Excel Care at the Pines

Inspectors wroteBased on interviews, review of facility policy, and review of pertinent facility documents, it was determined that the facility failed to implement their abuse policy to a.) complete reference checks on employees before their start date and b.) complete criminal background checks prior to their start date of employment. This deficient practice was identified for 12 of 50 employee files reviewed (Employee #2, #3, #5, #6, #9, #31, #42, #45 and #50), and was evidenced by the following:A review of the facility's Employee Health Screening, Background Checks, and License Verification policy dated 5/1/2025 included, The facility shall ensure that all employees, contractors, and licensed practitioners are qualified, competent, and medically fit for duty, and do not pose a risk to residents, in compliance with Federal and New Jersey regulations. [...]

Inspectors wroteBased on interview and review of pertinent facility documents, it was determined that the facility failed to ensure the designated Infection Preventionist (IP) was dedicated solely to the infection prevention and control program (IPCP). This deficient practice was identified for one (1) of one (1) staff and was evidenced by the following:On 4/1/2026 at 10:46 AM, the surveyor interviewed the interim Director of Nursing (DON) who stated that she was hired at the facility as a part-time, 20 hours per week, Infection Preventionist (IP). However, since the former DON resigned she has been acting as both the full-time DON and part-time IP in the facility. The DON further explained that she was doing both the IP and DON positions with the help of the [NAME] President of Clinical Services (VPCS). [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to implement, revise and update care plans (CP) for 3 of 28 residents (Resident #7, #8, #17) reviewed. This deficient practice was evidenced by the following:1.) On 4/01/2026 at 1:01 PM, the surveyor interviewed Resident #17 who stated that he/she had wounds on the left foot and had a single lumen peripherally inserted central line (PICC) (a long, thin, flexible tube inserted into a peripheral vein (usually in the upper arm) and threaded into a large vein near the heart) in the left upper arm. The surveyor reviewed Resident #17's electronic medical record which revealed the following information: [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that a resident's refusal of an anticoagulant (a medication that reduces the risk of blood clot formation) was promptly communicated to the resident's physician and documented within the progress notes of the resident's electronic medical record (EMR) in accordance with professional standards of nursing practice. This deficient practice was identified for 1 of 1 resident (Resident #7) reviewed for the use of an anticoagulant and was evidenced by the following:Refer to F656 and F756Reference: 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, record review, and review of other facility documentation, it was determined that the facility failed to ensure that a resident received care and services for the provision of dressing changes to a peripherally inserted central catheter (PICC-is a long, thin, flexible tube inserted into a peripheral vein (usually in the upper arm) and threaded to a large vein near the heart) site consistent with professional standards of practice. [...]

Inspectors wroteBased on record review, and review of pertinent facility documents, it was determined that the Consultant Pharmacist (CP) failed to report irregularities found in the medical record to the facility. This deficient practice was identified for 1 of 1 resident (Resident #7) reviewed for anticoagulant (a medication that reduces the risk of blood clot formation) usage and was evidenced by the following:On 3/30/2026 at 11:46 AM, during the initial tour of the facility, the surveyor observed Resident #7 lying in bed awake. The resident indicated that he/she received an anticoagulant via injection and had no complaints about bleeding or bruising. On 3/31/26 at 10:29 AM, the surveyor reviewed the Electronic Medical Record (EMR) for Resident #7. [...]

Inspectors wroteBased on interview, record review and review of pertinent facility documents, it was determined that the facility failed to ensure that the required members were present during the quarterly Quality Assurance and Performance Improvement (QAPI) Committee Meetings. This deficient practice occurred during 4 of 4 meetings reviewed and was evidenced by the following:On 4/6/2026 at 9:57 AM, the surveyor was provided with the last four quarters of the QAPI meeting sign-in sheets for review that were dated July 31, 2025, April 2025 (date not specified), October 2025 (date not specified), and 1/29/2026 and reviewed them with the Licensed Nursing Home Administrator. [...]

Inspectors wroteBased on observations, interviews, record review, and review of facility documents, it was determined that the facility failed to maintain a clean, safe, and home like environment for one resident room (room [ROOM NUMBER]) on 1 of 4 nursing units (Veteran's Unit). This deficient practice was evidenced by the following:On 3/31/2026 at 12:39 PM, the surveyor entered room [ROOM NUMBER] with an unsampled resident's permission and noted that one of the square shaped ceramic tile flooring pieces had been removed from the subflooring and was placed over the top of the opening from which it was previously adhered to, and the surveyor noted a shallow opening in the flooring at the foot of bed C which was not occupied at that time. [...]

