Inspection Reports for Excelcare at Newark LLC
49459 Ogletown-Stanton Road, DE, 19713
Back to Facility ProfileInspection Report Summary
The most recent inspection on April 17, 2025 found the facility to be in substantial compliance with no deficiencies identified. Earlier inspections showed a pattern of multiple deficiencies related primarily to care planning, resident rights, medication management, infection control, and emergency preparedness. Complaint investigations included substantiated findings in 2023 involving care planning, pressure ulcer treatment, and medication management, while most other complaints were unsubstantiated. The facility was cited once in March 2025 for staffing ratio issues but took corrective actions including staff education and audits. The recent clean follow-up inspection suggests improvement after prior citations.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
9.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
5% worse than Delaware average
Delaware average: 8.8 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
93 residents
Based on a April 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Follow-Up
Census: 93
Deficiencies: 0
Date: Apr 17, 2025
Visit Reason
An unannounced follow-up survey was conducted for the annual, emergency preparedness, and complaint survey ending February 19, 2025, at the facility from April 16, 2025 through April 17, 2025.
Findings
The facility was found to be in substantial compliance with 42 CFR Part 483 Subpart B Requirements for Long Term Care Facilities as of March 31, 2025. No deficiencies were identified at the time of the survey.
Report Facts
Survey sample size: 12
Inspection Report
Routine
Deficiencies: 1
Date: Mar 25, 2025
Visit Reason
The inspection was conducted as a routine staffing audit by the State of Delaware, Division of Health Care Quality, Office of Long-Term Care Residents Protection to assess compliance with minimum staffing levels for nursing services in residential health facilities.
Findings
The facility was found noncompliant with Delaware Code Chapter 11 Nursing Facilities staffing requirements, specifically failing to maintain the CNA ratio of 1:8 on the day shift during the week of 1/12/25 to 1/18/25. Supervisors were educated on calculating CNA ratios, and corrective actions including audits and education were planned.
Deficiencies (1)
Failure to maintain the CNA ratio of 1:8 on the day shift during the week of 1/12/25 to 1/18/25.
Report Facts
CNA ratio: 8
Inspection week: Jan 12, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Nursing Home Administrator | Completed Facility Staffing Worksheets revealing staffing deficiency |
Inspection Report
Annual Inspection
Census: 76
Deficiencies: 18
Date: Feb 19, 2025
Visit Reason
An unannounced annual and complaint survey was conducted at the facility from February 11, 2025, through February 19, 2025, to assess compliance with federal and state regulations.
Findings
The survey identified multiple deficiencies related to emergency preparedness, resident rights, personal funds management, care planning, pain management, medication administration, and food safety among others. The facility failed to meet several regulatory requirements as evidenced by observations, interviews, and document reviews.
Deficiencies (18)
Emergency Preparedness Plan was not updated to include missing residents as a potential hazard.
Facility failed to ensure residents were treated with respect and dignity; staff did not knock before entering rooms.
Facility failed to provide quarterly personal funds statements to residents.
Facility failed to protect personal privacy and confidentiality of residents' medical records.
Facility failed to provide adequate coordination of PASARR assessments and screenings.
Facility failed to develop and implement baseline care plans and comprehensive person-centered care plans for residents.
Facility failed to ensure ADL care was provided to dependent residents.
Facility failed to assist residents with shaving and grooming as needed.
Facility failed to ensure proper application of splints and oversight of residents with splint orders.
Facility failed to assist dependent residents with activities of daily living including toileting and hygiene.
Facility failed to follow physician orders for bowel and bladder care and wound treatment.
Facility failed to maintain continence care and toileting programs for residents with bowel and bladder incontinence.
Facility failed to provide adequate pain management and monitoring for residents.
Facility failed to ensure proper respiratory care and oxygen tubing management.
Facility failed to provide routine and emergency dental services to residents.
Facility failed to develop and maintain policies and procedures for monthly drug regimen review.
Facility failed to ensure proper use and monitoring of psychotropic medications and PRN orders.
Facility failed to ensure food safety and sanitation policies were followed in food storage and preparation areas.
Report Facts
Residents in investigative sample: 18
Facility census: 76
Deficiency completion dates: 2025
BIMS score: 14
BIMS score: 15
Pain scale: 10
PRN order duration: 14
Inspection Report
Annual Inspection
Census: 90
Deficiencies: 19
Date: Mar 19, 2024
Visit Reason
An unannounced annual and complaint survey was conducted at Churchman Village from February 29, 2024 through March 19, 2024 to assess compliance with applicable regulations and investigate complaints.
Findings
The survey identified multiple deficiencies related to tuberculosis testing, clinical record maintenance, incident reporting, resident rights, medication administration, infection control, and other regulatory requirements. The facility failed to meet several requirements but submitted plans of correction and audit processes to address these issues.
