Excelcare At Newark Llc

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, it was determined that for one (Resident R4) out of three residents reviewed for death,

the facility failed to promote and facilitate Resident R4's self determination with respect to signing multiple consents upon his admission to the facility. Findings include:Review of Resident R4's clinical record revealed: [DATE REDACTED] - Resident R4 was admitted to the facility on Friday evening shift with a diagnosis that included, but was not limited to prostate cancer with metastasized (spread) to the bone and brain. Resident R4's facesheet revealed that he was listed as the Responsible Party. [DATE REDACTED] (untimed) - A speech therapy evaluation and plan of treatment documented that Resident R4's BIMS was a 14 out of 15, which represented that Resident R4 had a normal cognitive function. [DATE REDACTED] 1:22 PM - A BIMS evaluation was performed by E16 (former social worker) that documented a score of 10 out of 15, which represented that Resident R4 had a moderate cognitive impairment. [DATE REDACTED] - The admission MDS assessment documented Resident R4's BIMS score as a 10. Review of the following signed facility consents revealed that Resident R4 did not sign them despite that Resident R4 was evaluated and documented as cognitively intact:-CPR/DNR documentation form was signed on [DATE REDACTED] by FF1 (friend), E10 (LPN/Charge Nurse) and E11 (NP).-Consent to treatment was signed on [DATE REDACTED] by FF1;-Care Management Services consent form was signed on [DATE REDACTED] by FF1;-Consent to treat/assignment of benefits and receipt of notice of privacy practices was signed on [DATE REDACTED] by FF1; and-Consents to administer influenza vaccination, pneumococcal vaccination, respiratory syncytial virus (RSV) vaccination and Covid-19 vaccination were signed by E10 (LPN/Charge Nurse) on [DATE REDACTED] with the following handwritten documentation: verbal consent by [FF2, friend] family doesn't want vaccine. [DATE REDACTED] 11:55 AM - During an interview, E10 (LPN/Charge Nurse) stated that she did not complete Resident R4's admission on Friday evening. E10 stated that the admitting nurse should have obtained the signed consents as part of the admission process. E10 stated that she was told to complete the consents because they were not done. E10 stated that FF1 (friend) was here all the time and was referred to as a brother. E10 stated that she used the BIMS score that was documented 10, revealing that Resident R4 was cognitively impaired. E10 stated that a resident with a BIMS score of 11 or lower cannot sign consents. When asked if she was aware of the BIMS score completed by the Speech Therapist (ST) on [DATE REDACTED] that documented Resident R4 as a 14/15, E10 stated that nobody shared the speech therapy BIMS score.

E10 also stated that she learned later on that FF1 was not Resident R4's real brother. [DATE REDACTED] 9:25 AM - Finding was reviewed with E4 (VPO). The facility failed to promote and facilitate Resident R4's self determination when obtaining multiple consents upon admission. [DATE REDACTED] 4:20 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (DON), E3 (ADON) and E4.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Excelcare at Newark LLC

4949 Ogletown-Stanton Road Newark, DE 19713

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Based on record review and interview, it was determined that for one (Resident R1) out of three residents reviewed for change in condition, the facility failed to consult with Resident R1's physician when Resident R1 complained of shortness of breath and when oxygen therapy was initiated. Findings include:Cross refer F68411/13/25 - Resident R1 was admitted to the facility with diagnoses including a right femur fracture.11/23/25 2:52 PM - E8 (COTA) documented in Resident R1's clinical record, [Resident R1] presents with labored breathing, oxygen saturation of 89% .session shortened.[Resident R1] unable to participate.Resident R1's clinical record lacked evidence that the medical provider was consulted of this new onset of respiratory distress.11/25/25 5:51 AM - A review of EMS documentation revealed a 911 call was made requesting emergency assistance for Resident R1 at the facility.11/25/25 7:04 AM - An EMS Prehospital Care Report documented, .Nursing staff relayed at around 3am [sic] [Resident R1] began complaining of SOB [shortness of breath].they [nursing staff] placed [Resident R1] on 5 lpm [liters per minute] of oxygen via NRB [non-rebreather mask].12/19/25 8:00 AM - During an interview, E7 (LPN) stated, I answered the call bell. [Resident R1]'s roommate said that [Resident R1] can't breathe. I saw [Resident R1] and she didn't look well. [Resident R1] said she couldn't breathe. [Resident R1] was at 88%. I put her on O2 [oxygen] at 2 liters.It was between 3:00 and 4:00 AM. It was before my break .The facility lacked evidence of documentation of consultation with Resident R1's medical provider when she complained of shortness of breath, had a low oxygenation saturation level and was started on oxygen therapy.12/19/25 11:17 AM - During an interview (E8) stated, I remember [Resident R1] did not do therapy that day [11/23/25]. I asked why she couldn't do therapy. [Resident R1] told me she couldn't do therapy because of her breathing. I checked her vitals and put them in my note. I told the nurse whose cart was immediately outside of [Resident R1]'s room.The facility lacked evidence that Resident R1's physician was consulted when Resident R1 complained of shortness of breath when it was reported to nursing staff on 11/23/25.12/23/25 11:58 AM - Findings were confirmed with E1, E2, and E3.12/23/25 4:20 PM - Findings were reviewed

