Excelcare at Newark: Resident Choice Rights - DE
That was between 3:00 and 4:00 in the morning. It was not the last time that night that staff would watch her struggle and fail to act.
Federal inspectors cited Excelcare at Newark, a nursing home at 4949 Ogletown-Stanton Road, with an Immediate Jeopardy violation following a complaint inspection completed December 23, 2025. Immediate Jeopardy is the most serious designation available under federal nursing home oversight — it means inspectors concluded that the facility's failures had placed a resident in serious risk of harm, serious injury, or death.
The resident at the center of the finding is identified in inspection records only as R1. What the records show is a timeline of missed assessments, undocumented vital signs, delayed provider notification, and a facility that could not maintain adequate oxygen delivery to a woman who was visibly in respiratory distress.
The nursing assistant who first noticed the drop, identified in records as E7, described the moment plainly. R1's oxygen saturation had gone up to 92 percent on two liters of supplemental oxygen. E7 told the nurse, identified as E5. Then E7 went on break. When inspectors asked whether any vital signs or oxygen saturation readings had been documented from that early morning check, E7 said: "I did not document them."
No documentation from that period appears anywhere in R1's clinical record.
Later that same day, a therapist, identified as E8, found R1 unable to participate in therapy. R1 told E8 directly that she couldn't do therapy because of her breathing. E8 checked her vitals, made a note, and told the nurse whose cart was positioned immediately outside R1's room. That nurse, according to E8, took R1's pulse ox again.
None of it made it into the nursing record. R1's clinical file contained no nursing documentation of her shortness of breath that day, no record of her inability to participate in therapy, no interventions, and no evidence that anyone notified a medical provider.
The facility's own internal document, an undated assessment of nursing competencies, listed exactly what staff were supposed to be capable of: vital signs monitoring, nursing assessment, recognition and timely reporting of changes in resident condition, oxygen therapy, respiratory treatments, and emergency response. The document was provided to inspectors during the survey. It described a standard of care the facility had committed to on paper.
What inspectors found was something else.
A licensed practical nurse, E10, told inspectors during an interview: "We are not trained on oxygen use. If someone is in respiratory distress, I would put them on nasal cannula at 2 liters. If they are under 92%, I will inform the provider." That statement — from a licensed nurse, at a facility that had identified oxygen therapy as a core competency — was one of the more striking moments in the inspection record.
The Staff Development Coordinator, E13, described the training differently. She told inspectors that nurses were trained to document the times vitals are taken and when the provider was called, that a non-rebreather mask should be used with 10 to 15 liters of oxygen, and that if a resident cannot be maintained at 92 percent on nasal cannula at 2 liters, the protocol is to call 911. "If a non-rebreather is being used," E13 said, "911 should already be in route." She confirmed that the most recent in-service training, held before the inspection, had covered oxygen therapy, vital signs monitoring, nursing assessment, and emergency response.
The training had happened. The knowledge, apparently, had not transferred.
At some point during the night, E5 called a charge nurse, identified as E6. E6 went to R1's room. R1 already had oxygen on. E6 described her as comfortable. Then E5 called again: R1 was having shortness of breath. E5 put a non-rebreather mask on R1.
When inspectors asked E6 what oxygen saturation level R1 was at when the non-rebreather went on, E6 said: "I cannot remember what oxygen level [R1] was on." When inspectors asked what liter flow of oxygen R1 was receiving, E6 could not remember that either. When inspectors asked why none of this had been documented, E6 said: "We did not have time to document the vitals."
A non-rebreather mask is emergency-level oxygen delivery. It is the kind of intervention that, by the facility's own stated protocol, should have had 911 already on the way. It did not.
Inspectors called Immediate Jeopardy at noon on December 23. The formal finding was that the facility had failed to adequately assess R1's change in condition, failed to consult the provider in a timely way, and failed to promptly request emergency medical assistance when R1 was complaining of not being able to breathe and showing low oxygen saturation readings. The facility also failed, inspectors found, to maintain oxygen delivery at an appropriate level until emergency help arrived.
The facility submitted an abatement plan the same afternoon. Licensed nursing staff were re-educated on recognizing respiratory distress, on conducting respiratory assessments including vital signs and oxygen saturation monitoring, on initiating and monitoring oxygen therapy, and on timely provider notification. All residents were screened for respiratory distress. Those identified with distress were assessed and had interventions put in place.
The findings were reviewed at an exit conference with the facility's nursing home administrator, director of nursing, assistant director of nursing, and vice president of operations.
What the inspection record does not contain is any account of what happened to R1 after the non-rebreather went on, or whether emergency services eventually came, or what her condition was when the survey was completed. The record stops where the documentation stopped, which is to say: at the point where the people responsible for writing things down decided they did not have time.
A nursing assistant noticed a woman struggling to breathe at 3:00 in the morning and did the right thing. She told the nurse. After that, for hours, in a facility that had written down on paper exactly what its nurses were supposed to know and do, a woman in respiratory distress waited while the people around her forgot to call, forgot to document, and forgot to remember what oxygen level she was on when they finally put the emergency mask on her face.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Excelcare At Newark LLC from 2025-12-23 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
EXCELCARE AT NEWARK LLC in NEWARK, DE was cited for violations during a health inspection on December 23, 2025.
That was between 3:00 and 4:00 in the morning.
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.