Inspection Reports for Excel Care At Wayne
296 Hamburg Turnpike, Wayne, NJ, 07470
Back to Facility ProfileInspection Report Summary
The most recent inspection on October 29, 2025, identified deficiencies related to documentation and supervision of residents at risk for elopement, including an Immediate Jeopardy finding. Earlier inspections showed a pattern of deficiencies involving resident care such as incontinence management, medication administration errors, staffing shortages, and life safety code violations including fire safety and electrical system maintenance. Complaint investigations substantiated issues with supervision, documentation, incontinence care, and staffing levels, but enforcement actions such as fines or license suspensions were not listed in the available reports. Prior reports noted multiple life safety and care-related deficiencies, with some improvements in staffing and care plans following corrective actions. The trend indicates ongoing challenges with resident supervision and care processes despite some efforts to address prior deficiencies.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
6.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
21% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
104 residents
Based on a December 2024 inspection.
Occupancy over time
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Oct 29, 2025
Visit Reason
The inspection was conducted based on complaint #265013 regarding the facility's failure to ensure proper documentation and adequate supervision of a resident's elopement incident.
Complaint Details
Complaint #265013 involved failure to document Resident #2's elopement and failure to provide adequate supervision, resulting in Immediate Jeopardy. The complaint was substantiated based on interviews, record reviews, and observations conducted on 10/27/2025 and 10/29/2025.
Findings
The facility failed to document Resident #2's elopement incident in the medical record and failed to provide adequate supervision to prevent elopement, resulting in an Immediate Jeopardy situation. The facility also failed to ensure all staff were aware of residents at risk for elopement, specifically Resident #4, who was not properly identified on the Neighborhood Watch list initially.
Deficiencies (3)
Failure to ensure nursing staff documented Resident #2's elopement in the medical record according to professional standards.
Failure to provide adequate supervision to a severely cognitively impaired resident (Resident #2) who eloped, resulting in Immediate Jeopardy.
Failure to ensure all staff were able to identify Resident #4 as a wanderer to provide adequate supervision to prevent elopement.
Report Facts
Residents reviewed for elopement: 4
BIMS score: 4
BIMS score: 5
Date of elopement incident: Oct 19, 2025
Removal Plan implementation date: Oct 29, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Provided key statements regarding Resident #2's elopement and search efforts. |
| LPN #2 | Licensed Practical Nurse, Unit Manager | Assessed Resident #2 as elopement risk and placed wanderguard; authored progress notes. |
| LPN #3 | Licensed Practical Nurse | Assigned nurse during elopement incident; failed to document elopement; unavailable for interview. |
| LPN #4 | Licensed Practical Nurse | Cared for Resident #4 and confirmed wanderguard use. |
| Director of Nursing (DON) | Director of Nursing | Provided statements on documentation standards, tested wanderguard bracelets, and acknowledged oversight of Neighborhood Watch list. |
| Licensed Nursing Home Administrator (LNHA) | Administrator | Provided information on elopement incident, facility layout, and corrective actions. |
| Director of Maintenance (DM) | Director of Maintenance | Reported wanderguard pin pad malfunction and corrective actions. |
| Housekeeping Director (HD) | Housekeeping Director / Manager on Duty | Confirmed failure to check wanderguard alarm on day of elopement. |
| Assistant Director of Nursing (ADON) | Assistant Director of Nursing | Provided information on Neighborhood Watch list and resident movements. |
| Certified Nursing Aide (CNA #1) | Certified Nursing Aide | Provided information on Resident #4's behavior and wanderer status. |
Inspection Report
Annual Inspection
Census: 104
Deficiencies: 12
Date: Dec 13, 2024
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long-Term Care Facilities. Complaint investigations were also completed during this survey.
Complaint Details
Complaint # NJ175927 was investigated during this survey. Deficiencies were cited related to reasonable accommodations, medication administration, and care provision.
