Excel Care at Egg Harbor

Inspectors wroteComplaint #: 2601823, 421288, 2646782Based on interviews, medical record review, and review of pertinent facility documentation on 1/2/26 and 1/5/26, it was determined that the facility failed to consistently document Activities of Daily Living (ADL) as being provided to residents for 5 of 5 residents reviewed for ADLs. The facility also failed to follow its policy titled, Activities of Daily Living (ADLs)/Maintain Abilities. This deficient practice was evidenced by the following: According to the admission Record (AR), Resident #1 was admitted with diagnoses that included but were not limited to: End Stage Renal Disease (ESDR) and Dialysis. According to the Minimum Data Set (MDS), an assessment tool dated 12/29/2025, Resident #1 had a Brief Interview of Mental Status (BIMS) that was not completed at the time of survey due to recent admission. [...]

Inspectors wroteC/O # NJ 182995 Based on observation, interview, review of the medical record, and review of other facility documentation, it was determined that the facility failed to provide adequate supervision for a cognitively impaired resident with a known history of aggressive exit seeking which resulted in the resident eloping on 12/12/2024. This deficient practice was identified for 1 of 3 residents reviewed for elopement (Resident #160). Resident #160, who was cognitively impaired with a known history of aggressive exit seeking, eloped from the facility on 12/12/2024. The staff reported last seeing Resident #160 in the dining room between 05:00 PM and 05:30 PM on 12/12/2024. The resident wore a wander guard to their left ankle that the physician ordered to be checked for placement and function every shift, and was last checked on 12/12/2024 at 02:00 PM. [...]

Inspectors wroteBased on observation and interview, it was determined that the facility failed to ensure that the residents' leisure experience was provided in a manner to promote the dignity and respect of the residents, a) who were seated in the dayroom where a television program broadcast contained profanity and vulgar language was observed for 1 of 2 dining rooms, first floor, b.) the facility failed to maintain Resident dignity when staff were observed standing while feeding Residents their meals on 3 of 3 dining rooms observed for dining and c.) did not serve all residents seated at the same table at the same time for 1 of 3 dining areas, 2nd floor. This deficient practice was evidenced by the following: During the initial tour of the facility on 01/27/2025 at 7:15 PM, Surveyor #1 entered the first-floor dayroom. There were four residents and one staff member in the room. [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to maintain a homelike environment by serving meals on trays on 1 of 2 floors (2nd floor). This deficient practice was evidenced by the following: On 01/28/2025 at 11:53 AM, Surveyor #1 observed Certified Nursing Assistant (CNA #4) in the feeding dining room on the 2nd floor during lunch, feeding a resident their meal without removing the food items from the meal tray. On 01/28/2025 at 11:54 AM, Surveyor #1 observed a facility staff member in the feeding dining room on the 2nd floor during lunch bringing in a meal tray for a resident and began feeding the resident without removing the food items from the tray. [...]

Inspectors wroteBased on interview and review of other facility documentation, it was determined that the facility failed to issue the required beneficiary notices for 2 of 3 residents reviewed for Beneficiary Protection Notification, (Resident #1 and Resident #27). This deficient practice was evidenced by the following: On 01/28/2025 at 01:25 PM, the surveyor reviewed the SNF Beneficiary Protection Notification Review (SNFBPNR) completed by the facility for Resident #1 and Resident #27 as follows; 1. The SNFBPNR indicated Resident # 1 last covered Medicare day was 10/15/2024 and Resident # 1 remained in the facility. The SNFBPNR further revealed that a Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage Form CMS-10055 was not given to Resident #1. Under 1. Was a SNFABN, Form CMS-10055 provided to the resident? No was checked. If no explain why the form was not provided: [...]

Inspectors wroteRefer to F 689 C/O # NJ 182995 Based on interview, review of the Electronic Medical Record (EMR) and review of other facility documentation, it was determined that the facility failed to report and submit the facility investigation to the New Jersey Department of Health (NJDOH) within 5 days, specifically when a resident eloped for 1 of 3 residents reviewed for elopement (Resident #160). This deficient practice was evidenced by the following: A review of the EMR on 01/30/2025 at 2:20 PM revealed the following: According to the admission Record Resident #160 was admitted with diagnoses including but not limited to: unspecified Dementia. A review of the most recent comprehensive Minimum Data Set (MDS) an assessment tool dated 09/26/2024 revealed Resident #160 had a Brief Interview for Mental Status (BIMS) score of 4/14 indicating Resident #160 was cognitively impaired. [...]

