Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

EXCEL CARE AT WAYNE

WAYNE, NJ · 120 certified beds · Last Life Safety survey December 13, 2024

CMS Certification Number 315103 · first certified July 1970

Ownership

Operated by EXCELCARE · For profit - Limited Liability company

  • Ownership changed December 20, 2021 (change of ownership)from REGENCY GARDENS NURSING CENTER LLC
18
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
3
Tags cited more than once
Across separate surveys
11
Inspection & testing records
Of the citations on file

Position within NJ

18 citations — more than 63% of the 348 certified nursing homes in NJ. Compared within NJ rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Slippingmore citations at the latest survey than at its earlier surveys in the window.

The latest survey found 8 citations; the earlier surveys in the window averaged 5. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

Past the typical window (April 2026 to August 2026). Most NJ facilities have been surveyed by January 2027. This facility’s last Life Safety survey was December 2024. Facilities in NJ are typically surveyed 16–20 months after the last one (median 17), measured over 431 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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Which alerts

2 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Physical environment (health survey)

1 physical-environment citation on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 18 Life Safety citations above. The Physical Environment Index

  • F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

How that compares

Citations on file over three years

Compared with the median facility in NJ, and nationally. Surveyors differ markedly between states, so the NJ figure is the meaningful one.

This facility18NJ median15National median11
Citations on file over three years, compared
MeasureCitations
This facility18
Median facility in NJ15
Median facility nationally11

Survey history

Citations at each Life Safety survey
42021-1262023-0982024-12
Citations at each Life Safety survey
Survey dateCitations
December 2, 20214
September 21, 20236
December 13, 20248

Most-cited tags

Most-cited tags at this facility
K-09183K-03512K-05212K-02931K-07611K-02911K-03551K-02111
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0918Have generator or other power source capable of supplying service within 10 seconds.32024-12-13
K-0351Install an approved automatic sprinkler system.22023-09-21
K-0521Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.22024-12-13
K-0293Have properly located and lighted "Exit" signs.12024-12-13
K-0761To conduct inspection, testing and maintenance of fire doors by qualified individuals.12023-09-21
K-0291Install emergency lighting that can last at least 1 1/2 hours.12021-12-02
K-0355Properly select, install, inspect, or maintain portable fire extinguishes.12024-12-13
K-0211Keep aisles, corridors, and exits free of obstruction in case of emergency.12023-09-21

What the citations cover

Citations by CMS category
  • Smoke Deficiencies 7
  • Gas, Vacuum, and Electrical Systems Deficiencies 5
  • Egress Deficiencies 3
  • Services Deficiencies 2
  • Other 1
Citations by CMS category
CategoryCitations
Smoke Deficiencies7
Gas, Vacuum, and Electrical Systems Deficiencies5
Egress Deficiencies3
Services Deficiencies2
Miscellaneous Deficiencies1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

December 13, 2024 — 8 citations

Citations issued on December 13, 2024
TagWhat the surveyor checksStatus
K-0293Have properly located and lighted "Exit" signs.Deficient, Provider has date of correction (December 23, 2024)
K-0321Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.Deficient, Provider has date of correction (December 14, 2024)
K-0324Provide properly protected cooking facilities.Deficient, Provider has date of correction (January 6, 2025)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (January 31, 2025)
K-0355Properly select, install, inspect, or maintain portable fire extinguishes.Deficient, Provider has date of correction (December 25, 2024)
K-0521Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.Deficient, Provider has date of correction (January 13, 2025)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (January 21, 2025)
K-0921Ensure that testing and maintenance of electrical equipment is performed.Deficient, Provider has date of correction (December 24, 2024)

September 21, 2023 — 6 citations

Citations issued on September 21, 2023
TagWhat the surveyor checksStatus
K-0211Keep aisles, corridors, and exits free of obstruction in case of emergency.Deficient, Provider has date of correction (September 25, 2023)
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has date of correction (September 25, 2023)
K-0351Install an approved automatic sprinkler system.Deficient, Provider has date of correction (September 25, 2023)
K-0761To conduct inspection, testing and maintenance of fire doors by qualified individuals.Deficient, Provider has date of correction (November 20, 2023)
K-0914Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.Deficient, Provider has date of correction (September 25, 2023)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (September 25, 2023)

December 2, 2021 — 4 citations

Citations issued on December 2, 2021
TagWhat the surveyor checksStatus
K-0291Install emergency lighting that can last at least 1 1/2 hours.Deficient, Provider has date of correction (December 13, 2021)
K-0351Install an approved automatic sprinkler system.Deficient, Provider has date of correction (December 3, 2021)
K-0521Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.Deficient, Provider has date of correction (December 13, 2021)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (December 3, 2021)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.