Findings
Deficiencies were cited related to reasonable accommodations, professional standards of care, medication administration, incontinent care, life safety code violations including exit signage, hazardous area enclosures, cooking facilities, sprinkler system maintenance, fire extinguisher placement, HVAC maintenance, essential electrical system maintenance, and electrical equipment testing and maintenance.
Deficiencies (12)
Facility failed to maintain call bell within reach of residents.
Facility failed to ensure blood pressure apparatus was used according to manufacturer's specifications and antibiotic treatment was administered as ordered.
Facility failed to provide care for dependent resident's incontinent needs timely.
Facility failed to ensure medication administration without error rate less than 5%.
Exit signage missing 'NO Exit' sign on stairwell door likely to be mistaken for an exit.
Hazardous areas not properly enclosed with self-closing or automatic-closing doors.
Failed to perform monthly inspections of kitchen range-hood fire suppression system wet chemical cylinder.
Sprinkler system heads missing escutcheon plates and ceiling tiles missing or displaced near sprinkler heads.
Class K portable fire extinguisher lacked instructional placard.
HVAC exhaust fans in resident bathrooms not operational.
Essential electrical system lacked remote manual stop station for generator.
Electrical equipment testing and maintenance program for patient care related electrical equipment was not established or documented.
Report Facts
Census: 104
Sample Size: 24
Medication administration error rate: 7.6
Number of residents affected by call bell deficiency: 2
Number of residents affected by medication administration deficiency: 2
Number of residents affected by incontinent care deficiency: 1
Number of sprinkler heads missing escutcheon plates: 2
Number of bathrooms with non-operational exhaust fans: 3
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 13, 2024
Visit Reason
The inspection was conducted based on Complaint NJ#175927 to investigate allegations related to incontinence care for a dependent resident.
Complaint Details
Complaint NJ#175927 regarding failure to provide proper incontinence care to Resident #71 was substantiated based on observations and interviews.
Findings
The facility failed to provide appropriate incontinence care to Resident #71, who was found with two saturated incontinence briefs. The resident's care plan did not address incontinence care, and the CNA assigned had not provided care that morning due to workload. The Director of Nursing acknowledged the improper use of double briefs and confirmed the care plan was only initiated after the surveyor's inquiry.
Deficiencies (1)
Failed to ensure incontinence care was provided to a dependent resident, resulting in the use of two saturated incontinence briefs.
Report Facts
Residents on CNA assignment: 12
Brief Interview for Mental Status (BIMS) score: 7
Date of Minimum Data Set (MDS) assessment: Sep 26, 2024
Date of facility's Incontinent Care policy: May 1, 2024
Date of survey visit: Dec 2, 2024
Date of survey completion: Dec 13, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) | CNA assigned to Resident #71 who had 12 residents on her assignment and did not provide care that morning. | |
| Hospitality Aide | Staff member present in Resident #71's room who was not assigned to provide direct care. | |
| Director of Nursing (DON) | Acknowledged improper use of double incontinence briefs and confirmed care plan initiation after surveyor inquiry. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Dec 2, 2024
Visit Reason
The inspection was conducted based on complaints and observations related to resident care deficiencies, including call bell accessibility, medication administration errors, incontinence care, and professional standards of nursing care.
Complaint Details
Complaint NJ#175927 involved failure to provide adequate incontinence care to resident #71.
Findings
The facility was found deficient in maintaining call bells within residents' reach, improper use of blood pressure apparatus, missed antibiotic doses without physician notification, inadequate incontinence care, and medication administration errors exceeding 5%. These deficiencies affected multiple residents and involved several nursing staff.
Deficiencies (4)
Failed to maintain the call bell within reach of residents #8 and #11.
Blood pressure apparatus was not utilized according to manufacturer's specifications and antibiotic treatment was not administered as ordered for residents #20 and #16.
Failed to provide incontinence care to resident #71, including use of double saturated briefs and lack of care plan.
Medication administration error rate of 7.6% observed during medication pass affecting residents #97 and #20.
