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Complaint Investigation

Excel Care At Manalapan

August 13, 2025 · Manalapan, NJ · 104 Pension Road
Citations 3
CMS Rating 2/5
Beds 132
Provider ID 315282
Healthcare Facility
Excel Care At Manalapan
Manalapan, NJ  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

EXCEL CARE AT MANALAPAN in MANALAPAN, NJ — inspection on August 13, 2025.

Found 3 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0755
Pharmacy Service Deficiencies

Cefuroxime 500 MG dose.

Escitalopram 5 MG dose.

  • On 8/12/25 at 9:03 AM the LPN #4 documented “awaiting delivery” for the
  • Pantoprazole 40 MG dose.

There were no progress notes regarding the physician being notified.

On 8/13/2025 at 11:02 AM, the surveyor interviewed LPN #5 who stated that she was the nurse administering medications to Resident #55 that day but was not here yesterday. LPN #5, in the presence of the surveyor, reviewed the medication cart and removed Escitalopram 5 MG and Pantoprazole 40 MG labelled for Resident #55. LPN #5 stated they were in the bottom drawer of the medication cart. LPN #5 added that sometimes agency nurses do not look for the medications.

On 8/13/2025 at 11:25 AM, the surveyor interviewed Resident #55 in their room.

The resident stated that the nurses brought their medications and had no concerns.

The resident added that they had a lot of medications and was unable to speak to which medications or what times the nurses gave them their medications.

On 8/13/2025 at 11:50 AM, the surveyor interviewed the DON, who stated that she would have to educate the nurses who indicated “awaiting delivery” for Resident #55’s medications.

The DON stated that Cefuroxime, Escitalopram and Pantoprazole were medications stocked in the back up supply and should have been administered.

The DON added that she would expect the nurses to notify a supervisor if a medication was not available and there would be follow up such as getting the medication from the backup system, calling the provider pharmacy, or emergency pharmacy.

The DON stated that the goal was to get the medication and administer it and if that was not possible then the physician needed to be notified for follow up.

A review of the electronic medication back up supply list reflected that Cefuroxime 250 MG tablets, Escitalopram 10 MG tablets and Pantoprazole 20 MG tablets were available.

A review of the facility policy dated as revised April 2019 for “Administering Medications” provided by the DON reflected “Medications are administered in a safe and timely manner, and as prescribed.” In addition, the policy interpretation and implementation included but not limited to; “4.

Medications are administered in accordance with prescriber orders, including any required time frame. 7.

Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).” NJAC 8:39-11.2(b), 29.2(a)(d)

315282 08/13/2025

Excel Care at Manalapan 104 Pension Road Manalapan, NJ 07726

stated that the staff usually fed the resident, and the nurse should have noticed the straw at that

reason that the resident was not permitted to have a straw had something to do with their

the Director of Nursing (DON) of the concerns with Resident #43 who received a drinking straw on their tray during the lunch meal service on 8/6/25 and 8/7/25, despite the meal ticket indicating No Straw.A review of the facility's undated Tray Accuracy included:.Routine tray line audits to confirm tray accuracy will be conducted by the Food Service Director or designated employee.A review of the facility's Preparing the Resident for a Meal policy, revised September 2010, included: .Review the resident's care plan and provide for any special needs of the resident.NJAC 8:39-17.4(a)1

315282 08/13/2025

Excel Care at Manalapan 104 Pension Road Manalapan, NJ 07726

supplies needed before he rendered care to the resident. CNA #3 stated that the facility offered both

that it would not get contaminated. CNA #3 stated that if we used a soiled brief to wipe a resident it

8/7/25 at 11:19 AM, the surveyor interviewed CNA #2 who stated that she used the resident's soiled brief to clean Resident #43's urine and stool because it was there, and CNA #1 wanted to clean the resident in the shower. CNA #2 stated that there were wipes that were not used and the resident was not properly cleaned. CNA #2 further stated that by using the brief to clean the resident instead of a wipe the resident could get an infection. On 8/7/25 at 11:28 AM, the surveyor interviewed Registered Nurse (RN) #1 who stated that the aides could have pressed the call bell and called for wash cloths to cleanse the resident. RN #1 further stated that there was a potential for infection because the resident had a history of urinary tract infection. On 8/7/25 at 11:36 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #1, who stated that a soiled brief should not be used to do incontinence care because you must use a wet washcloth to clean the resident appropriately.

The LPN/UM #1 stated that it could cause an infection if a soiled brief were used instead.

The LPN/UM #1 further stated that Resident #43 has had UTIs since day one and had been going to the urologist, but they have not specified the cause of the resident's UTIs. On 8/7/25 at 12:20 PM, the surveyor interviewed the Infection Preventionist (IP), who stated that 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 IP stated that he would have instructed the aides to wait and get the appropriate supplies to clean the resident because there was a concern for infection, and it could cause a potential UTI. On 8/7/25 at 1:41 PM, the surveyor interviewed the Director of Nursing (DON), who stated that it was not appropriate to use a soiled brief to clean the resident.

The DON stated a clean diaper maybe, or a washcloth, wipe or toilet tissue could be used to clean the resident but not a soiled diaper, until the aides showered the resident.

The DON stated, 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.

The DON stated that the doctor has deemed the resident chronic for UTI. A review of the facility's Urinary Continence and Incontinence-Assessment and Management policy, revised September 2010, included: The staff and practitioner will appropriately screen for, and manage, individuals with urinary incontinence.

Management of incontinence will follow relevant clinical guidelines.A review of a staff in-service that was provided to staff which included CNA #2 on 7/2/25, revealed the following:.Nurses and CNA play a key role in UTI prevention through patient education and promoting healthy habits.Female Patients: 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.

Finally, have the patient turn on their side to clean the anal area.Male Patients: For circumcised males, start cleaning at the top of the penis and move downwards in a circular motion to the base.

For uncircumcised males, gently retract the foreskin before cleaning and remember to reposition it afterward. NJAC 8:39-19.4

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 MANALAPAN, 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 MANALAPAN or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.