Excel Care at Manalapan: Staff Used Soiled Brief - NJ
The incident occurred during routine personal care at Excel Care at Manalapan when CNA #1 and CNA #2 were changing Resident #43. When CNA #2 questioned using the soiled brief to clean the resident, CNA #1 said it was acceptable since the resident was getting a shower anyway.
CNA #2 continued cleaning the resident with the contaminated diaper and prepared them for bathing.
The resident has battled UTIs since admission and regularly sees a urologist, though doctors haven't determined the underlying cause of the recurring infections. The facility's own infection preventionist and director of nursing confirmed the practice created serious infection risks.
"Even if a section of the resident's brief that was not soiled were used to clean the resident it was still soiled and dirty," the infection preventionist told state inspectors. He said he would have instructed staff to wait and obtain appropriate cleaning supplies because of infection concerns and the potential for causing UTIs.
The director of nursing was equally blunt about the violation. "A soiled brief was not clean, and it is an infection issue because there was both urine and bowel movement in the diaper and it can cause an infection," she said. She noted that the resident's doctor had classified their UTI condition as chronic.
Multiple staff members confirmed proper protocols were ignored. CNA #3, interviewed the same day, explained that facility policy required two washcloths for female residents during incontinence care, with cleaning performed from front to back to prevent contamination.
"If we used a soiled brief to wipe a resident it was not appropriate for infection control purposes because the resident could get an infection," CNA #3 said.
The registered nurse on duty said staff could have pressed the call button to request washcloths. She emphasized the infection risk was particularly concerning given the resident's history of urinary tract infections.
When questioned by inspectors, CNA #2 acknowledged the violation. She admitted using the soiled brief "because it was there" and said CNA #1 wanted to clean the resident in the shower. She confirmed that wipes were available but unused, and that the resident wasn't properly cleaned.
CNA #2 also admitted understanding the consequences: "By using the brief to clean the resident instead of a wipe the resident could get an infection."
The facility's unit manager stated definitively that soiled briefs should never be used for incontinence care, explaining that wet washcloths were required for appropriate cleaning and that using contaminated materials could cause infections.
Just one month before the incident, Excel Care had provided staff training on UTI prevention that specifically outlined proper cleaning procedures. The July 2nd in-service, which CNA #2 attended, instructed staff that nurses and nursing assistants "play a key role in UTI prevention through patient education and promoting healthy habits."
The training detailed exact protocols: "Spread the labia majora and wipe down the center, using a clean part of the washcloth for each stroke. Then, clean each side, rinsing and drying the area thoroughly."
Despite this recent education, staff chose contaminated material over the clean washcloths and wipes that were present in the room.
The facility's own incontinence policy, established in 2010, requires staff to "appropriately screen for, and manage, individuals with urinary incontinence" and states that "management of incontinence will follow relevant clinical guidelines."
State inspectors found the violation represented a breakdown in basic infection control practices that put a vulnerable resident at unnecessary risk. The resident's chronic UTI condition made proper hygiene protocols especially critical for preventing additional infections.
The inspection revealed that multiple levels of staff, from nursing assistants to the director of nursing, understood the infection risks created by using soiled materials for personal care. Yet two certified nursing assistants proceeded with the unsafe practice during routine care.
Excel Care's infection preventionist said he would have halted the procedure entirely, instructing staff to wait for appropriate cleaning supplies rather than risk the resident's health with contaminated materials.
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.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
EXCEL CARE AT MANALAPAN in MANALAPAN, NJ was cited for violations during a health inspection on August 13, 2025.
The incident occurred during routine personal care at Excel Care at Manalapan when CNA #1 and CNA #2 were changing Resident #43.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.