Report Facts
Residents reviewed for accommodation of needs: 21
Residents reviewed for medication pass: 6
Medication administration error rate: 7.6
Residents reviewed for incontinence care: 4
BIMS score for Resident #8: 8
BIMS score for Resident #11: 5
BIMS score for Resident #71: 7
BIMS score for Resident #16: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in findings related to improper blood pressure measurement and medication administration error |
| LPN #2 | Licensed Practical Nurse | Named in findings related to medication administration and blood pressure measurement |
| CNA #1 | Certified Nursing Assistant | Acknowledged failure to place call bell within resident #8's reach |
| CNA #2 | Certified Nursing Assistant | Acknowledged failure to place call bell within resident #8's reach |
| CNA #3 | Certified Nursing Assistant | Acknowledged call bell should not be on floor for resident #11 |
| Director of Nursing | Director of Nursing | Acknowledged concerns regarding call bell placement, missed antibiotic doses, and medication pass errors |
| RN/UM | Registered Nurse/Unit Manager | Observed blood pressure measurement errors and provided education to LPN #1 |
| President of Clinical Services | President of Clinical Services | Participated in discussion of medication pass concerns |
| Licensed Nursing Home Administrator | Licensed Nursing Home Administrator | Confirmed call bell placement standards and participated in medication pass discussion |
Inspection Report
Complaint Investigation
Census: 106
Capacity: 118
Deficiencies: 10
Date: Sep 21, 2023
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long-Term Care Facilities. Complaint investigations were also completed during this survey.
Complaint Details
Complaint investigations were conducted for multiple complaint numbers including NJ00164324, NJ00159354, NJ00155340, NJ00160076, NJ00163192, NJ00160703, NJ00164427, and NJ00163988. Staffing shortages were substantiated with documented deficiencies in CNA staffing ratios over multiple weeks. Other complaints related to MDS transmission, medication administration, food safety, and life safety code violations were also substantiated.
Findings
Deficiencies were cited related to failure to electronically transmit Minimum Data Set (MDS) assessments timely, pharmaceutical services documentation errors, food safety violations, staffing shortages, and multiple life safety code violations including fire safety and electrical system maintenance.
Deficiencies (10)
Failure to electronically transmit Minimum Data Set (MDS) assessments within 14 days for multiple residents.
Failure to accurately document administration of physician ordered medications in the electronic medication administration record (EMAR) for multiple residents.
Failure to store potentially hazardous foods properly, sanitize and air-dry kitchen pans, and maintain kitchen equipment in a sanitary manner.
Failure to maintain required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey.
Means of egress obstructed by storage rooms accessed from within stairway enclosures.
Failure to complete smoke detection sensitivity testing every alternate year as required.
Sprinkler head missing under HVAC unit larger than 4 feet wide.
Failure to inspect and test fire doors annually with proper documentation.
Failure to conduct annual electrical outlet testing.
Failure to complete three-year load bank test on emergency generator.
Report Facts
Census: 106
Total Capacity: 118
Sample Size: 25
Deficiency Count: 10
Staffing Deficiencies: 7
Staffing Deficiencies: 7
Staffing Deficiencies: 7
Staffing Deficiencies: 12
Staffing Deficiencies: 7
Inspection Report
Routine
Deficiencies: 3
Date: Sep 21, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with regulatory requirements related to resident assessments, medication administration, pharmaceutical services, and food safety.
Findings
The facility failed to electronically transmit Minimum Data Set (MDS) assessments within the required timeframe for 5 residents, failed to accurately document medication administration in the electronic medication administration record (EMAR) for 4 residents, and failed to maintain proper food storage, sanitation, and kitchen equipment cleanliness, posing potential risks for resident care and foodborne illness.
Deficiencies (3)
Failed to electronically transmit Minimum Data Set (MDS) assessments within 14 days for 5 of 25 residents reviewed.
Failed to accurately document administration of physician ordered medications in the electronic medication administration record (EMAR) for 4 unsampled residents.
Failed to store potentially hazardous foods properly, sanitize and air-dry steam table pans and sheet pans, and maintain kitchen equipment in a sanitary manner.
