Excel Care at the Pines

In the surveyor’s words

From the most serious findings on record at Excel Care at the Pines, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF607Apr 6, 2026

  Based 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… […]

• No harm, potential for more than minimal, widespreadF882Apr 6, 2026

  Based 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). […]

• No harm, potential for more than minimal, widespreadF812Nov 19, 2024

  Based 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 [DATE] 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 [DATE]. The mustard had a manufacturer's BEST BY date of [DATE]. 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. […]

• No harm, potential for more than minimal, patternF656Apr 6, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF658Apr 6, 2026

  Based 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. […]