Deficiencies (19)
Failure to ensure pre-employment tuberculosis testing for employees.
Failure to complete history and physical examination by a physician within 14 days of admission.
Failure to complete incident reports for incidents involving residents and staff.
Failure to ensure residents' rights to self-determination and choice were honored.
Failure to inform Medicaid-eligible residents of changes in services and charges.
Failure to provide adequate supervision and assistance to prevent accidents and falls.
Failure to investigate and prevent potential abuse allegations.
Failure to provide accurate and complete assessments and care plans for residents.
Failure to ensure medication regimen review and timely response to irregularities.
Failure to ensure safe, clean, and sanitary environment including housekeeping and food safety.
Failure to maintain accurate medical records and protect resident-identifiable information.
Failure to provide adequate respiratory care and nebulizer therapy.
Failure to provide adequate dialysis transportation and care coordination.
Failure to provide adequate training and monitoring for staff on infection prevention and control.
Failure to maintain an effective infection prevention and control program.
Failure to ensure accurate and timely urine culture testing and reporting.
Failure to ensure residents receive appropriate psychotropic drug monitoring and assessments.
Failure to ensure residents receive appropriate physical therapy and restorative services.
Failure to ensure residents receive adequate nutrition and food safety.
Report Facts
Facility census: 90
Survey sample size: 23
Dates of survey: February 29, 2024 through March 19, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E41 | MD | Named in findings related to failure to complete history and physical examination within 14 days |
| E18 | CNA | Named in findings related to resident rights and care refusal |
| E2 | DON | Director of Nursing involved in multiple interviews and findings |
| E3 | Corporate Clinical Operations | Involved in findings review |
| E4 | Regional Clinical Specialist | Involved in findings review |
| E5 | Cooperate Director of Human Resources | Interviewed regarding tuberculosis testing findings |
| E36 | CNA | Involved in incident report findings |
| E37 | RN | Involved in care plan and medication administration findings |
| E58 | RN Unit Manager | Involved in discharge planning and restorative care findings |
| E42 | Dietary Services Director | Involved in food safety findings |
| E26 | Staff Developer | Involved in infection control and training findings |
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 5
Date: Mar 14, 2023
Visit Reason
An unannounced Complaint Survey was conducted at this facility from March 6, 2023 through March 14, 2023 based on interviews, review of clinical records, and other facility documentation.
Complaint Details
The survey was complaint-initiated and unannounced, conducted from March 6 to March 14, 2023. The complaint involved issues with care planning, bathing, pressure ulcer treatment, and medication management. The report includes substantiated findings based on clinical record reviews and interviews.
Findings
The facility was found deficient in multiple areas including failure to develop and implement baseline care plans for residents with surgical wounds, failure to provide bathing as per resident preference, inadequate treatment and prevention of pressure ulcers, and failure to ensure residents were free of significant medication errors. Specific deficiencies involved residents R1, R2, and R3 with issues related to care planning, skin integrity, and medication management.
Deficiencies (5)
Failure to develop and implement a baseline care plan for resident R3's surgical wounds.
Failure to provide bathing in accordance with resident R2's preference and scheduled frequency.
Failure to provide necessary treatment and services to prevent and heal pressure ulcers for resident R2.
Failure to provide orders for immediate care and needs for residents R1 and R3 related to medication management.
Failure to ensure residents are free of significant medication errors, including missing medications for resident R1.
Report Facts
Facility census: 85
Survey sample size: 6
Medication errors: 13
Braden Scale score: 17
Missing fax pages: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Nursing Home Administrator (NHA) | Participated in exit conference and review of findings |
| E2 | Assistant Director of Nursing (ADON) | Participated in exit conference and review of findings |
| E3 | Assistant Director of Nursing (ADON) | Interviewed regarding resident care plans and bathing |
| E4 | Vice President of Operations (VPO) | Participated in exit conference and review of findings |
| E5 | Physician Assistant (PA) | Provided physician orders and notes related to resident care |
| E6 | Nurse Practitioner (NP) | Reviewed medication regimen for resident R1 |
| E7 | Medical Doctor (MD) | Performed physician note and medication reconciliation |
| E8 | Physician (PA) | Provided orders for wound care and treatment |
Inspection Report
Annual Inspection
Census: 87
Deficiencies: 12
Date: Aug 17, 2022
Visit Reason
An unannounced Annual and Complaint Survey was conducted at Churchman Village from August 4, 2022 through August 17, 2022 to assess compliance with federal and state regulations.
Findings
The survey identified multiple deficiencies related to communicable disease control, resident privacy, safe environment, care planning, pain management, medication errors, infection control, and abuse prevention. The facility failed to meet several regulatory requirements, including tuberculosis testing for employees, privacy protections for residents, safe and clean environment standards, comprehensive care plans, and proper medication administration.