during the exit conference with E1, E2, E3 and E4.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Excelcare at Newark LLC

4949 Ogletown-Stanton Road Newark, DE 19713

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Based on interview and record review, it was determined that for one (Resident R4) out of three residents reviewed for death, the facility failed to ensure all the required IDT (interdisciplinary team) members contributed to

the 11/14/25 care plan conference. Findings include: Review of Resident R4's clinical record revealed: 11/14/25 10:58 AM - The facility's unsigned and incompleted Care Conference Summary documented that Therapy discussed the resident's progress. Discharge planning was discussed. Nursing went over the resident's care. Under Section D. IDT participants who contributed to plan of care lacked evidence of that a specific Physician/Nurse Practitioner/Physician Assistant contributed and how they contributed. 12/22/25 10:30 AM - During an interview, E12 (SSD) stated that the only facility participants that attended Resident R4's care plan conference was E12 from social services, [name of E10, LPN/Charge Nurse] and an unidentified therapy person. E12 stated that E15 (dietician) provided input ahead of the conference as she would not be present. E12 also stated that Resident R4 had two individuals with him (FF1 and FF2). 12/22/25 11:55 AM - During

an interview, E10 (LPN/Charge Nurse) stated that the Provider (Physician/NP) did not participate in Resident R4's care plan conference or Provider input. E10 stated that if there are concerns by the resident during the conference, they would be shared with the Provider after the care conference. 12/23/25 9:25 AM - Finding was reviewed with E4 (VPO). The facility failed to ensure all required IDT members contributed to Resident R4's care plan conference. 12/23/25 4:20 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (DON), E3 (ADON) and E4.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Excelcare at Newark LLC

4949 Ogletown-Stanton Road Newark, DE 19713

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

liters. [Resident R1] went up to 92%. I told her nurse [E5]. It was between 3:00 and 4:00 AM. It was before my break.

The Surveyor asked, Were any vitals or oxygen saturation readings documented? E7 stated, I did not document them.The facility lacked evidence of documentation of Resident R1's vital signs even though she complained of difficulty breathing and exhibited signs of respiratory distressXXX[DATE REDACTED] 11:17 AM - During

an interview, E8 stated, I remember [Resident R1] did not do therapy that day [[DATE REDACTED]]. I asked why she couldn't do therapy. [Resident R1] told me she couldn't do therapy because of her breathing. I checked her vitals and put them in my note. I told the nurse whose cart was immediately outside of [Resident R1]'s room. The nurse took [Resident R1]'s pulse ox again.Resident R1's clinical record lacked evidence of nursing documentation of Resident R1's shortness of breath, inability to participate in therapy, any interventions that were implemented or notification to the medical provider on