Inspectors wroteComplaint #2632496 Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to provide incontinence care to residents who were unable to carry out activities of daily living (ADLs) for 2 out of 8 residents (Resident #1 and #36) observed during an incontinence tour. This deficient practice was evidenced by the following:On 4/2/2026 at 9:15 AM, the surveyor conducted an incontinence tour with Licensed Practical Nurse/Nursing Supervisor (LPN/NS) #1 on the third floor. Resident #36 was observed lying in bed. When Resident #36 was asked if their incontinence brief was clean and dry, they stated that it was wet and they needed to be changed. They added that they had been wet since 5 AM. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure that an air mattress was accurately set according to the resident's weight. This deficient practice was identified for 1 of 2 residents (Residents #1) reviewed for pressure ulcers and was evidenced by the following: On 3/31/2026 at 12:36 PM, the surveyor observed Resident #1 in bed on an air mattress set at 200 pounds. The surveyor reviewed the medical record for Resident #1. A review of the admission Record (an admission summary), revealed the resident had diagnoses which included: Dependence on ventilator, pressure ulcer of sacral region, and anxiety. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to provide the necessary respiratory care and services for 1 of 2 residents (Resident # 16) reviewed. This deficient practice was evidenced by the following:A review of the admission Record (admission summary) indicated that Resident #16 was admitted to the facility with the diagnoses that included but was not limited to chronic obstructive pulmonary disease (COPD) and acute respiratory distress syndrome. A review of the quarterly Minimum Data Set (MDS), an assessment that facilitates a resident's care, dated 1/26/26, indicated that Resident #16 scored 14 out of 15 on the Basic Interview of Mental Status (BIMS) which indicated that the resident was cognitively intact. The MDS also indicated that Resident #16 was independent with all aspect of activities of daily living (ADLs). [...]

Inspectors wroteBased on observation, interview, record review, and document review, it was determined that the facility failed to provide sufficient nursing staff to ensure all residents reached their highest practical wellbeing by failing to: a) provide timely incontinence care to 2 out of 8 residents (Resident #1 and #36) reviewed for Activities of Daily Living, and b) provide sufficient nursing staff for 4 of 4 weeks of staffing prior to the recertification survey date of 4/6/2026 . This deficient practice was evidenced by the following:On 4/2/2026 at 9:15 AM, the surveyor conducted an incontinence tour with Licensed Practical Nurse/Nursing Supervisor (LPN/NS) #1 on the third floor. Resident #36 was observed lying in bed. When Resident #36 was asked if their incontinence brief was clean and dry, they stated that it was wet and they needed to be changed. They added that they had been wet since 5 AM. [...]

Inspectors wroteBased on observation and interview, it was determined that the facility failed to ensure that the daily Nursing Home Resident Care Staffing Report was posted and displayed in the front lobby. This deficient practice was identified on 1 of 1 main entrance and was evidenced by the following: On 4/6/2026 at 10:15 AM, the surveyor observed the facility's Nursing Home Staffing Report Form dated 4/2/2026, posted on the receptionist's desk in the front main lobby. On 4/6/2026 at 10:20AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated that he posts the schedule out front so that visitors and patients know what the staffing is like. He added that on Fridays, he preprints the staffing reports for Saturdays and Sundays and places them in the stand behind Friday's report. [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent facility documents, it was determined that the facility failed to ensure 1.) a resident received a Renal-Regular Double Portions diet for a lunch meal in accordance with physician orders, and 2.) a resident received a Regular Diet with small portion starches, double portions of entree and vegetable; provide extra sandwich with lunch and dinner in accordance with physician orders. This deficient practice was identified for 2 of 3 residents reviewed for nutrition (Resident #7, #18). This deficient practice was evidenced by the following: 1.) On 3/30/2026 at 10:29 AM, during the initial tour, the surveyor observed Resident #18 lying in bed. Resident #18 had oxygen in place and stated to the surveyor that he/she did not feel well and stated, sick. [...]