Deficiencies (12)
Facility failed to ensure three employees received pre-employment tuberculosis testing or chest x-ray.
Facility failed to ensure resident privacy and confidentiality, including discussions at nurse's station being overheard.
Facility failed to provide a safe, clean, comfortable, homelike environment; issues included fruit flies, soiled linens, and unsanitary conditions in resident room.
Facility failed to provide proper bed hold notices for residents hospitalized or on therapeutic leave.
Facility failed to develop and implement comprehensive person-centered care plans for residents, including communication and discharge planning.
Facility failed to provide adequate assistance with activities of daily living and communication for residents with deficits.
Facility failed to ensure licensed staff followed pain management orders and monitored pain medication effects.
Facility failed to ensure medication error rate was below 5%, with a 7.4% error rate identified.
Facility failed to maintain food safety standards, including proper storage, labeling, and sanitation.
Facility failed to maintain an effective infection prevention and control program, including proper use of PPE and hand hygiene during COVID-19 outbreak.
Facility failed to ensure all staff and residents received education and documentation related to COVID-19 vaccination.
Facility failed to ensure abuse, neglect, and exploitation prevention training was completed and documented for staff.
Report Facts
Facility census: 87
Survey sample size: 52
Medication error rate: 7.4
Medication error threshold: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E34 | Employee who did not receive pre-employment tuberculosis testing | |
| E12 | Certified Nursing Assistant (CNA) | Employee who did not receive pre-employment tuberculosis testing |
| E33 | Staff Supportive Device (SSD) | Employee who did not receive pre-employment tuberculosis testing |
| E5 | Infection Control Preventionist (ICP) | Confirmed tuberculosis testing findings during interview |
| E1 | Nursing Home Administrator (NHA) | Reviewed findings during exit conference |
| E2 | Director of Nursing (DON) | Reviewed findings during exit conference |
| E27 | Assistant Director of Nursing (ADON) | Involved in wound care and privacy deficiency findings |
| E28 | Wound Care Doctor | Involved in wound care and privacy deficiency findings |
| E69 | Family Member (FM1) | Reported concerns about fall mat and room conditions |
| E10 | Maintenance Director | Confirmed room condition issues |
| E11 | Housekeeping Manager | Confirmed room condition issues and safety concerns |
| E3 | Vice President of Operations (VPO) | Confirmed bed hold policy deficiency |
| E6 | Licensed Practical Nurse (LPN) | Interviewed regarding care plan and medication administration |
| E9 | Registered Nurse (RN) | Interviewed regarding care plan and medication administration |
| E20 | Registered Nurse (RN) | Interviewed regarding care plan and medication administration |
| E13 | Food Service Director | Confirmed food service deficiencies |
| E26 | Licensed Practical Nurse (LPN) | Administered medications and confirmed medication errors |
| E131 | Resident involved in COVID-19 vaccination deficiency | |
| E14 | Certified Nursing Assistant (CNA) | Involved in dementia training deficiency |
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 0
Date: Apr 16, 2021
Visit Reason
An unannounced complaint survey was conducted at the facility from April 13, 2021 to April 16, 2021.
Complaint Details
The survey was complaint-related and no deficiencies were identified, indicating no substantiated issues.
Findings
No deficiencies were identified at the time of the survey.
Report Facts
Survey sample size: 4
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 0
Date: Mar 3, 2021
Visit Reason
An unannounced COVID-19 Focused Infection Control Survey and Complaint Survey was conducted by the State of Delaware Division of Health Care Quality, Office of Long Term Care Residents Protection from February 25, 2021 to March 3, 2021.
Complaint Details
The survey included a complaint investigation component, but no deficiencies were identified and the facility was found compliant.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices to prepare for COVID-19. No deficiencies were identified at the time of the survey.
Report Facts
Facility census: 67
Inspection Report
Abbreviated Survey
Census: 66
Deficiencies: 0
Date: Dec 23, 2020
Visit Reason
An unannounced COVID-19 Focused Infection Control Survey and Complaint Survey was conducted by the State of Delaware Division of Health Care Quality, Office of Long Term Care Residents Protection from December 15, 2020 to December 23, 2020.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices to prepare for COVID-19. No deficiencies were identified at the time of the survey.
Report Facts
Facility census: 66
Inspection Report
Routine
Census: 78
Deficiencies: 0
Date: Nov 18, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the State of Delaware Division of Health Care Quality, Office of Long Term Care Residents Protection on November 18, 2020.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices to prepare for COVID-19. No deficiencies were identified at the time of the survey.
Report Facts
Facility census: 78
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