Excelcare at Newark: Medical Records Breach - DE
That moment, and the hours that followed it at Excelcare at Newark LLC, would eventually trigger one of the most serious citations federal inspectors can issue: Immediate Jeopardy, a finding that a facility's failures put a resident in immediate risk of serious harm or death. The citation was issued December 23, 2025, following a complaint inspection at the facility on Ogletown-Stanton Road.
The resident, identified in inspection records only as R1, had been showing signs of respiratory distress. The nursing assistant, identified as E7, told inspectors she had checked the resident's vitals and oxygen saturation and found the reading at 92 percent. She told the nurse. She did not document anything. When inspectors later reviewed R1's clinical record, there was no documentation of the nighttime check, no record of the low reading, no note that the resident had complained of difficulty breathing at all.
It did not stop there.
Later that same day, a therapy staff member, identified as E8, found that R1 could not participate in her scheduled therapy session. The reason was her breathing. "I asked why she couldn't do therapy," E8 told inspectors. "R1 told me she couldn't do therapy because of her breathing." E8 checked the resident's vitals and entered them into a note, then told the nurse whose cart was parked immediately outside R1's room. That nurse checked R1's pulse ox again.
Inspectors went looking for any nursing documentation from that encounter, any record that R1 had reported shortness of breath, that she had been unable to do therapy, that a nurse had been told, that any intervention had been put in place, or that a doctor had been contacted. There was nothing. R1's clinical record had no nursing note from that interaction. No interventions documented. No provider notification documented.
The facility's own internal document, an undated assessment of nursing competencies, listed among the skills required for safe care delivery: vital signs monitoring, nursing assessment, recognition and timely reporting of changes in resident condition, oxygen therapy and respiratory treatments, and emergency response and clinical escalation. The document was provided to inspectors during the survey. The gap between what it described and what had actually happened for R1 was the length of a shift.
When inspectors interviewed an LPN identified as E10, the nurse said: "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." The staff development coordinator, E13, told inspectors that nurses are trained to document the times vitals are taken and when the provider was called in their progress notes. She said a training session had been held that included oxygen therapy, non-rebreather mask use, vital signs monitoring, nursing assessment, and emergency response. A non-rebreather mask, she explained, should be used with 10 to 15 liters of oxygen. If a non-rebreather was already in use, she said, 911 should already be on the way.
It was not.
A charge nurse identified as E6 described what happened when R1's condition deteriorated further. The nurse on duty, E5, called E6 into R1's room. R1 already had oxygen on. E6 said R1 appeared comfortable at that point. Then E5 called again: R1 was having shortness of breath. E5 put a non-rebreather mask on R1. "I cannot remember what oxygen level R1 was on," E6 told inspectors. "We did not have time to document the vitals."
According to the facility's own staff development coordinator, the moment a non-rebreather mask goes on a resident, 911 should already be in route.
Inspectors called Immediate Jeopardy at noon on December 23. The citation covered four distinct failures: the facility had not adequately assessed R1's change in condition, had not consulted her provider in a timely way, had not promptly called for emergency medical assistance when she began reporting she could not breathe and her oxygen saturation readings were falling, and had not maintained her 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, conducting respiratory assessments including vital signs and oxygen saturation, initiating and monitoring oxygen therapy, and notifying providers in a timely way. All residents were screened for respiratory distress. Those found to have respiratory distress were assessed and interventions were put in place.
The findings were reviewed at an exit conference with the nursing home administrator, the director of nursing, the assistant director of nursing, and a vice president of operations.
What the inspection record does not contain is a full account of what happened to R1. Her clinical record, by the inspectors' own finding, was stripped of the documentation that would tell that story. The nursing assistant who checked her oxygen in the early morning hours did not write it down. The nurse who was told about the low reading left no note. The therapy staff member who found her too short of breath to exercise documented what she saw, but the nursing staff who were told about it did not. When the non-rebreather mask went on, no one recorded what her oxygen saturation was at that moment or what flow rate the oxygen was set to.
The facility's competency document said nurses were responsible for the recognition and timely reporting of changes in resident condition. A resident who could not breathe well enough to do physical therapy in the morning, whose oxygen had already been checked in the middle of the night by an aide who found it low enough to worry about, represented exactly the kind of change that document described.
The aide told the nurse. The therapist told the nurse. The nurse told the charge nurse. At each step, the information moved forward and the documentation did not. By the time a non-rebreather mask was on R1's face, hours had passed since the first sign that something was wrong, and the clinical record still showed almost none of it.
The staff development coordinator told inspectors that if a resident cannot be maintained at 92 percent on two liters of nasal cannula, the provider should be called. If a non-rebreather is already in use, 911 should already be on the way. She said nurses are trained on this.
R1 had a non-rebreather mask on her face before anyone called for help.
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.
The citation was issued December 23, 2025, following a complaint inspection at the facility on Ogletown-Stanton Road.
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.