Inspectors wroteC/O # NJ 177719, 180562 Based on observation, interview, and review of the Electronic Medical Record (EMR), and review of other facility documentation, it was determined that the facility failed to a.) ensure medications were administered in accordance with a physician's orders, b.) failed to follow physician order specifically for obtaining a urine culture, and c.) ensure physician's medication order was transcribed accurately. This deficient practice was identified for 3 of 32 sampled residents (Resident # 311, Resident #312, and Resident #414). This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wroteBased on observation, interview, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 01/29/2024 at 09:23 AM during a tour of the second-floor pantry the surveyor observed no thermometer in the freezer. There were 5 plastic containers of food in the freezer. The temperature log was marked with NA for the whole month of January. During that same tour the surveyor observed a paper wrapped sandwich labeled with a resident's room number and dated for 01/25/2025 in the refrigerator. During an interview on 01/29/2025 with the surveyor, the Quality Assurance Director (QAD) said that night shift nursing staff were responsible for the cleaning the refrigerator and checking the temperature. [...]

Inspectors wroteBased on observation, interview, review of medical records, and review of other facility documentation, it was determined that the facility failed to a.) follow appropriate hand hygiene practices for 3 of 3 staff observed during medication pass and lunch service, respectively b.) implement infection control measures for the handling and storage of respiratory equipment for 3 of 3 residents reviewed for respiratory care (Residents # 23, #315, and #413). This deficient practice was evidenced by the following: 1. On 01/28/2025 at 08:06 AM, Surveyor #1 observed Licensed Practical Nurse (LPN) #4 during medication pass. LPN#4 did not perform hand hygiene including not using Alcohol Based Hand Rub (ABHR) after administration of medications. On 01/28/2025 at 08:20 AM, Surveyor #1 observed LPN #4 administer medication to Resident #82. [...]

Inspectors wroteBased on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to a) maintain professional standards of clinical practice by not following the physician's order for blood pressure (BP) parameters for 1 of 28 sampled residents (Resident # 29) and b) follow professional standards of nursing practices and facility policy by not notifying the Licensed Independent Practitioner of a prescribed medication that was not administered as ordered for 1 of 2 residents during a medication pass observation. This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45 Chapter 11, Nursing Board. The Nurse Practice Act for the State of New Jersey states; [...]

Inspectors wroteBased on interview, record review, and review of other facility documentation, it was determined that the facility a)failed to ensure that the Consultant Pharmacist (CP) reported irregularities of drug regimen to the physician, and b.) failed to act upon the CP report of irregularities found while reviewing the drug regimen. This deficient practice was identified for 1 of 28 sampled residents, (Resident #29) and was evidenced by the following: There was no adverse effects to Resident #29. According to the admission Face Sheet Resident #29 was admitted with diagnoses including but not limited to: Cerebral Vascular Accident (stroke) and hypotension. According to the March 2023 Physician Order Sheet, resident #29 had an order dated 12/17/2022 for an anti-hypotensive medication; [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 03/21/2023 from 9:33 to 10:13 AM, the surveyor accompanied by the Director of Dietary (DOD), observed the following in the kitchen: 1. In the pot and pan drying rack area of the kitchen a stack of third pans on a middle shelf were in the inverted position and stacked upon each other. The surveyor removed the top third pan from the stack and observed a wet, watery substance on the outside of the pan below. The DOD stated, That's wet nesting. The DOD removed the third pans from the drying rack. [...]

Inspectors wroteBased on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to develop a comprehensive, person-centered care plan for 3 of 28 sampled Residents, (Resident # 189, Resident #48, and Resident #135). This deficient practice was evidenced by the following: 1.) During the initial tour of the facility on 03/21/2023 at 10:54 AM, Resident # 189 was observed in bed with nasal oxygen at 2 liter/minute in use. Resident #189 said he/she does not use oxygen at home and has only used since being hospitalized . A review of the admission Face Sheet revealed Resident #189 was admitted to the facility with diagnoses including but not limited to: Shortness of Breath. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that facility failed to identify and eliminate a known and foreseeable accident hazard in the residents environment specifically by leaving an open lid garbage receptacle in the outside smoking area. The deficient practice was identified in 1 of 1 outside smoking areas and was evidenced by the following: On 03/31/2023 at 11:10 AM during an observation of the outside smoking area, the surveyor observed multiple extinguished cigarettes on the ground throughout the area. Further, the surveyor also observed a gray plastic garbage receptacle not fully covered by the lid. Within the garbage receptacle was a clear, plastic bag filled with combustible materials such as a paper cup. Also, within the garbage receptacle were extinguished cigarettes floating in small amount of water. [...]