Inspectors wroteComplaint #NJ184191/394091 Based on observations, interviews, and record review, it was determined that the facility failed to document treatments administered to a resident on the electronic Treatment Administration Record (eTAR) for 1 of 4 residents reviewed for professional standards of nursing practice (Resident #2). 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, and review of other facility documentation, 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 11/12/2024 at 09:32 AM, the surveyor, accompanied by the Food Service Director (FSD), observed the following in the kitchen: 1. On a lower shelf a one (1) gallon container of Deli Mustard was dated received 11/21/22. The mustard had a manufacturer's BEST BY date of 10/25/23. On interview the FSD agreed that the mustard was expired and should have been removed from stock. The FSD then removed the mustard from storage. 2. On a lower shelf in the walk-in freezer two (2) bags of frozen French fries were removed from their original container. The French fries had no dates. [...]

Inspectors wroteC/O # NJ 168401, NJ# 174304 Based on observation, interview and review of other facility documentation, the facility failed to ensure the facility was maintained in a safe, clean and homelike environment. This deficient practice was identified for 2 of 3 units, 2nd and 3rd floor and was evidenced by the following: 1. On 11/14/24 at 08:29 AM the surveyor conducted an interview and observation with Resident #70 while he/she was lying in bed. The sheet covering the mattress was observed to have holes in it at the lower end of the bed towards the foot board and exposed the mattress underneath. Resident #70 expressed to the surveyor that he/she would prefer a sheet that did not have holes. On 11/15/2024 at 09:28 AM the surveyor observed room [ROOM NUMBER]. The surveyor observed that the C-bed bottom dresser drawer was broken, with the right side of the drawer face hanging on the floor. [...]

Inspectors wroteBased on observation and interview, it was determined that the facility failed to make State of New Jersey inspection results in a place readily accessible to facility residents. This deficient practice was evidenced by the following: On 11/12/2024 at approximately 9:00 AM, the surveyor observed the state survey results binder in the facility reception area upon entry. The results were on top of the receptionist desk in a black plastic binder. During the Resident Council Meeting on 11/13/2024 at approximately 10:30 AM, 4 of 4 alert and oriented residents in attendance stated to the surveyor that they were not aware of the location of State Survey results. The residents indicated that they would like to be able to have access to the results upon completion of the survey. [...]

Inspectors wroteNJ 173880 Based on observation, interview, review of the medical record and review of other facility documentation, it was determined that the facility failed to notify a physician of a resident's blood sugar levels exceeding the established parameters (Resident #173) in accordance with professional standards of practice. This deficient practice was identified for 1 of 1 residents reviewed for insulin usage. 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, medical record review and review of other facility documentation, it was determined that the facility failed to implement infection control measures for the handling and storage of respiratory equipment for 1 of 4 residents (Resident #70) reviewed for respiratory care. This deficient practice was evidenced by the following: On 11/12/2024 at 10:56 AM, during the initial tour of the facility the surveyor observed that Resident #70 was not present in the room. The surveyor observed a nebulizer mask placed on top of the nebulizer machine while not in use. The mask was uncovered and exposed to contamination. On 11/14/2024 at 08:25 AM Resident #70 was observed lying in bed. The surveyor observed Resident #70's nebulizer mask not in use and placed in the opened top drawer of the bedside table. [...]

Inspectors wroteBased on observation, interview and review of other facility documentation, it was determined that the facility failed to follow appropriate infection control practices and perform proper hand hygiene (HH) a.) during medication administration task on 1 of 4 units, the ventilator unit for 2 of 7 resident (Resident #3 and Resident #61) and b.) follow appropriate infection control practices and perform hand hygiene during tracheostomy care (a surgical procedure that creates an opening in the neck to provide an airway and remove secretions from the lungs) for 1 of 1 residents reviewed for Ventilator/Trach. This deficient practice was evidenced by the following: 1. During medication pass on the ventilator unit on 11/13/2024 at 9:45 AM, the surveyor observed the following: [...]

Inspectors wroteBased on observation, interview and review of other facility documentation, it was determined that the facility failed to provide a A.) sanitary and orderly environment for 3 of 39 rooms on the second floor and various areas on the 3rd floor and B.) a homelike dining atmosphere for 2 of 2 floors, 2nd and 3rd. This deficient practice was evidenced by the following: A.) On 8/14/2023 at 9:44 AM, during the initial tour of the facility, Surveyor #1 entered room [ROOM NUMBER]. A strong odor of urine emanated inside the room. Surveyor #1 observed a floor stain that appeared to be dried, brown liquid. On 8/14/2023 at 10:19 AM, during the initial tour of the facility, Surveyor #1 entered room [ROOM NUMBER]. A strong odor of urine emanated from the room. On 8/15/2023 at 11:31 AM, Surveyor #1 entered room [ROOM NUMBER]. A strong odor of urine continued to emanate from the room. [...]