Report Facts
Residents with late MDS transmission: 5
Residents with medication documentation issues: 4
Dented cans observed: 2
Burner stove tops soiled: 4
Oven knobs soiled: 5
Convection knobs soiled: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Observed administering medications and acknowledged not signing EMAR immediately. | |
| Unit Manager (UM)/LPN | Assisted with medication pass and explained EMAR documentation issues. | |
| Director of Nursing (DON) | Interviewed regarding MDS transmission and medication administration issues. | |
| Registered Nurse (RN) MDS Coordinator | Responsible for completing and transmitting MDS assessments. | |
| Consultant Pharmacist (CP) | Provided medication administration observations and in-service training. | |
| Assistant Director of Nursing (ADON) | Educates nurses on medication pass techniques and completes competencies. | |
| Food Service Director (FSD) | Present during kitchen observations and discussed food safety concerns. | |
| Licensed Nursing Home Administrator (LNHA) | Met with survey team regarding medication administration issues. |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Dec 2, 2021
Visit Reason
The inspection was conducted to assess compliance with New Jersey Administrative Code standards for licensure of long term care facilities, specifically focusing on staffing ratios as required by state law.
Findings
The facility was found not in compliance with mandatory staffing ratios for 4 of 14 day shifts and 3 of 14 overnight shifts reviewed, with staffing ratios exceeding the minimum required. No negative outcomes were observed. The facility submitted a plan of correction to address staffing deficiencies and improve recruitment and retention.
Deficiencies (1)
Failed to ensure staffing ratios were met for 4 of 14 day and 3 of 14 overnight shifts checked out of 42 total shifts reviewed.
Report Facts
Shifts reviewed: 42
Day shifts with staffing deficiencies: 4
Overnight shifts with staffing deficiencies: 3
Staffing ratio: 15.33
Staffing ratio: 11.88
Staffing ratio: 15.83
Staffing ratio: 8.55
Staffing ratio: 13.43
CNA hourly rate: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Discussed staffing ratio concerns with surveyor | |
| Director of Nursing | Discussed staffing ratio concerns with surveyor |
Inspection Report
Life Safety
Capacity: 120
Deficiencies: 4
Date: Dec 2, 2021
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 12/02/2021 to assess compliance with Medicare/Medicaid participation requirements and the 2012 NFPA 101 Life Safety Code for existing health care occupancy.
Findings
The facility was found to be noncompliant with several life safety code requirements including emergency lighting, sprinkler system installation, HVAC ventilation in resident bathrooms, and generator testing. Specific deficiencies included lack of emergency lighting independent of the building electrical system, incomplete sprinkler coverage in a nursing storage closet, non-functioning bathroom ventilation fans, and failure to certify generator transfer time within 10 seconds.
Deficiencies (4)
Failed to provide battery backup emergency light above the emergency generator's transfer switch independent of the building's electrical system and emergency generator.
Did not provide complete sprinkler coverage in a nursing storage closet approximately 3' x 3' in size near the nurse station and resident room.
Resident bathroom ventilation systems in multiple units were not functioning, failing to provide adequate ventilation as required.
Failed to certify that the emergency generator transfers power to the building within the required 10-second time frame during monthly load tests.
Report Facts
Certified beds: 120
Monthly generator load tests missing transfer time data: 12
Size of nursing storage closet without sprinkler coverage: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed and verified deficiencies related to emergency lighting, sprinkler coverage, ventilation, and generator testing. | |
| Administrator | Notified of deficiencies at the Life Safety Code exit conference on 12/02/21. |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Dec 2, 2021
Visit Reason
The inspection was conducted as a standard annual survey of the nursing home facility.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 28, 2020
Visit Reason
The inspection was conducted as a complaint survey based on complaint number 129497.
Complaint Details
Complaint #129497 was investigated with a sample size of 3, and the facility was found compliant.
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
Notice
Deficiencies: 0
Date: Apr 15, 2011
Visit Reason
This document serves as a Notice of Privacy Practices to inform individuals about how their medical information may be used and disclosed by NJDHSS and their rights related to this information.
Findings
The notice explains 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.
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 and privacy policies. |
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