention and control program and in-service training for nurse aides. | SS=D |
| Facility failed to ensure proper food safety including labeling, dating, and disposal of expired food items. | SS=E |
| Facility failed to ensure proper storage and maintenance of CPAP/BiPAP equipment and supplies. | SS=E |
| Facility failed to maintain minimum staffing ratios for Certified Nursing Assistants (CNAs) on multiple shifts. | — |
| Facility failed to ensure battery backup emergency lighting and sprinkler system compliance with NFPA standards. | SS=E |
| Facility failed to ensure corridor doors were self-closing and smoke resistant as required by fire safety codes. | SS=E |
| Facility failed to ensure electrical outlets near water sources were equipped with Ground-Fault Circuit Interrupter (GFCI) protection. | SS=D |
| Facility failed to provide annual in-service training for nurse aides on resident rights and infection control. | SS=D |
| Facility failed to ensure new employees received required physical examinations and Mantoux tuberculosis testing. | — |
Report Facts
Census: 112
Sample Size: 28
Deficiency Count: 13
Staffing Ratios: 10
Staffing Ratios: 14
Staffing Deficiency Period: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #9 | Did not receive required physical examination and Mantoux tuberculosis testing as part of new hire process | |
| Licensed Practical Nurse (LPN) #1 | Licensed Practical Nurse | Observed medication tablets left unattended and was unsure if tablet and capsule belonged to a specific resident |
| Surveyor #1 | Observed multiple deficiencies including call bell accessibility, sanitation issues, and medication management | |
| Surveyor #2 | Observed food safety and infection control deficiencies | |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding emergency preparedness training, call bell policy, medication management, and staffing |
| Clinical Vice President (CVP) | Clinical Vice President | Interviewed regarding emergency preparedness training |
| Administrator | Facility Administrator | Informed of deficiencies and corrective actions, involved in monitoring and corrective action plans |
| Licensed Nursing Home Administrator (LNHA) | Licensed Nursing Home Administrator | Interviewed regarding emergency preparedness training |
Inspection Report
Life Safety
Census: 89
Capacity: 151
Deficiencies: 12
Jul 28, 2021
Visit Reason
A Life Safety Code Comparative Federal Monitoring Survey was conducted by CMS following a state survey to assess compliance with Medicare/Medicaid participation requirements related to life safety from fire and the 2012 NFPA 101 Life Safety Code.
Findings
The facility was found not to be in compliance with multiple life safety code requirements including failure to conduct daily inspections of construction areas, inadequate fire resistance-rated separations, improper egress door locking and signage, obstructed exit discharge paths, insufficient emergency lighting, deficient hazardous area enclosures, incomplete sprinkler system coverage and maintenance, lack of monthly fire extinguisher inspections, improper smoking area maintenance, unlocked electrical panels without guarding, and missing remote manual stop stations for generators.
Severity Breakdown
SS=E: 7
SS=F: 5
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to conduct daily inspection of construction repair, alterations or additions and means of egress. | SS=E |
| Failed to provide two-hour fire resistance-rated elements and assemblies separating non-health care occupancies. | SS=F |
| Failed to provide signs at exits with delayed egress locking devices and exit doors were obstructed or required excessive force to open. | SS=E |
| Failed to maintain unobstructed exit discharge paths free of obstructions and provide a hard packed all-weather travel surface. | SS=E |
| Failed to provide emergency illumination that operates automatically along means of egress. | SS=E |
| Failed to provide fire barriers with one-hour fire resistance rating, maintain self-closing doors to hazardous areas, and prohibited transfer grilles in corridor walls or doors. | SS=E |
| Failed to provide complete sprinkler coverage and install sprinkler system in accordance with NFPA 101 and NFPA 13 standards. | SS=F |
| Failed to maintain sprinkler system and ensure smoke resisting ceiling assembly at sprinkler level. | SS=F |
| Failed to visually inspect fire extinguishers monthly and ensure they are ready for use. | SS=F |
| Failed to maintain smoking areas with proper ashtray containers and prevent cigarette butts and ash in trash cans. | SS=E |
| Failed to maintain required clearance around electrical panels, guard live parts, and keep panels locked in resident accessible areas. | SS=E |
| Failed to provide remote manual stop station for the generator to prevent inadvertent or unintentional operation. | SS=F |
Report Facts
Certified beds: 151
Census: 89
Residents affected: 20
Residents affected: 89
Residents affected: 40
Residents affected: 50
Residents affected: 10
Residents affected: 89
Residents affected: 20
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 1
Jun 30, 2021
Visit Reason
The inspection was conducted based on a complaint visit (Complaint #: NJ 00146151) to determine compliance with long term care facility regulations.
