Excel Care at Wayne

Inspectors wroteBased on observation, interview, record review, and review of other pertinent documents, it was determined that the facility failed to: a) complete pre and/or post dialysis assessments for 2 of 2 residents (Resident #11 and #96); and b) ensure timing of a resident's medication was adjusted to accommodate their dialysis schedule, for 1 of 2 residents (Resident #96) reviewed for dialysis services. This deficient practice was evidenced by the following: 1. On 5/17/26 at 10:50 AM, the surveyor observed Resident #96 resting in bed, with their eyes closed. There were no observed concerns. On 5/18/26 at 9:48 AM, the surveyor reviewed the electronic medical record (EMR) of Resident #96. [...]

Inspectors wroteBased on observation, interview, record review and review of pertinent facility documentation, it was determined that the facility failed to follow appropriate infection control practices for: a) personal protective equipment (PPE) use while performing high contact care in an enhanced barrier precaution (EBP) room for 1 of 1 Certified Nurse Aide (CNA) observed on 1 of 2 units; b) handling of personal care items for a resident for 1 of 1 CNA observed on 1 of 2 units; and c) storage of medical equipment and linens to decrease the possibility of spreading infection during a tour of the laundry area. 2. On 5/20/26 at 10:37 AM, the surveyor toured the laundry area with the Housekeeping Director (HKD), who stated that the facility collected the soiled laundry every 2 hours from units and they used two containers in soiled utility rooms. [...]

Inspectors wroteRepeat Deficiency Based on observation, interview, and record review, it was determined that the facility failed to ensure the resident's call device was readily accessible. The deficient practice was identified for 5 of the 22 residents (Resident #2, 15, 33, 67, and #92) reviewed for reasonable accommodations of needs/preferences. This deficient practice was evidenced by the following: 1. On 5/17/26 at 9:54 AM, the surveyor observed Resident #2 in bed asleep. The surveyor observed that the resident's call device was wrapped around the resident's right side rail, almost touching the floor. On 5/18/26 at 8:58 AM, the surveyor observed that Resident #2 was awake, and the call device was wrapped around the resident's side rail, almost touching the floor. Resident #2 stated that they don't know where the call device is. [...]

Inspectors wroteBased on observation, interviews, and review of pertinent facility documents, it was determined that the facility failed to maintain a homelike environment. Specifically, the facility failed to: a) keep the facility's environment in an adequate state of repair on 1 of 2 nursing care units surveyed, and b) failed to clean and maintain the equipment for 1 of 22 residents (Resident #5) reviewed for homelike environment. The deficient practice was evidenced by the following:On 5/17/26 at 10:17 AM, during an initial tour of 2nd floor nursing care unit the surveyor observed a two foot wide by two foot long area of damaged sheet rock and a large torn flap of wallpaper next to the door bed in room [ROOM NUMBER]. [...]

Inspectors wroteBased on the interview and record review, it was determined that the facility failed to code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care of all residents, accurately for 1 of 25 residents reviewed (Resident # 122). The deficient practice was evidenced by the following:The surveyor reviewed Resident # 122's records. The resident was discharged from the facility to the emergency room (ER) and according to the Discharge Return Not Anticipated MDS, an assessment tool used to facilitate the management of care, dated 2/19/26, the resident was assessed as having an unplanned discharge to home/community. A review of Resident # 122's progress notes dated 2/19/26 revealed the resident was discharged to the ER.During an interview on 5/19/26 at 1:13 PM, the surveyor brought the above concerns to the attention of the Director of Nursing and Administrator. [...]

