Excel Care At The Pines
Inspection Findings
F-Tag F0658
F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
gentamicin cream bid to open wound to left lower extremity, dated 03/22/24.- Hydrocortisone external gel 2 % (hydrocortisone (Topical)); apply to head topically two times a day for rash, dated 03/07/24.- Mupirocin external ointment 2 % (mupirocin); apply to left upper inner thigh topically two times a day for wound care.
Cleanse wound with Dakins, apply mupirocin, then cover with border gauze, dated 01/07/24.- Mupirocin external ointment 2 % (mupirocin); apply to right lower abdomen topically two times a day for wound care.
Cleanse wound with Dakins, apply mupirocin, then cover with border gauze, dated 01/07/24.A review of the corresponding March 2025 eTAR revealed blank spaces for the day shifts on the 03/06/25, 03/07/25, 03/11/25, 03/17/25, 03/18/25, 03/20/25, 03/21/25, and 03/27/25, for the following POs: clotrimazole-betamethasone cream to the abdomen and left upper thigh; collagen external cream; bacitracin; Dakins (1/4 strength) external solution to the left upper inner thigh and right lower abdomen; hydrocortisone external gel; and mupirocin external ointment to the left upper inner thigh and right lower abdomen.A review of the corresponding Progress Notes did not include any documentation regarding the blank treatment orders on the above dates.A review of the March 2025 eTAR revealed a blank space for the resident's PO for a skin assessment on the 03/17/25 day shift.A review of the corresponding Progress Notes did not include any documentation regarding the skin assessment for that day.A review of the March 2025 eTAR revealed blank spaces for the day shifts on the 03/10/25 and 03/16/25, for gentamicin sulfate external cream to left low extremity.A review of the corresponding Progress Notes did not include documentation for the blank treatment orders on those dates.On 09/16/25 at 10:43 A.M., the surveyor interviewed the Registered Nurse (RN), who stated that the treatments were signed on the eTAR after administering the treatments to the residents. The RN also stated that there should not be any blank spaces on the eTAR.On 09/16/25 at 11:02 A.M., the surveyor interviewed the Nursing Supervisor (NS), who stated that all physician's orders were documented in the eTAR, and that there should never be blank spaces. When questioned why there should be no blank spaces on the eTAR, the NS answered that blanks indicated that the treatment was not documented which meant the treatment was not performed.On 09/16/25 at 01:51 P.M., the surveyor interviewed the Director of Nursing (DON), who stated that her expectations regarding documentation by her nursing staff was that all documentation was completed prior to the end of the nurse's shift. The DON further stated that there should be no blanks on the eTAR and that if it was not documented, the treatment was not done. The surveyor presented the DON with the eTAR for Resident #2, and the DON confirmed there were blanks on Resident #2's TAR.A review of the facility's policy titled Nursing Documentation dated 05/01024, revealed under Purpose, This policy is to establish guidelines and procedures for nursing documentation at [name redacted] facilities to ensure accurate, timely, and legally compliant documentation practices. Proper documentation provides a clear, consistent
record of care, facilitates communication among care team members, and ensures continuity of care for residents. Under General Guidelines (in Nursing Documentation), 2. Timeliness: Documentation should occur promptly after providing care or receiving new information. Late entries should be clearly noted and explain why the entry was delayed.NJAC 8:39-27.1(a)
Event ID:
Facility ID:
If continuation sheet
EXCEL CARE AT THE PINES in ATLANTIC CITY, NJ inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in ATLANTIC CITY, NJ, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from EXCEL CARE AT THE PINES or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.