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Deficiency Records for The Estates at Excelsior LLC
View the most recent health deficiencies and inspection results for The Estates at Excelsior LLC. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for The Estates at Excelsior LLC. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide properly protected cooking facilities. | Fire Safety | 2026-04-07 | 2026-05-22 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2026-04-07 | 2026-05-22 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2026-04-07 | 2026-05-22 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2026-04-07 | 2026-05-22 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2026-04-07 | 2026-05-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2026-04-07 | 2026-05-22 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2026-04-07 | 2026-05-22 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2026-04-07 | 2026-05-22 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2026-04-07 | 2026-05-22 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2026-04-07 | 2026-05-22 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2026-04-07 | 2026-05-22 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2026-04-07 | 2026-05-22 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2026-04-07 | 2026-05-22 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2026-04-07 | 2026-05-22 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2026-04-07 | 2026-05-22 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2026-04-07 | 2026-05-22 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2026-04-07 | 2026-05-22 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2025-06-16 | 2025-07-30 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2025-06-16 | 2025-07-30 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2025-06-16 | 2025-07-30 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2025-06-16 | 2025-07-30 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2025-06-16 | 2025-07-30 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2025-06-16 | 2025-07-30 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2025-06-16 | 2025-07-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2025-06-16 | 2025-07-30 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2025-06-16 | 2025-07-30 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2025-06-16 | 2025-07-30 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2025-06-16 | 2025-07-30 | N |
| Implement a program that monitors antibiotic use. | Health | 2025-06-16 | 2025-07-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2025-06-16 | 2025-07-30 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2025-06-16 | 2025-07-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2025-06-16 | 2025-07-30 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2025-06-16 | 2025-07-30 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2025-06-16 | 2025-07-30 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2025-06-16 | 2025-07-30 | N |
| Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. | Health | 2025-06-16 | 2025-07-30 | N |
| Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. | Health | 2025-06-16 | 2025-07-30 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2025-06-16 | 2025-07-30 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2025-06-16 | 2025-07-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2025-01-29 | 2025-02-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-01-29 | 2025-02-28 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-11-07 | 2024-11-29 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-05-16 | 2024-06-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-05-16 | 2024-06-18 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-05-16 | 2024-06-18 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2024-05-16 | 2024-06-18 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2024-05-16 | 2024-06-18 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-05-16 | 2024-06-07 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-05-16 | 2024-06-07 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-04-25 | 2024-05-08 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2023-08-11 | 2023-09-01 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-08-11 | 2023-09-01 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-08-11 | 2023-09-01 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-08-11 | 2023-09-01 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-06-02 | 2023-07-28 | Y |
| Provide specialized rehabilitative services by qualified personnel, when ordered for a resident by a doctor. | Health | 2023-06-02 | 2023-07-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-06-02 | 2023-07-28 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2025-11-26 | Not Fixed | Y |