Findings
The facility was found not in compliance with New Jersey Administrative Code staffing requirements, failing to meet minimum nurse staffing ratios for 12 of 39 shifts reviewed. The deficiency had the potential to affect all residents, though no residents were directly affected.
Complaint Details
The facility was not in compliance with 42 CFR Part 483, Subpart B, based on this complaint visit (Complaint #: NJ 00146151).
Deficiencies (1)
| Description |
|---|
| Failure to ensure staffing ratios were met for 12 of 39 shifts reviewed, violating mandatory nurse staffing requirements. |
Report Facts
Shifts with insufficient staffing: 12
Census: 86
Sample size: 19
Day shifts not meeting ratio: 6
Evening shifts not meeting ratio: 4
Night shifts not meeting ratio: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Acknowledged sometimes the facility is short of CNAs and misunderstood the mandate regarding nurse counts. |
| Staffing Coordinator | Staffing Coordinator | Stated awareness of the new staffing mandates. |
Inspection Report
Life Safety
Deficiencies: 5
Jun 24, 2021
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 06/24/21 and 06/28/21 to assess compliance with Medicare/Medicaid participation requirements related to fire safety and life safety code standards.
Findings
The facility was found to be in noncompliance with several life safety code requirements including malfunctioning delayed egress door features, lack of emergency lighting in mechanical rooms, incomplete sprinkler system coverage and maintenance issues, and absence of remote annunciators for emergency generators. Multiple deficiencies related to fire sprinkler sealing and electrical system alarms were identified.
Severity Breakdown
SS=D: 2
SS=E: 3
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure the 15-second delayed egress feature on one of nine exit discharge doors would activate and lacked proper signage on one door. | SS=D |
| Failed to provide emergency lighting in two mechanical/electrical rooms containing emergency generator transfer switches. | SS=D |
| Did not provide complete sprinkler coverage in one of four stairwells and allowed combustible storage in a locked out-of-order elevator without sprinkler coverage. | SS=E |
| Failed to maintain sprinkler system by ensuring ceiling level was smoke resistant and fire rated; multiple sprinkler heads had gaps or improper sealing allowing smoke passage. | SS=E |
| Failed to provide a remote annunciator for two of three emergency generators to alert staff of system conditions. | SS=E |
Report Facts
Exit discharge doors with delayed egress feature: 9
Mechanical/electrical rooms reviewed for emergency lighting: 3
Fire sprinkler areas reviewed for smoke resistance and fire rating: 12
Fire sprinkler heads with deficiencies: 12
Emergency generators: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Maintenance Staff Member | Present during observations and confirmed findings related to door egress, emergency lighting, sprinkler deficiencies, and electrical system issues. | |
| Maintenance Director | Verified findings during observations and responsible for corrective action plans and audits. | |
| Administrator | Provided documentation and was informed of findings during exit conferences. |
Document
Deficiencies: 0
Apr 13, 2021
Visit Reason
Document is not related to regulatory oversight or inspection of a healthcare or care facility.
Findings
No inspection or regulatory content present; document is an instruction to open the PDF portfolio with specific software.
Inspection Report
Abbreviated Survey
Census: 86
Deficiencies: 0
Jan 5, 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: 7
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