Inspectors wroteRepeat Deficiency Based on observation, interview, and review of the pertinent medical record, it was determined that the facility failed to ensure that necessary care was provided to a dependent resident who required staff assistance for personal hygiene for 1 (one) of 4 sampled residents (Resident #13) reviewed for Activities of Daily Living (ADL). This deficient practice was evidenced by the following: On 5/17/26 at 10:01 AM, the surveyor observed Resident #13 lying in bed awake, able to answer the surveyor's inquiry. The surveyor observed that both residents' fingernails are long, and there is blackish debris underneath the fingernails. On 5/19/26 at 10:30 AM, the surveyor and the Registered Nurse/Unit Manager (RN/UM) went to the resident's room to observe that Resident #13's fingernails were long, and there was blackish debris underneath the fingernails. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure the facility remained free of accident hazards. The deficient practice was identified for 1 of the 22 sampled residents and 1 unsampled resident reviewed for safe and homelike environment. The deficient practice was evidenced by the following:On 5/17/26 10:30 AM, the surveyor observed in room [ROOM NUMBER] the surveyor noted the grab bar in the bathroom of room was loose at both ends and pulling away from the wall. The surveyor observed an unopened plastic vial of nebulizer solution on the bedside table next to the window bed. On 5/17/26 at 10:58, the surveyor interviewed the Licensed Practical Nurse (LPN) assigned to the second floor nursing care unit in room [ROOM NUMBER]. The LPN was asked about the vial of medication on the bedside table of the window bed. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that a resident with an indwelling catheter (inserted into the urethra (tube) and draining urine to the bag) had a privacy bag for dignity. This deficient practice was identified in 1 (one) of 3 residents (Resident #13) who were reviewed for urinary catheter use. This deficient practice was evidenced by the following: On 5/17/26 at 10:01 AM, the surveyor observed Resident #13 lying in bed awake, able to answer the surveyor's inquiry. The surveyor observed that the resident's indwelling catheter is on the right side of the bed, not in the privacy bag facing the door and the roommate. On the same day, the surveyor interviewed the Licensed Practical Nurse (LPN), who stated that the resident should have a privacy bag. [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent facility documents, it was determined that the facility failed to ensure that residents received the necessary respiratory care and services, according to the standard of clinical practice, specifically documenting PRN (as needed) of oxygen (O2) use and provide enough water in the humidifying bottle according to the facility's policy and procedure for 1 (one) of 1 resident (Resident #15) reviewed for respiratory care. This deficient practice was evidenced by the following: 1. On 5/17/2026 at 10:35 AM, the surveyor observed a nebulizer machine on the bedside table of the window bed in room [ROOM NUMBER]. The tubing of the nebulizer machine tubing lying on floor behind the bedside table, the surveyor was unable to visualize the date on the tubing. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to: a) consistently ensure an as needed (PRN) pain medication was administered according to the physician orders (PO) and acceptable standards of practice in accordance with the New Jersey Board of Nursing for (one) 1 of four (4) residents (Resident #18), administered by one (1) of four (4) nurses, observed during medication administration; and b) provide pharmaceutical services in accordance with professional standards to ensure appropriate transcription and administration of a medication for 1 of 22 residents (Resident #125) reviewed. 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 record review it was determined the facility failed to: a) administer medications with parameters in accordance with a physician's order and standards of practice for 1 of 2 residents (Resident #96) reviewed for dialysis services. The deficient practice is 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: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as casefinding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure a prescription medication was labeled, sterile treatment supply and IV treatment were stored and discarded in accordance with currently accepted professional principles and facility's policy. This deficient practice was identified for 1 of 3 medication carts inspected and 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 wroteComplaint #2713977Based on observation, interview, and record review, it was determined that the facility failed to maintain accurately documented, complete and readily accessible medical records. This deficient practice was identified for 1 of 22 residents (Resident #125) reviewed. On 5/18/26 at 9:09AM, the surveyor reviewed the electronic medical record (EMR) of Resident #125. The resident no longer resided at the facility. The admission Record (a summary of important information about the resident) documented that the resident had diagnoses that included but were not limited to urinary tract infection, acute on chronic congestive heart failure (a condition where the heart muscle is too weak or stiff to pump blood efficiently), and polyosteoarthritis (chronic degenerative joint disease in which the tissues in the joint wears down in five or more joints at the same time). [...]

Inspectors wroteComplaint #: 2650138 Based on observation, interviews, review of medical records, and review of other pertinent facility documents on 10/27/2025 and 10/29/2025, it was determined that the facility failed to provide adequate supervision to a severely cognitively impaired resident (Resident #2) with a known history of wandering and wore a wander guard, who eloped from the facility on 10/19/2025. The deficient practice was identified for 1 of 4 residents reviewed for elopement (Resident #2). On 10/19/2025 at approximately 2:30 PM, the Licensed Practical Nurse (LPN #1) noticed Resident #2 was not in their room, and she could not find the resident. LPN #1 initiated a search, and a visiting family (VF #1) of another resident stated that they observed a [gender redacted] outside wearing [sleepwear], and LPN #1 and other staff immediately went outside to search for Resident #2. [...]