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 sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 8/15/2023 from 8:25 to 9:03 AM, the surveyors, accompanied by the Food Service Director (FSD) and Regional Manager (RM), observed the following in the kitchen: 1. On a middle shelf in the walk-in refrigerator a sheet pan contained 17 defrosted house shakes. The shakes had no pull date or manufacturer expiration date. The RM stated that the shakes are good for 14 days after pulling from freezer to defrost. The RM agreed that there was no way to determine how long the house shake supplements were in the refrigerator. 2. [...]

Inspectors wroteBased on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to provide reasonable accommodation of resident needs specifically by failing to ensure call devices were in reach of 2 of 6 residents (Residents #68 and Resident #23) reviewed under the Environmental Task. The deficient practice was evidenced by the following: A.) On 8/14/2023 at 9:44 AM, during the initial tour of the facility, Surveyor #1 observed Resident #68 asleep in bed. At that time, Surveyor #1 observed the call device on the floor adjacent to the bed. On 8/15/2023 at 11:33 AM, Surveyor #1 observed Resident #68 asleep in bed. At that time, Surveyor #1 observed the call device on the floor adjacent to the bed. On 8/16/2023 at 8:40 AM, Surveyor #1 observed Resident #68 asleep in bed. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure a resident's environment is free from accident hazards specifically by having unattended, unpackaged medications left in 2 of 2 rooms reviewed for Accidents. The deficient practice was evidenced by the following: On 8/14/2023 at 9:46 AM during the initial tour of the facility, the surveyor observed two tablets and one capsule left on the night stand between two resident beds in room [ROOM NUMBER]. On 8/16/2023 at 9:26 AM, the surveyor again observed two tablets and one capsule left on the night stand between two resident beds in room [ROOM NUMBER]. At that time, the surveyor showed Licensed Practical Nurse (LPN #1) the tablets and capsule. LPN #1 stated that she believed one of the tablets may be Eliquis (medication used to thin blood). [...]

Inspectors wroteBased on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to identify and monitor a resident's hemodialysis (the clinical purification of blood by dialysis, as a substitute for the normal function of the kidney) treatment access site. This deficient practice was identified for 1 of 1 residents reviewed for dialysis (Resident #161) and was evidenced by the following: According to the admission Record Resident # 161 was admitted to the facility with diagnoses including but not limited to: End Stage Renal Disease. According to the most recent Minimum Data Set (MDS) an assessment tool used to facilitate care, dated 8/09/2023 revealed Resident #161 had a Brief Interview for Mental Status score of 15/15 indicating Resident #161 was cognitively intact. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to use appropriate precautions to store respiratory equipment in order to prevent the risk of infection, specifically by not containing a bilevel positive airway pressure (BiPAP) mask and a continuous positive airway (CPAP) mask in the appropriate manner increasing the risk of potential infection. The deficient practice was evident for 2 of 7 residents (Resident #21, #6) reviewed for Respiratory Care. The deficient practice was evidenced by the following: On 08/16/2023 at 09:35 AM while inside Resident #21's room, the surveyor observed a mask connected to a BiPAP machine left on top of a night stand adjacent to the resident's bed. The mask was not contained in a bag and left exposed to the environment. [...]

Inspectors wroteBased on interview and review of other facility documentation, it was determined that the facility failed to ensure 2 of 5 Certified Nursing Assistants ( CNA #2 and CNA #3) received 12 hours of education annually. This deficient practice was evidenced by the following: The surveyor requested five (5) random CNA education files for the year 2022. A review of a facility form titled 2022 In-Service Log revealed the following; CNA #2 completed 11.5 hours. CNA #3 completed 8.5 hours. During an interview with the surveyor on 8/21/2023 at 1:09 PM, the Director of Nursing (DON) said the CNA should have 12 hours of education annually. When asked what topics are required to be covered, the DON responded we have a list. She further said yes, Resident rights, abuse and neglect, Infection Control should be included. [...]