this date. [DATE REDACTED] 11:00 AM - An undated facility document entitled, Nursing Competencies Identified Through Facility Assessment provided to the Surveyor stated, .the facility has identified the following.to ensure safe and effective care delivery.vital signs monitoring and nursing assessment.recognition and timely reporting of changes in resident condition.oxygen therapy and respiratory treatments.emergency response and clinical escalation.XXX[DATE REDACTED] 1:50 PM - During an interview, E10 (LPN) stated, 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.[DATE REDACTED] 2:25 PM - During an interview, E13 (Staff Development Coordinator) stated, If any vitals are below baseline, the provider should be called. If anyone cannot be maintained at 92% on NC (nasal cannula) 2 liters, I would call 911. If a non-rebreather is being used, 911 should already be in route. The nurses are trained to document the times vitals are taken and when the provider was called in their progress note. The Surveyor asked, When was the last in-service training for nurses held? E13 stated, It was held on [DATE REDACTED]. The Surveyor asked, Did the training include how to use a non-rebreather mask? E13 stated, Yes, O2 [oxygen] therapy was discussed. A non-rebreather should be used with 10-15 liters of oxygen. The Surveyor the asked, Are the areas of vital signs monitoring, nursing assessment and emergency response addressed in this training? E13 stated, Yes.[DATE REDACTED] 7:15 AM During an interview, E6 stated, The nurse [E5] called me, and I went in [Resident R1's] room. [Resident R1] already had oxygen on. [Resident R1] was comfortable. [E5] called me again saying [Resident R1] was having shortness of breath. [E5] put

the non-rebreather on [Resident R1]. The Surveyor asked, Do you remember the approximate time this occurred? E6 stated, I don't remember. The Surveyor asked, Do you remember [Resident R1]'s oxygen saturation level at the time or how much oxygen [Resident R1] was given? E6, I cannot remember what oxygen level [Resident R1] was on. We did not have time to document the vitals.[DATE REDACTED] 12:00 PM - An Immediate Jeopardy (IJ) was called due to the facility's failure to adequately assess Resident R1's change in condition, timely consult the provider, and to promptly request emergency medical assistance when Resident R1 began complaining of not being able to breathe and had low oxygen saturation readings. The facility also failed to maintain oxygen delivery to Resident R1 at an appropriate level until emergency medical assistance arrivedXXX[DATE REDACTED] 4:15 PM - The facility's abatement plan for the Immediate Jeopardy included:Licensed nursing staff were re-educated on: a) recognition of respiratory distress, respiratory assessments, including vital signs and oxygen saturation b) initiation and monitoring of oxygen therapy c) timely provider notification All residents were immediately screened by licensed nursing staff for respiratory distress. Residents identified with respiratory distress were assessed and interventions were implemented.The facility failed to ensure that Resident R1 was assessed and appropriate interventions were implemented, including emergency care and services, when she complained of difficulty breathing and was noted with obvious respiratory distressXXX[DATE REDACTED] 4:20 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (DON), E3 (ADON), and E4 (VPO).

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Excelcare at Newark LLC

4949 Ogletown-Stanton Road Newark, DE 19713

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Based on interview and record review, it was determined that for one (Resident R4) out of one resident reviewed for death, the facility failed to ensure Resident R4 had a completed and signed resident agreement upon admission to

the facility. Findings include: Review of Resident R4's clinical record revealed: 11/7/25 - Resident R4 was admitted to the facility on Friday evening shift with a diagnosis that included, but was not limited to prostate cancer with metastases to the bone and brain. Resident R4's facesheet revealed that he was listed as the Responsible Party. 12/2/25 9:40 PM - A nursing note documented that Resident R4 passed away in the facility. Review of Resident R4's 11/7/25 DE (Delaware) admission Packet revealed that it was unsigned and incomplete. A written statement by E14 (admission Director) revealed, On November 10th patient [Resident R4] was asleep when trying to do the admission agreement; went back in the afternoon and was still sleeping. On November 11th patient refused due to being tired. Facesheet from the hospital had 2 people listed as siblings that we did not find out they were NOT family members until the brother came in the day he [Resident R4] passed away. Agreement. was in progress until the day patient passed away. 12/23/25 9:25 AM - Finding was reviewed with E4 (VPO). The facility failed to ensure Resident R4's medical record included a completed and signed DE admission Packet, a legal document that clearly communicated the resident's rights, facility's policies and described the healthcare services to be provided to the resident. 12/23/25 4:20 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (DON), E3 (ADON) and E4.

Event ID:

Facility ID:

If continuation sheet