Inspectors wroteComplaint # 265013 Based on interviews and review of other pertinent facility documents on 10/27/2025 and 10/29/2025, it was determined that the facility failed to ensure the nursing staff documented a resident's (Resident #2) elopement from the facility in the resident's medical record in accordance with professional standards of practice. This deficient practice was identified for 1 of 4 residents reviewed for elopement (Resident #2). 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 pertinent facility documents, it was determined that the facility failed to maintain the call bell within reach of residents. This deficient practice was identified for 2 of 21 residents reviewed for the accommodation of needs (Resident #8 and #11), and was evidenced by the following: On 12/2/24 at 11:00 AM, the surveyor observed the door to room [ROOM NUMBER] was closed. The surveyor heard someone from 232 calling out for assistance. The surveyor knocked and with permission entered the room. The surveyor observed Resident #8 in their room seated in a wheelchair to the left of the bed. The surveyor observed that the resident's call bell (used to summon staff for assistance) was affixed to the right enabler, not within his/her reach. On 12/3/24 at 9:30 AM, the surveyor observed Resident #8 seated in a wheelchair to the left of the bed. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure a.) blood pressure apparatus was utilized in accordance with the manufacturer's specifications, b.) an antibiotic treatment was administered as ordered by the physician, and in accordance with professional standards of practice. This deficient practice was observed during the medication pass observation of 1 of 5 nurses who administered to 1 of 6 residents (Resident #20) and identified for 1 of 1 resident investigated for abuse (Resident # 16). The evidence was as follows: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wroteComplaint NJ#175927 Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure that incontinence care was provided to a dependent resident for 1 of 4 residents reviewed for incontinence care (Resident #71) on 1 of 2 nursing units, 2nd-floor unit. This deficient practice was evidenced by the following: On 12/2/24 at 11:00 AM, the surveyor observed Resident #71 in the bathroom seated in a wheelchair. The surveyor observed the resident exposed their incontinence brief. The surveyor observed two incontinence briefs were in place, both saturated with urine. At that time, the Hospitality Aide who was in Resident #71's room, stated that she was not assigned to provide direct care and left to summon the Certified Nursing Assistant (CNA) assigned to Resident #71's care. [...]

Inspectors wroteBased on observation, interviews, and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the medication pass on 12/4/24, the surveyor observed five (5) nurses administer medications to six (6) residents. There were 26 opportunities and two (2) errors observed which calculated to a medication administration error rate of 7.6 %. The deficient practice was identified for 2 of 5 nurses for 2 of 6 residents, (Resident #97 and #20) as evidenced by the following: 1. On 12/4/24 at 08:46AM, the surveyor observed the Licensed Practical Nurse (LPN #1) prepare medications for Resident #97. The medications included a physician's order for Sennosides - Docusate sodium 8.6 milligram (mg) - 50 mg (Senna Plus), 1 tablet by mouth every 12 hours for constipation with an order date of 10/28/24. [...]

Inspectors wroteBased on the interview and record review, it was determined that the facility failed electronically transmit the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care of all residents, within 14 days of completing the resident's assessment for 5 of 25 residents, (Resident #103, #92, #31, #76, and #107) reviewed for resident assessment. The deficient practice was evidenced by the following: 1. Resident #103 was observed to have a Death MDS of 4/02/23 and was due to be transmitted no later than 4/16/23. The Death MDS was not transmitted until 4/28/23. 2. Resident #92 was observed to have an Entry MDS of 4/05/23 and was due to be transmitted no later than 4/20/23. The Death MDS was not transmitted until 4/28/23. 3. Resident #31 was observed to have an admission MDS of 3/31/23 and was due to be transmitted no later than 4/14/23. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to accurately document the administration of physician ordered medications in the electronic administration record by one (1) of three (3) nurses observed administering medications. The deficient practice occurred for four (4) unsampled residents (#1, #2, #3, and #4). 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, record review and policy review, it was determined that the facility failed to a.) store potentially hazardous foods in a manner to prevent food borne illness, b.) failed to sanitize and air-dry steam table pans and sheets pans in a manner to prevent microbial growth and c.) failed to maintain the kitchen equipment in a sanitary manner to prevent contamination from foreign substances and potential for the development a food borne illness. This deficient practice was evidenced by the following: On 9/13/23 at 10:49 AM, in the presence of the Food Service Director (FSD) the surveyor observed the following: 1. In the dry storage area, the surveyor observed a random sampling of dented cans which were in rotation for use. The surveyor observed the following: [...]