Inspectors wroteBased on observation, interview, review of the medical record and review of other facility documentation, it was determined that the facility failed to maintain resident dignity when the urine catheter drainage bag was visible from the hallway and in the unit dining room for 1 of 2 Residents reviewed for indwelling urinary catheters (Resident # 87). This deficient practice was evidenced by the following: On 03/22/2023 at 09:38 AM, the surveyor observed Resident #87 in the unit dining room with his/her spouse. The Foley leg bag (attaches directly to the catheter tube and collects urine produced during the day and becomes heavier as it fills) was observed to hanging next to the resident's leg under the wheelchair, not attached to Resident #87's leg and below the hem of their pants. The Foley leg bag was exposed, and urine was visible from the hallway and in the dining room. [...]

Inspectors wroteBased on interview and review of other facility documentation, it was determined that the facility failed to ensure that the incoming and outgoing nurses reconciled controlled substances at change of shift. This deficient practice was identified for 2 of 2 medication carts on 2 of 2 nursing units. The deficient practice was evidenced by the following: On 03/27/23 at 08:52 AM, the Surveyor reviewed the narcotic log book on the 2nd floor nursing unit Low Hall medication cart. A review of the Controlled Substance Inventory log for the 2nd floor Low Hall medication cart for the month of March revealed that the signature of the incoming nurse and/or signature of outgoing nurse was blank on the following days/times: [...]

Inspectors wroteBased on observation, interview, review of the medical record and review of other facility documents, it was determined that the facility failed to consistently provide a physician ordered nutritional supplement at mealtimes for 1 of 2 residents (Resident #102) reviewed for food. This deficient practice was evidenced by the following: On 03/21/2023 at 11:16 AM, while on the initial facility tour of the facility, Resident #102's spouse complained that the food is wrong when meals are delivered. Resident #102's spouse also complained that he/she won't eat sometimes and that he/she has lost about 26 pounds since January 9th of 2023. Resident #102's spouse stated, I'm here twice a day every day for lunch and dinner. On 03/23/2023 at 08:31 AM, the surveyor observed Resident #102 in their room during the breakfast meal. [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to have a cover over the opening of 1 of 2 garbage dumpsters. This deficient practice was evidenced by the following: On 3/31/2023 at approximately 10:00 AM, the surveyor, accompanied by the facility Director of Dietary (DOD went outside the facility to the designated garbage area. Upon arriving the surveyor observed 3 green dumpsters that had (2) black plastic lids on each dumpster to cover the contents. The DOD explained that 2 of the 3 dumpsters were designated for garbage and (1) dumpster was designated for recycling materials. The middle dumpster had 1 of 2 black plastic lids open. [...]

Inspectors wroteBased on interview and review of other facility documentation, it was determined that the facility failed to issue the required beneficiary notice for 1 of 3 residents (Resident #193) reviewed for the Beneficiary Protection Notification. This deficient practice was evidenced by the following: On 03/22/2023 at 11:32 AM the surveyor requested (3) random residents, (1) of whom discharged to home (Resident #193) and (2) who remained in the facility to determine if the facility provided documentation of appropriate notifications On 3/24/2023, the surveyor reviewed the SNF (Skilled Nursing Facility) Beneficiary Protection Notification Review (SNFBPNR) completed by the facility for Resident # 193. The SNFBPNR indicated Resident # 193's last covered Medicare day was 11/16/2022. [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain kitchen sanitation in a safe consistent manner designed to prevent food borne illness. This deficient practice was evidenced by the following: On 4/14/2021 from 9:08 to 9:54 AM the surveyor, accompanied by the Food Service Director (FSD), observed the following in the kitchen area: 1. On a top shelf of a multi-tiered rack in the walk-in freezer, a bag of frozen chopped collard greens was removed from its original container. The bag had no dates. When interviewed the FSD stated, They should have put a date on it when they removed it from the original container. The FSD threw the frozen collard greens in the trash. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to 1.) remove personal protective equipment (PPE) gowns when exiting resident rooms on the Persons Under Investigation unit (PUI) and 2.) wear gloves when entering resident rooms on the PUI unit to minimize the potential spread of infection. The deficient practice was observed on 1 of 2 hallways designated for PUI for COVID-19 (a potentially deadly respiratory virus). The deficient practice was evidenced by the following: On 4/15/21 at 11:40 AM, the surveyor observed CNA (Certified Nurse Aide) #1 and CNA #2 passing lunch trays on the Observation Unit that included rooms 101 through 112. The surveyor observed that there were COVID-19 Personal Protective Equipment for Healthcare Personnel signs outside each occupied room. [...]