Excel Care At Wayne

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

warm and dry, skin color within normal limit (WNL) and turgor is normal. Resident does not have an external device. 1. Foot evaluation completed. The Progress Notes did not include any documentation that

the resident eloped from the facility on 10/19/2025. During an interview with LPN #1 on 10/27/2025 at 11:19 AM, she stated that at approximately 2:30 PM, the resident was walking around back and forth by the nurse's station. LPN #1 stated that the assigned nurse (LPN #3) gave her the keys to LPN #3's medication cart because LPN #3 was going on break. LPN #1 stated that Resident #2 complained they had a headache and she was going to give the resident a Tylenol. LPN #1 stated when she went to Resident #2's room, the resident was not there. LPN #1 stated that she checked the hallway and did not find the resident, so she paged all staff to come to the First-Floor nursing unit. LPN #1 stated that as staff came, VF #1 of a different resident told her that they just saw a [gender retracted] outside wearing [sleepwear]. LPN #1 stated that she, along with the other staff members, ran outside and ran for about 1-2 minutes, and there was VF #2 sitting by the gazebo on the facility's property that told them that the resident went that way (pointing to the right). LPN #1 stated that they found the resident a block down on the right standing on the sidewalk with two women who stated that the resident looked out of place with [sleepwear] on. LPN #1 stated that the resident was brought back inside the building and the assigned nurse (LPN #3) assessed

the resident and there were no injuries. During an interview on 10/27/2025 at 5:04 PM, with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and the [NAME] President of Clinical (VPC), the surveyor asked what should be documented in the resident's medical record in accordance with professional standards of practice. The DON stated falls, wounds, changes in status, medication changes, appointments, and behaviors. The surveyor asked if an elopement was considered a behavior, the VPC confirmed it would be and technically should have been documented in the resident's medical record.

During a follow-up interview on 10/29/2025 at 12:06 PM, LPN #1 stated that the assigned nurse (LPN #3) had stepped away for five minutes and it was her responsibility to document Resident #2's elopement incident. LPN #1 confirmed that there should have been a Progress Note that included the resident's elopement on 10/19/2025, so other staff were aware the resident had eloped. LPN #1 stated that charting was usually done on post incidents, and that this was an incident that should have been documented. On 10/29/2025 at 12:56 PM, the surveyor attempted to conduct a telephone interview with LPN #3, who did not answer. LPN #3 did not return the surveyor's telephone call, and she was not present during the survey for

an interview. A review of the facility's policy titled Nursing Documentation dated 5/01/2025, included Purpose: This policy is to establish guidelines and procedures for nursing documentation . 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. Policy Statement General Guidelines included: 1. Accuracy: All nursing documentation must be factual, accurate, and free from abbreviations that could cause confusion. 2. Timeliness: Documentation should occur promptly after . Or receiving new information. Consistency: Documentation should be consistent across all records, ensuring that data is cohesive and easily understood by the entire team. The same policy under Documentation Requirements included: 3. Documentation: Document all nursing interventions and observations, including but not limited to: . changes in condition or behavior. 4.

Nursing Notes: Write concise, chronological notes on the resident status, interventions, and outcomes.

NJAC 8:39-27.1 (a)

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

10/29/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Excel Care at Wayne

296 Hamburg Turnpike Wayne, NJ 07470

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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Note: The nursing home is disputing this citation.

were aware of all the residents who were wanderers. The ADON stated that during morning huddle, staff were made aware of who the residents that wandered were. The ADON further stated that there was a new Neighborhood Watch sign that included all four residents at the nurse's station, but it was not hung earlier.

At that time, the surveyor requested the ADON inform the DON that they wanted to test the function of Resident #4's wanderguard bracelet.

On 10/27/2025 at 1:19 PM, the DON tested Resident #4's wanderguard bracelet for function. At that time,

the surveyor asked the DON why he did not test Resident #4's wanderguard earlier, and the DON stated because the surveyor only requested three residents' wanderguard bracelets tested. The surveyor stated that they did not specify which three residents so how did the DON determine which residents the surveyor wanted tested. The DON stated that it slipped my mind when asked for three, and I forgot there was a fourth. When the surveyor questioned the DON that he forgot, the DON sated he did not forget, I misremembered. The DON stated that there were originally three residents who wandered, and Resident #4 was recently added.

On 10/27/2025 at 5:04 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), DON, and the [NAME] President of Clinical (VPC), and the DON stated that the nurses identified someone at risk for elopement and placed a wanderguard bracelet on them. The DON continued that the Receptionist updated the facility's Neighborhood Watch list, and during morning meeting with the department heads, they were made aware of any changes. At that time, the surveyor informed the facility about their observation of the Neighborhood Watch list with three residents only and that staff were unaware Resident #4 was at risk for elopement.

NJAC 8:39-27.1 (a)

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

Event ID:

Facility ID:

If continuation sheet