The medication mix-up involved three different drugs for one resident over nearly two weeks. On August 1, a licensed practical nurse documented that a 500-milligram dose of the antibiotic Cefuroxime was "awaiting delivery" at 6:29 p.m.
Eleven days later, another nurse made the same notation for two more medications within one minute of each other. At 9:02 a.m. on August 12, LPN #4 marked the resident's 5-milligram Escitalopram dose as "awaiting delivery." At 9:03 a.m., the same nurse made an identical notation for a 40-milligram Pantoprazole dose.
None of the nurses notified a physician about the missed medications, inspection records show.
When inspectors arrived the next day, they discovered the medications had been available all along. LPN #5, who was administering drugs that morning, pulled both the Escitalopram and Pantoprazole from the bottom drawer of the medication cart, labeled for the same resident. The drugs were sitting exactly where they should have been.
"Sometimes agency nurses do not look for the medications," LPN #5 told inspectors.
The resident, interviewed in their room, said nurses brought their medications regularly and expressed no concerns. But the person acknowledged having "a lot of medications" and couldn't specify which drugs they received or when nurses administered them.
The facility's Director of Nursing admitted the documentation errors represented a training failure. She told inspectors she would need to educate nurses about proper procedures when medications appear unavailable.
"Cefuroxime, Escitalopram and Pantoprazole were medications stocked in the back up supply and should have been administered," the director said.
The nursing director outlined what should have happened: nurses should notify supervisors when medications seem unavailable, then follow up by checking backup supplies, calling the pharmacy, or contacting an emergency pharmacy. Only if none of those options worked should nurses skip doses and notify the physician.
"The goal was to get the medication and administer it," she said.
Facility records confirmed backup supplies were available for all three missed medications. The electronic inventory listed Cefuroxime 250-milligram tablets, Escitalopram 10-milligram tablets, and Pantoprazole 20-milligram tablets in stock.
The medication errors violated the facility's own policies. Excel Care's administration guidelines, revised in April 2019, require that "medications are administered in a safe and timely manner, and as prescribed." The policy specifically mandates that drugs be given "in accordance with prescriber orders, including any required time frame" and "within one hour of their prescribed time."
Escitalopram is an antidepressant commonly prescribed to treat depression and anxiety disorders. Missing doses can trigger withdrawal symptoms and mood changes. Pantoprazole reduces stomach acid production and is often prescribed to prevent ulcers or treat gastroesophageal reflux disease. Skipping doses can allow acid-related damage to return.
The antibiotic Cefuroxime treats bacterial infections. Inconsistent dosing can reduce the drug's effectiveness and potentially contribute to antibiotic resistance.
Federal inspectors classified the violation as causing "minimal harm or potential for actual harm" and affecting "few residents." But the incident highlighted broader concerns about medication management at the 120-bed facility.
The inspection occurred in response to a complaint, though federal records don't specify what prompted the investigation. Excel Care at Manalapan is owned by Excel Care Management and has operated at 104 Pension Road since 2008.
Agency nurses, who work temporary assignments at multiple facilities, may be less familiar with each location's medication storage systems and backup procedures. The nursing director's comment about agency staff not looking for medications suggests this wasn't an isolated incident.
The resident affected by the medication errors continues living at the facility. Federal records don't indicate whether the person experienced any adverse effects from the missed doses, or whether Excel Care implemented additional training to prevent similar documentation mistakes.
The facility was required to submit a correction plan to state health officials, but those details weren't available in the inspection report.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Excel Care At Manalapan from 2025-08-13 including all violations, facility responses, and corrective action plans.